Week 1- Vestibular Disorders Flashcards
PART 1- MENIERE’S DISEASE, VESTIBULAR NEURITIS, AND LABYRINTHITIS
PART 1- MENIERE’S DISEASE, VESTIBULAR NEURITIS, AND LABYRINTHITIS
List some central vestibular dysfunctions.
- Stroke
- Traumatic Brain Injury
- Cerebellar Degeneration
- Arnold-Chiari Malformation
- Cancer
- Multiple Sclerosis
- Migraine
List some peripheral vestibular dysfunctions. (8)
- Ménière’s Disease
- Vestibular Neuritis
- Labyrinthitis
- Acoustic Neuroma/Vestibular Schwannoma
- Perilymph Fistula
- Semicircular Canal Dehiscence
- Benign Paroxysmal -Positional Vertigo (BPPV)
- Bilateral Vestibular Dysfunction
Things to look at when creating differential diagnosis with vestibular dysfunction? (5)
- Dizziness characteristics (description of dizziness, severity, temporal)
- Onset (sudden vs. gradual, spontaneous vs. motion-induced)
- Duration and Frequency
- +/- Auditory Involvement (hearing loss, tinnitus, ear fullness)
- +/- Imbalance
____________ is the 2nd most common cause of dizziness. It is a chronic, incurable disorder characterized by recurrent, episodic bouts of vestibular symptoms.
-Meniere’s Disease
What is the mechanism for Meniere’s Disease?
- Swelling in the inner ear leading to increased pressure and damage within membranous labyrinth.
- Leads to hair cell death and mechanical changes in ear (otoliths)
- What is the cause of Meniere’s Disease?
- It is most prevalent onset in __s-__s but can develop at any age.
- Unknown, patient’s sometimes report “triggers” leading to attacks (stress, fatigue, emotional distress, additional illness, pressure change, diet).
- 40s-60s
Meniere’s Disease is often characterized by periodic “_______” of vertigo, oscillopsia ear fullness, fluctuating unilateral tinnitus and hearing loss but can also have non-vestibular S/Sx.
-It can also be preceded by “_____”, which is a specific set of morning symptoms (imbalance, dizziness, lightheadedness, light sensitivity).
- “attacks”
- “aura”
How long can Meniere’s Disease “attacks” last?
-Minutes to 24 hours, highly variable in frequency.
- _____________ is a “drop attack” that is conscious and has no warning.
- It is attributed to sudden mechanical changes to otolith organs and if present, is ____ treatable.
- Otolith Crisis
- very
Those with Meniere’s Disease are often __________ between attacks.
-1 in 5 will progress to ________ involvement.
- asymptomatic
- bilateral
-What are the (3) stages of progression with Meniere’s Disease?
- Unpredictable attacks of vertigo.
- Vertigo>tinnitus>hearing loss.
- Hearing loss>balance difficulties>tinnitus.
- Diagnosis of Meniere’s Disease is largely __________.
- What are (4) exclusion criteria?
- Exclusion
- 2 or more episodes of spontaneous vertigo of >20 minutes to 24 hours, hearing loss, tinnitus, aural fullness
What are some lab tests that may be done with Meniere’s Disease?
- ENG/VNG
- vEMP
- Posturography
Is conservative or surgical/invasive intervention better with Meniere’s Disease?
- Conservative (80%)
- Invasive/Surgical (20-40%)
What are the 3 main ways Meniere’s Disease is treated conservatively?
- Diet Restrictions
- Medications
- Vestibular Rehabilitation Therapy
What are the diet restrictions when treating Meniere’s Disease? (3)
- salt
- chocolate
- caffeine
What is the most common conservative long-term treatment for Meniere’s Disease?
-Salt reduction and diuretic
Vestibular Rehabilitation Therapy
- _____ during attacks!
- Not indicated for those with ________ episodes.
- Can provide support for those with _________ periods between attacks.
- Common sequelae: BPPV → rehab appropriate.
- Most appropriate ______ surgical interventions.
- NOT
- frequent
- asymptomatic
- after
When do we use surgical/invasive interventions with Meniere’s Disease?
-Typically considered after failed conservative measures.
What are (3) common surgical/invasive measures used with Meniere’s Disease?
- Intratympanic Gentamicin
- Vestibular Nerve Section
- Labyrinthectomy
- What is Intratympanic Gentamicin?
- What is the biggest con of this procedure?
- Injected medication that destroys vestibular tissue to chemically erode vestibular system by getting rid of involved side.
- Mod-High risk of losing hearing.
What is the advantage of Vestibular nerve Section?
-Hearing is left intact.
What is labyrinthectomy?
-Taking out whole labyrinth and hearing is definitely lost during this.
_____________ is the 3rd most common cause of dizziness. It is a viral infection of the vestibular branch of vestibulocochlear nerve or ganglion.
-Vestibular Neuritis
- Vestibular Neuritis has a preceding upper respiratory or gastrointestinal infection in about ___% of cases.
- ____-__ is a common preceding virus.
- 50%
- HSV-1
Is Vestibular Neuritis acute or chronic?
-Can be acute or chronic.
Acute Vestibular Neuritis:
- ________ onset of vertigo associated N/V and imbalance.
- Typically ______ in duration.
- Auditory system _____.
- Sudden
- days
- WNL
Chronic Vestibular Neuritis:
-Period of gradual recovery that may last several weeks, some will have symptoms completely resolved. Others left with residual complaints of imbalance and ________ with head movements.
-oscillopsia
What are (2) ways that acute vestibular neuritis is diagnosed?
- Clinical Exam (diagnosis of exclusion)
- vHIT/HIT (vHIT with symptoms lasting longer than a few days are highly suspecting of neuritis.
What are some ways chronic/severe vestibular neuritis are diagnosed? (5)
- Rotary Chair Test
- Audiogram
- vEMP
- MRI
- Blood Work
- What medications may be used to treat vestibular neuritis?
- What do we need to be careful of when medication for vestibular neuritis?
- Vestibular suppressants
- Use for too long can prolong recovery.
Vestibular rehabilitation involve vestibular adaptation exercises to help speed recovery. Recovery can take anywhere from ___-___.
-2 months to 1 year
- __________ occurs when there is an infection, however it attacks to whole vestibulocochlear nerve and causes inflammation.
- What does this mean?
- Labyrinthitis
- Hearing loss will also occur.
How is Labyrinthitis treated differently from Vestibular Neuritis?
It is treated the same, with the addition of antibiotic if there is evidence for a middle ear infection.
Recurrent Labyrinthitis leads to a diagnosis of what?
Meniere’s Disease
PART 2: ACOUSTIC NEUROMAS, PERILYMPH FISTULAS, SCC DEHISCENCES, BVD
PART 2: ACOUSTIC NEUROMAS, PERILYMPH FISTULAS, SCC DEHISCENCES, BVD
_____________/______________ is a benign, slow growing tumor that grows from vestibular nerve or inner ear canal. It comes from overproduction of Schwann cells.
-Acoustic Neuroma/ Vestibular Schwannoma
Acoustic Neuroma Clinical Presentation:
- What are the most common first symptoms?
- What are other symptoms?
- Symptoms tend to depend on what?
- Hearing loss (95%), Tinnitus (65%)
- Balance, Vertigo, Disequilibrium (50%)
- Location of the tumor.
Acoustic Neuroma:
- With small tumors, _______ may be preserved and patient may not yet have symptoms.
- As the tumor grows, it can compress CN __ or __.
- Can cause pressure on the ________ or ________ if large enough.
- hearing
- CN V or CN VII
- brainstem or cerebellum
What is the gold standard for diagnosis of Acoustic Neuroma/ Vestibular Schwannoma?
-MRI w/ contrast
What are the (3) interventions used for Acoustic Neuroma/Vestibular Schwannoma?
- Surgical Removal
- Radiation
- Monitoring
When can vestibular rehab occur with Acoustic Neuroma/Vestibular Schwannoma?
-Only once tumor has been FULLY resected.
_______________ is an abnormal connection (opening) between middle and inner ear caused by rupture in the oval window of the ear and leads to perilymph leaking into middle ear.
-Perilymph Fistula
- What is perilymph fistula most commonly associated with?
- What are some other causes?
- Usually trauma involving direct blow to ear.
- Other causes: ear trauma, objects perforating ear drum, rapid increases in ICP.
Perilymphatic Fistula: Clinical Presentation
- Sudden onset _______, motion intolerance, ear fullness, fluctuating hearing. (severe _____ and / can occur).
- Symptoms _______ with activity and ________ with rest. (also worsen with changes in _________, or valsalva-eliciting activities)
- Not unusual to notice that use of ones own voice or a musical instrument will cause dizziness (“________ phenomenon”).
- vertigo (HA and N/V)
- Worsen with activity, improve with rest. (changes in altitude)
- Tulio’s phenomenon
What are some tests that are utilized to help diagnose Perilymph Fistula? (5)
- Fistula test
- Valsalva test
- Audiogram
- ENG/VNG
- MRI
- Both the fistula and valsalva test elicit an increase in _________ in the middle ear which can cause abnormal eye movement.
- Why is a audiogram performed?
- What is an MRI utilized for?
- pressure
- Audiogram helps determine involved side.
- MRI to rule out CNS.
- The good news about perilymph fistulas is that ___% will heal themselves IF the patients take it easy for a little bit.
- What activities do they have to avoid?
- 90%
- Ones that will increase pressure.
If conservative management doesn’t work, what 2 surgical options may be utilized?
-Is vestibular rehabilitation warranted post-op?
- Exploratory Tympanotomy
- Vestibular Nerve Section
-Yes, it is often warranted.
____________ is a congenital disorder and is when the bony labyrinth degrades over time and will be left uncovered by bone over time.
Semicircular Canal Dehiscence
In which canal is Semicircular Canal Dehiscence most common?
-Superior Canal
Semicircular Canal Dehiscence: Clinical Presentation
- Transient vertigo precipitated by ______, _____ noises, and _______ changes in ear.
- _________ sensitivity (coughing, sneezing, Valsalva, lifting, bowel movement)
- _________ sensitivity (internal: heel strike w/ gait, eye movement, heart beat, own voice; external: phone ring, music)
- Imbalance (may be constant, accentuated with head movement, dark environments)
- Hearing loss, tinnitus, aural fullness
- coughing, loud noises, and pressure changes in ear
- pressure sensitivity
- sound sensitivity
What are (3) ways Semicircular Canal Dehiscence is diagnosed?
- Bedside evaluation
- Radiographic Imaging (CT scan)
- Audiogram
What do we do with bedside evaluation when looking at Semicircular Canal Dehiscence?
- Test for Tulio’s phenomenon
- Valsalva test
- Bone conduction sensitivity test (tuning fork on lateral malleoli (patient hears sound in inner ear))
Will patients with Semicircular Canal Dehiscence benefit from rehab?
-NO, will have to go into surgery with canal “plugging” or resurfacing surgery.
__________________ is idiopathic in ~50% of cases, otherwise it is generally caused by ototoxic agents (drugs/antibiotics).
-Bilateral Vestibular Hypofunction
Bilateral Vestibular Hypofunction: Clinical Presentation
- What is the primary complaint?
- Vertigo _____ if loss is sequential in nature.
- Functional tasks become _______ and _________.
- Severe oscillopsia (particularly during walking)
- ONLY
- inefficient and exhausting
What is the gold standard test for Bilateral Vestibular Hypofunction?
-Rotary Chair Test
What other tests may be + when looking at Bilateral Vestibular Hypofunction?
- HIT bilaterally
- Dynamic Visual Acuity
- Caloric testing
What is the primary mode of management for Bilateral Vestibular Hypofunction?
- Vestibular Rehabilitation
- There is no medical management nor surgical intervention available.
PART 3: BPPV
PART 3: BPPV
What is the number 1 cause of dizziness in the adult population?
-BPPV
What does BPPV stand for? And what does each mean?
- Benign = non malignant
- Paroxysmal = recurrent, sudden intensification of symptoms
- Positional = placement dependent (of ear)
- Vertigo = false inner sensation of rotational movement
BPPV has variable “triggers”, but symptoms are almost always precipitated by a change of position of the head with respect to _______.
-gravity
What is the mechanism of BPPV?
-Otoconia displacement from normal location on the utricle.
- BPPV is the most common cause of vertigo and is the number 1 cause of dizziness in patients >__ years old.
- Does the prevalence increase or decrease as we get older?
- Does it affect women or men more?
- 60 years old
- Increase, 50% of people >70 will experience BPPV.
- Women (1.6) > Men (1)
What canal is most affected by BPPV?
- Posterior (76-95%)
- Horizontal (5-12%)
- Anterior (1-2%)
Can BPPV be bilateral or multi-canal?
Yes
- Bilateral BPPV in 15-20% of cases.
- Multi-canal in 5-10% of cases.
What is canalithiasis?
- When the otoconia fall off and are displaced into the semicircular canals. (“canal rocks”)
- Results in abnormal endolymphatic flow with the affected canal.
- ____________ cupular displacement = towards utricle.
- What canals does this excite/inhibit?
- Utriculopedal
- Excitatory for horizontal canal, inhibitory for anterior/posterior canal.
- __________ cupular displacement = away from utricle.
- What canals does this excite/inhibit?
- Utriculofugal
- Excitatory for anterior/posterior canal, inhibitory for horizontal canal.
The displaced otoconia is gravity dependent and will respond to positional changes and roll one way or the other while in the canal. What is the problem with this?
-Normally the semicircular canals respond to rotational forces alone, which are gravity independent. Now that otoconia are being moved by gravity, it turns the canals into gravity dependent gyroscopes.
BPPV Characteristics:
- Delay in the onset of vertigo of 1-40 seconds after the patient has been placed in the provoking position = “_______”.
- Nystagmus that appears after period of latency with + _________.
- Fluctuation in the intensity of the vertigo and nystagmus, which increases and then decreases while the person is in a provoking position, disappearing within ___ seconds.
- “LATENCY”
- vertigo
- 60 seconds
BPPV is mainly seen with posterior and horizontal canals, why is anterior BPPV rare?
Whether we are upright or on our side, our anterior canal rarely finds itself in a gravity dependent position underneath the utricle and saccule.
Otoconia have the best opportunity to fall into the canal when?
When we are asleep.
When is the posterior canal most sensitive?
When we turn our head back and 45 degrees off midline.
Normal VOR and Corresponding Eye Movements:
- RHC = ______
- RAC = ______
- RPC = ______
- LHC = ______
- LAC = _______
- LPC = _______
- RHC = left
- RAC = left torsion and up
- RPC = left torsion and down
- LHC = right
- LAC = right torsion and up
- LPC = right torsion and down
Free-Floating Otoconia Abnormal Eye Movements:
- RHC = ______
- RAC = ______
- RPC = ______
- LHC = ______
- LAC = _______
- LPC = _______
- RHC = right beating nystagmus
- RAC = downward and right torsional nystagmus
- RPC = upward and right torsional nystagmus
- LHC = left beating nystagmus
- LAC = downward and left torsional nystagmus
- LPC = upward and left torsional nystagmus
***This nystagmus pattern is only specific to BPPV in which there is an inappropriate excitation of a canal.
What is cupulolithiasis?
-Otoconia adherent to the cupula of the affected SCC. The canal becomes gravity sensitive which is not the normal function of the SCCs.
What are the 2 characteristics of cupulolithiasis?
- Immediate onset of vertigo when patient moved into provoking position.
- Persistence of the vertigo and nystagmus as long as the head is maintained in the provoking position.
Does BPPV happen spontaneously?
No, it is positional-evoked.
What are the 2 most common predisposing factors of BPPV?
- Age
- Head Trauma- sudden acceleration or deceleration of the head/falls (more likely to see bilateral involvement and/or multi-channel involvement)
What are some other predisposing factors of BPPV other than age and head trauma?
- Inner Ear Disease
- Genetics
- Osteopenia/Osteoporosis
- CV Disease
- Diabetes
- Migraine
- Vitamin D Deficiency
- Sleeping position/prolonged immoility
How is BPPV diagnosed?
-Clinical Examination
How is BPPV treated?
- Repositioning Maneuvers
- Post-Maneuver Activity Restrictions
***Average 1.25 sessions for complete resolution for idiopathic BPPV. Multi-canal/bilateral involvement will need longer.
PART 4: CENTRAL VESTIBULAR PATHOLOGY, PSYCHOLOGICAL CONSIDERATIONS
PART 4: CENTRAL VESTIBULAR PATHOLOGY, PSYCHOLOGICAL CONSIDERATIONS
What are some common central causes of vestibular pathology?
- Migraines
- TIA
- Stroke (PICA and AICA)
- Cerebellar degeneration
- Arnold-Chiari Malformation
- Multiple Sclerosis
- TBI
-Migraine is a chronic neurologic disorder affecting __-__% or more of adult population in the US. It is under-recognized, under diagnosed, and untreated (50% never recieve any medical diagnosis).
-10-15%
- What is the gold standard for diagnosis of migraines?
- What is the mechanism?
- There is no gold standard.
- Thought to be caused by changes in nerve cell electrical and chemical activity in brain. (Changes in cerebral blood flow - vasospasm and vasodilation).
- Are migraines a risk factor for peripheral vestibular dysfunction?
- It often can look similar to _______________.
- Patients with migraine commonly show vestibular symptoms as an ______.
- Yes, 44% of individuals with migraines have some degree of vestibulopathy.
- Meniere’s Disease
- aura
Can vestibular rehab help with migraine and vestibular dysfunction?
-Yes, it is just tricky because they may look better when not having migraine. They also cant be pushed as hard intensity wise and have to work within tolerance.
- What is the most common site for TIA to bring on vestibular symptoms?
- What is the most common symptom?
- These patients also typically have underlying ______ risk factors.
- Vertebrobasilar Artery TIA
- VERTIGO (lasts minutes to hours, tends to be very intense)
What are the 2 most common brainstem and cerebellar CVAs linked to vestibular dysfunction?
- PICA (Wallenberg’s Syndrome)
- AICA
What are the symptoms of PICA (Wallenberg’s Syndrome)?
- vertigo
- HA
- facial pain (ipsilateral)
- disequilibrium
- N/V
- ataxia (ipsilateral)
- hiccups
- contralateral limb burning pain/altered sensation of temp
How are AICA symptoms different from PICA?
-PICA symptoms + HEARING
What are paraneoplastic disorders?
-When an individual has an unrecognized or undiagnosed cancer existing somewhere in body and our immune system has identified that we have cancer but gets confused and starts attacking cerebellum.
Why would the immune system attack the cerebellum if we have cancer?
-Malignancies look similar to main cells in the cerebellum.
- What is Arnold-Chiari Malformation?
- What are the symptoms?
- Where the cerebellum protrudes through the foramen magnum.
- HA, imbalance, aural fullness, tinnitus, vertigo
Do patients with Arnold-Chiari Malformation typically require rehab?
No
- If symptoms aren’t severe, can monitor and not require any interventions.
- If symptoms progress, requires surgery.
