Week 2 Vestibular Pathology Flashcards
1
Q
What is Meniere’s disease and its mechanism?
A
- chronic, incurable disorder characterized by recurrent, episodic bouts of vestibular symptoms
- swelling in inner ear leads to increased pressure and damage within membranous labyrinth (hair cell death and dilation of otoliths)
2
Q
Meniere’s disease clinical presentation and duration
A
- periodic attacks - violent vertigo, oscillopsia, fluctuating unilateral tinnitus and hearing loss
- sometimes have “aura” or warning signs
- minutes up to 24 hours
- otolithic crisis - drop attacks (conscious entire time, no pass out)
3
Q
What type of patient population is Meniere’s Disease most prevalent?
A
- 40s – 60s y/o but can develop at any age
4
Q
What are the 3 stages of progression for Meniere’s disease?
A
- unpredictable attacks of vertigo
- vertigo > tinnitus > hearing loss
- hearing loss > balance difficulties > tinnitus
5
Q
How is Meniere’s disease diagnosed? What are the steps?
A
diagnosis by exclusion
- 2 or more episodes of spontaneous vertigo of at least 20 min - 24 hours
- audiometrically documented hearing loss (audiogram)
- tinnitus or aural fullness
- exclusion of other causes
6
Q
What laboratory tests are done to a Meniere’s patient?
A
ENG/VNG
VEMP (alongside vHIT)
Posturography
7
Q
Does bilateral involvement occur with Meniere’s Disease?
A
- 1 in 5 will progress to bilateral involvement
8
Q
conservative treatment for Meniere’s disease
A
- diet restrictions - reduction in salt, chocolate, caffeine
- medications - diuretics, vestibular and CNS suppressants to manage symptoms, steroids
- Vestibular Rehab (VRT)
9
Q
T/F: A PT can treat a patient having a Meniere’s attack
A
false - there is nothing we can do
10
Q
When can a Meniere’s patient have PT?
A
- not having frequent episodes, can provide symptom relief in between attacks
- have common sequelae of BBPV
- after surgical interventions
11
Q
What are the 3 surgical interventions used with Meniere’s disease?
A
- intratympanic gentamicin
- vestibular nerve section
- labryinthectomy
12
Q
What is intratympanic gentamicin? What is a consequence?
A
antibiotic injected into inner ear and kills vestibular system on that side
- high risk of hearing loss
13
Q
What is vestibular nerve section? What is a consequence?
A
snip vestibular branch of vestibulocochlear nerve (CN 8)
- hearing is spared
14
Q
What is a labyrinthectomy? What is a consequence?
A
surgical removal of the labyrinth
- 100% hearing loss because cochlea is in labyrinth
15
Q
What vestibular pathology is rare in kids and caused by an upper respiratory or GI infection? What is the most common preceding virus to this condition?
A
vestibular neuritis
- Herpes (HSV-Type 1) is the most common virus cause
16
Q
mechanism of vestibular neuritis
A
viral infection of the vestibular branch of vestibulocochlear nerve or ganglion
17
Q
Acute vestibular neuritis clinical presentation and duration
A
- spontaneous vertigo w/ N&V and imbalance
- duration - days to months
- normal hearing
18
Q
chronic vestibular neuritis clinical presentation and duration
A
- gradual recovery but can take months for all vestibular symptoms to resolve
- some left with residual imbalance and oscillopsia with head movements
19
Q
acute vestibular neuritis diagnosis
A
- diagnosis by exclusion
- vHIT/HIT - head impulse test - + test w/ symptoms that last longer than a few days
20
Q
chronic/severe vestibular neuritis diagnosis
A
- rotary chair test
- audiogram
- VEMP
- MRI
- blood work
21
Q
Vestibular neuritis treatment
A
- vestibular suppressants (don’t want to use for too long)
- steroids + antivirals
Vestibular Rehab - vestibular adaption exercises to speed up recovery
22
Q
Labyrinthitis mechanism and cause
A
Cause - viral or bacterial infection - most common is viral upper respiratory tract infection
Mechanism - inflammation within labyrinth
23
Q
What is the most common cause of labyrinthitis in kids?
A
bacterial infection
- bacterial meningitis or ear infections
24
Q
Labyrinthitis clinical presentation
A
- sudden onset of vertigo, N&V, disequilibrium that lasts days
- HEARING LOSS
25
What can change diagnosis to Meniere's disease?
recurrent labyrinthitis
26
Which vestibular pathology that is commonly caused by a viral infection has hearing loss? Why?
labyrinthitis has hearing loss while neuritis does not
- labyrinthitis affects both branches of vestibulocochlear nerve
27
Labyrinthitis treatment
- vestibular suppressants (not too long)
- steroids + antivirals
- + antibiotic if evidence of a middle ear infection
- VRT - adaption exercises to speed recovery
28
acoustic neuroma mechanism
slow-growing tumors derived from Schwann cells of the vestibulocochlear nerve or internal auditory canal
29
acoustic neuroma clinical presentation. What are the most common first symtpoms?
- gradual or sudden onset of tinnitus, hearing loss, vertigo, or disequilibrium
- hearing loss and tinnitus are the most common first symptoms
- can cause facial numbness and tingling due to compression on CN 5 and 7
30
IF acoustic neuroma remains undiagnosed, what can occur?
- gradual compression on CN 5 (trigneminal) or CN 7 (facial)
- can cause pressure on brainstem or cerebellum
31
acoustic neuroma diagnosis What is the gold standard?
- MRI w/ contrast - gold standard
- audiogram
32
acoustic neuroma treatment
- surgical removal
- radiation
- monitoring
33
When can an acoustic neuroma patient begin vestibular rehab?
only once tumor has been fully resected
- patients tend to do well after surgery
34
perilymph fistula mechanism. What is the most likely cause?
mechanism - opening between middle and inner ear
- rupture in oval window of ear which leads to perilymph leaking into the middle ear
Most likely cause - head trauma
- direct blow to ear
- objects perforating ear drum
- rapid increases in intracranial pressure (weightlifting, childbirth)
35
perilymph fistula clinical presentation. When are symptoms worst?
- sudden onset vertigo
- motion imbalance
- ear fullness
- fluctuating hearing
- severe headaches and N/V can occur
symptoms worsen with activity (or altitude/pressure change) and improve with rest
- symptoms are triggered
36
What is a tell tell sign of perilymph fistula?
Tulio's phenomenon - use of ones own voice or a musical instrument will cause dizziness
37
perilymph fistula diagnosis
- fistula test
- Valsalva test
- audiogram - to determine involved side
- ENG/VNG
- MRI - to rule out CNS
38
What is a fistula test? What is a +?
push air into ear and record eye movement
- + sign = nystagmus
- - sign = no nystagmus
39
What is a Valsalva test? What is a + sign?
patient holds breath while recording eyes
+ sign = nystagmus
- sign = no nystagmus
40
perilymph fistula treatment
- conservative management with smaller fistulas - rest and avoid lifting or activities that change ICP
- surgical repair if > 6 months without healing - VRT after surgery
41
When is surgery necessary for a perilymph fistula?
> 6 months without healing
- followed by VRT
42
What vestibular pathology will not benefit from PT?
semicircular canal dehiscence
43
Semicircular canal dehiscence mechanism
- congenital (born this way) and worsens with age
- bony labyrinth degrades overtime
- gets worse after trauma (accelerates degrading)
44
What is the most common type of semicircular canal dehiscence?
Superior/Anterior canal dehiscence (SCDC)
45
semicircular canal dehiscence clinical presentation
- transient vertigo (caused by coughing, loud noises and pressure changes)
- pressure sensitivity
- sound sensitivity - can hear what is in their body
- imbalance
- hearing loss, tinnitus, aural fullness
46
What are some examples of internal sound sensitivity experienced with semicircular canal dehiscence?
- heel strike with gait
- eye movement
- heartbeat
- own voice
47
What are some examples of external sound sensitivity experienced with semicircular canal dehiscence?
- phone ring
- music
- cannot tolerate loud noises
48
semicircular canal dehiscence diagnosis
- Bone conduction sensitivity test (+ test when patient hears tuning fork on lateral malleoli)
- test for tulio's phenomena
- valsalva test
- CT scan
- audiogram
49
bilateral vestibular hypofunction causes
- idiopathic
- ototoxic agents (gentamycin, streptomycin)
- chemo agents (cisplatnin)
- autoimmune
- other vestibular and neurodegenerative conditions
50
bilateral vestibular hypofunction clinical presentation. What is the most common complaint?
- severe oscillopsia, particularly during walking
- imbalance
- possible hearing loss
- functional tasks become inefficient and exhausting
- no vertigo - only will occur in loss is sequential in nature
51
T/F: Bilateral vestibular hypofunction will have vertigo as a symptom
false - only will have vertigo if sequential in nature
- vertigo needs imbalance on 1 side
52
bilateral vestibular hypofunction diagnosis. What is the gold standard?
- rotary chair test - gold standard
- + Head impulse test BILATERALLY
- + dynamic visual acuity
- + caloric testing
53
bilateral vestibular hypofunction treatment
VRT
- postural control
- gaze stabilization exercises
- residual impairment - imbalance in dark environments, driving at night, etc.
54
T/F: Medications are typically not helpful for bilateral vestibular hypofunction
true
- vestibular suppressants often worsen symptoms because vestibular system is already suppressed
55
What are the surgical interventions available for bilateral vestibular hypofunction patients?
there are NO surgical interventions available to restore vestibular function
56
What is BPPV? What are the symptoms?
- Benign = not malignant
- Paroxysmal = recurrent, sudden intensification of symptoms
- Positional = placement dependent
- Vertigo = false inner sensation of rotational movement
bursts of vertigo, lightheadedness, imbalance, and nausea precipitated by a change of position of the head
57
What is the major symptom that BPPV patients complain of?
positional vertigo
58
What is canalithiasis?
free-floating otoconia in SCC resulting in abnormal endolymphatic flow with the affected canal
59
Canalithiasis clinical presentation
- Latency - delay in onset of vertigo (1-40 seconds) after positional change
- nystagmus appears after latency period with + vertigo
- vertigo fluctuation while in position - vertigo typically disappears after 60 seconds
60
What canal is mainly involved with canalithiasis? Why?
posterior and horizontal canals because otoconia usually settle in canal during sleep
- Want to ask if they are a side sleeper and if so what side? - usually indicates which side is involved
61
What is cupulolithiasis?
otoconia get stuck in cupula (ampulla) of affected canal
- affected canal becomes gravity sensitive
62
cupulolithiasis clinical presentation
- immediate onset of vertigo during positional change
- persistence of vertigo and nystagmus as long as patient is in the position
63
Why do vertigo symptoms persist with cupulolithiasis and not canalithiasis?
in cupulolithiasis, otoconia are constantly pulling on hair cells in the cupula which is excitatory and otoconia eventually settle to lowest point of SCC in canalithiasis
64
Slow phase VOR response in HEALTHY vestibular system: R horizontal canal
Left
65
Slow phase VOR response in HEALTHY vestibular system: R anterior canal
Left torsion and up
66
Slow phase VOR response in HEALTHY vestibular system: R posterior canal
left torsion and down
67
Slow phase VOR response in HEALTHY vestibular system: left horizontal canal
right
68
Slow phase VOR response in HEALTHY vestibular system: L anterior canal
right torsion and up
69
Slow phase VOR response in HEALTHY vestibular system: L posterior canal
Right torsion and down
70
T/F: Horizontal BBPV will have symptoms during head thrust test or shaking head no while stationary
false - otoconia aren't moving in horizontal canal during head thrust
71
Slow and fast phase (nystagmus) VOR response in BBPV patients: Right horizontal canal
slow = left
fast = Right beating nystagmus
72
Slow and fast phase (nystagmus) VOR response in BBPV patients: Right anterior canal
slow = left torsion and up
fast = downward and right torsional nystagmus
73
Slow and fast phase (nystagmus) VOR response in BBPV patients: right posterior canal
slow = left torsion and down
fast = upward and right torsional nystagmus
74
Slow and fast phase (nystagmus) VOR response in BBPV patients: Left horizontal canal
slow = right
fast = left beating nystagmus
75
Slow and fast phase (nystagmus) VOR response in BBPV patients: left anterior canal
slow = right torsion and up
fast = downward and left torsional nystagmus
76
Slow and fast phase (nystagmus) VOR response in BBPV patients: left posterior canal
slow = right torsion and down
fast = upward and left torsional nystagmus
77
Who is more likely to develop BPPV?
older women
- women > men
- 50% of people > 70 y/o will experience BPPV
78
What are lifestyle effects of BPPV?
- reduced independent ADLs
- + falls
- depression
79
What are some predisposing factors of BPPV?
- age
- head trauma
- inner ear disease
- genetics
- osteopenia/osteoporosis
- CV disease
- diabetes
- migraine
- Vitamin D deficiency
- sleeping position/prolonged immobility
80
Patients with migraine commonly show vestibular system as ________
an aura
81
What is the most common site for a TIA that will bring vestibular symptoms? What is the most common symptoms
vertebrobasilar artery TIA
- most common symptom is vertigo - intense that lasts minutes to hours
82
What symptom distinguishes a PICA and AICA stroke?
hearing with AICA stroke
83
What will cause a gradual degeneration of both spinal nerve roots and cerebellum?
spinocerebellar ataxias
84
What could be a possible diagnosis if all other pathologies have been ruled out or don't add up?
paraneoplastic disorders - undiagnosed cancer
- breast
- lung
- ovary
- uterine cancer
the immune system attacks cerebellum by mistake - thinks its Purkinje fibers are cancerous
85
What is persistent postural-perceptual dizziness (PPPD or 3PD)? How are they treated?
patients have persistent vestibular symptoms (not made up) but are largely psychogenic in nature
- should never have just PT alone for treatment
86
What are the 5 criteria for diagnosis of persistent postural-perceptual dizziness?
1) > or = of 1 symptoms of dizziness or unsteadiness present on most days for 3 months or longer
2) persistent symptoms without specific triggers, but exacerbated by upright position, active or passive motion, visual stimuli or complex visual patterns
3) precipitated by conditions that cause vertigo, unsteadiness, dizziness, or balance issues (vestibular issues, neuro pathology, medical or psychological distress)
4) symptoms cause significant distress or functional impairment
5) all other diagnoses ruled out
