vestib - diff dx

Question 1

what is the importance of asking good subjective Qs

Answer 1

help provide important diff dx info
- 80% chance that your diff dx is correct

Question 2

what are the main subjective questions to ask

Answer 2

primary complaint

h/o of HAs, migraines, GAD
-> can contribute to vertigo sx

Question 3

what can vertigo be attributed to

Answer 3

vestib system dysfunction

Question 4

what can lightheaded be attributed to

Answer 4

hypotension
(ie orthostasis, arrhythmia, syncopal episodes)

Question 5

what is a good strategy to get pts to clarify their sx

Answer 5

tell me what you are feeling w/o using the word dizzy

Question 6

what can disequilibrium be attributed to

Answer 6

imbalance stemming from multiple problems
(ie visual loss, neuropathy)
- all contribute to postural control

Question 7

what can oscillopia be attributed to

Answer 7

spontaneous nystagmus or severe, bilateral hypofunction
- can be uni, more commonly (B)

Question 8

what is oscillopsia

Answer 8

everything is moving as you moving
- everything is bouncing

Question 9

what can motion sensitivity be attributed to

Answer 9

migraine, BPPV

Question 10

what are diff dx for sx of floating, swimming, rocking, spinning inside of head

Answer 10

depression
anxiety
somatoform disorders
mild TBI/concussion
cervical spine dysfunction

Question 11

what are possible dx for a sx duration of seconds

Answer 11

BPPV
perilymphatic fistula

Question 12

what are possible dx for a sx duration of minutes

Answer 12

migraine
TIA
panic attack

Question 13

what are possible dx for a sx duration of hours

Answer 13

migraine
meniere’s
hypotension

Question 14

what are possible dx for a sx duration of days

Answer 14

neuritis
CVA
possibly a migraine

Question 15

what are possible dx for a sudden onset of sx

Answer 15

neuritis/labyrinthitis -> UVH
BPPV
meniere’s
stroke

Question 16

what are possible dx for a gradual onset of sx

Answer 16

acoustic neuroma
stroke (slow bleed)

Question 17

what are possible dx for an onset of sx preceded by infection

Answer 17

labyrinthitis/neuritis
- ear or sinus infections can travel to labyrinth or CN 8

Question 18

what are possible dx for an onset of sx preceded by trauma

Answer 18

cervicogenic dizziness
BPPV (knocked crystal into SCC)
post-concussive syndrome

Question 19

what are possible dx for an onset of sx d/t a change in meds

Answer 19

SE of meds
- ototoxicity from aminoglycoside antibiotics (toxic to otoliths -> BVH sx)

Question 20

what are possible dx for a positional dependent trigger

Answer 20

BPPV (moving SCCs)
vertebrobasilar insufficiency
UVH (impacts VOR)

Question 21

what is the path behind vertebrobasilar insufficiency vertigo

Answer 21

post aspect of circulation
- if tilt head posterior can cause occlusion of vertebrobasilar a.

Question 22

what are possible dx for a change in pressure (associated w sneezing/coughing) trigger

Answer 22

perilymphatic fistula
- fistula in peripheral vestib system causing pressure changes

Question 23

what are possible dx for a dark room trigger and why

Answer 23

bilateral hypofunction

in dark room take vision away, now don’t have vision or vestib system to help w balance

Question 24

what are examples of activities pts may avoid since sx onset

Answer 24

putting head back - VBI
turning head - BPPV

Question 25

what are possible dx for an associated sx such as hearing loss

Answer 25

labyrinthitis - how to diff from neuritis acoustic neuroma - tumor growing on CN 8 AICA infarct meniere's

Question 26

what are possible dx for an associated sx such as n/v

Answer 26

UVH - gaze instability BPPV brainstem involvement

Question 27

what are possible dx for an associated sx such as blurriness w head mvmt

Answer 27

UVH (VOR)

Question 28

what are possible dx for an associated sx such as HA

Answer 28

migraine of CNS

Question 29

what are possible dx for an associated sx such as ear fullness/pain, tinnitis

Answer 29

meniere's

Question 30

what are possible dx for an associated sx such as photo- / phonophobia

Answer 30

migraine

Question 31

what are follow up questions to ask to sus out possible dx for an associated sx such as unsteadiness/falls

Answer 31

with what activities? - figure out what position their head is in

Question 32

what are possible dx for an associated sx such as 5 neuro D's

Answer 32

Dizziness Diplopia Dysarthria Dysphagia Drop attack CNS dysfunction!

Question 33

what is one of the first things you want to figure out if someone is presenting w s/sx of vestib path

Answer 33

r/o stroke r/o CNS path

Question 34

what is the importance of the "HINTS" exam

Answer 34

dx stroke more sensitively than early MRI

Question 35

what are the criteria of HINTS exam (+) for central path

Answer 35

HI = Head Impulse is (-) or normal, no corrective saccad N = nystagmus changes direction or is vertical/torsional TS = Test of Skew deviation that has vertical saccadic correction

Question 36

what do you do w the info from the criteria of the HINTS exam

Answer 36

if any of the 3 are present or (+), indicative of CNS path and need imaging to r/o stroke - if all present pretty confident that it is a stroke or CNS path

Question 37

what are the criteria of HINTS exam (+) for peripheral path

Answer 37

HI = Head Impulse is (+) or abnormal, corrective saccade to midline w rotation N = nystagmus non-direction changing, horizontal TS = no skew deviation

Question 38

what is the Test of Skew deviation and what result would indicate central path

Answer 38

cover test of one eyeball - if uncover eye and it is in malaligned and you see vertical realignment as eye jumps back

Question 39

what is the ocular tilt response

Answer 39

triad of sx indicating dysfunction: 1. ocular tilt - head rotated toward affected side 2. skew deviation - vertical misalignment of eyes 3. ocular torsion - eyes will not rotate to stay vertical in orbit in presence of ocular tilt

Question 40

what are sx of vascular pathology involvement

Answer 40

vertigo n/v imbalance nystagmus intolerance to motion

Question 41

what is are 2 considerations with vascular path

Answer 41

CNS path can be vascular in nature infarct or hemorrhage can cause sx similar to those seen w peripheral vestib path

Question 42

what are the 3 main points to help differentiate b/w central and peripheral vestib dysfunction

Answer 42

pt hx and sx complaint oculomotor / vestib exam postural control and gait

Question 43

how can you differentiate between BPPV and VBI

Answer 43

VBI seated test: - lean upper trunk forward, head turned 45deg to test side and ext - look for sx as can occlude vessel (VBI brought on by position of cspine regardless of head position relative to gravity)

Question 44

what is an important consideration with VBI seated testing

Answer 44

little efficacy - perform test anyway bc of serious nature of a (+) VBI test