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Neuro 2 > Vestibular Exam > Flashcards

Vestibular Exam Flashcards

1
Q

T/F: Vertigo is frequently misdiagnosed.

A

TRUE

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2
Q

What types of lab testing is done to test for vestibular pathology?

A
  1. Audiogram
  2. ENG/VNG, caloric testing
  3. Vestibular Evoked Myogenic Potential (VEMP) testing
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3
Q

What does an audiogram test for?

A
  • auditory asymmetry
  • retrocochlear pathology
  • ear canal & tympanic membrane integrity
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4
Q

What characterizes auditory asymmetry?

A

significant difference in threshold hearing levels between ears

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5
Q

What does auditory asymmetry indicate?

A
  • peripheral vestibular pathology

- auditory nerve pathology

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6
Q

What specific pathologies could auditory asymmetry indicate?

A
  • Meniere’s disease
  • acoustic neuroma
  • perilymph fistula
  • labyrinthitis
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7
Q

What does retrocochlear pathology refer to?

A

the site of a lesion at the:

  • CN 8
  • cerebellopontine angle
  • CN 8 nerve root
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8
Q

What are the characteristics of retrocochlear pathology?

A
  • unilateral sensorineural hearing loss (auditory asymmetry)

- impaired speech recognition (especially at higher pitch)

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9
Q

What specific pathologies could retrocochlear pathlogy indicate?

A
  • acoustic neuroma
  • multiple sclerosis
  • brainstem lesions
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10
Q

What does an audiogram provide us with information on?

A
  • hearing
  • middle ear function
  • cochlear hair cell function
  • neural aspects for our hearing-balance system
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11
Q

What does ear canal and tympanic membrane integrity tell us?

A

there may be a wide variety of causes which range from mild to significant

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12
Q

What is electronystragmography (ENG ) testing?

A

electrodes are placed around the eye to measure the VOR via muscular activation

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13
Q

What is videonystagmography (VNG) testing?

A

utilizes video goggles to monitor eye movement and VOR

- more common than ENG

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14
Q

What is caloric testing?

A

a way of evaluating the integrity of the unilateral vestibular apparatus (horizontal canal)

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15
Q

In reference to a normal vestibular system for caloric testing, what does COWS stand for?

A

C-old irrigations generate nystagmus in the
O-pposite direction
W-arm irrigations generate nystagmus in the
S-ame direction

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16
Q

What is considered significant asymmetry for caloric testing?

A

25% difference in peak slow component eye movement velocities obtained bilaterally

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17
Q

What is Cervical Vestibular Evoked Myogenic Potential (cVEMP)?

A

a measurement of [otoliths] saccule function via its inhibitory control on the SCM
- short-latency muscle reflexes typically recorded from the neck muscles with surface electrodes

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18
Q

What other types of VEMP are there?

A

oVEMP - used with eye musculature

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19
Q

What is unique about VEMP testing?

A

it is the only test that evaluates the otolith/saccule

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20
Q

How does a cVEMP test occur in a normally functioning patient?

A
  • the patient is instructed to look to the side and hold their head up (SCM activation)
  • a loud sound is emitted
  • the saccule inhibits the SCM
  • the patient’s neck relaxes
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21
Q

How does a cVEMP test indicate abnormal saccule function?

A
  • no muscular response to sound

- asymmetrical response to sound (due to lack of inhibition of SCM on one side)

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22
Q

How does a cVEMP test indicate structural abnormality?

A

a response is evoked from softer sound waves

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23
Q

What pathologies may cVEMP indicate?

A
  • superior canal dehiscence syndrome (SCDS)
  • Meniere’s disease
  • multiple sclerosis
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24
Q

Why is it important to perform an in-depth systems review for patients who are referred for dizziness/vestibular?

A

there are many other causes of vestibular-like symptoms

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25
Q

Name some other causes of vestibular-like symptoms (13)

A
  • stroke
  • migraine
  • seizure
  • heart disease
  • head injury, temporal bone fracture
  • cervical cord compression
  • arrhythmias
  • orthostatic hypotension
  • hypertension
  • diabetes (retinopathy)
  • arthritis, spinal stenosis
  • ankylosis spondylitis
  • anxiety, panic
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26
Q

What are the four main topics we want to address during the subjective history?

A
  • type of dizziness/description of symptoms
  • triggers
  • onset/duration
  • frequency

also associated symptoms

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27
Q

Why is the subjective history so important?

A

Literature suggests that >80% of the information needed to confidently identify a specific vestibular dx over another is determined during the subjective history

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28
Q

Determining an accurate diagnosis depends on what four things?

A
  1. a thorough intake
  2. reviewing past medical hx
  3. identifying potential risk factors/red flags
  4. categorizing the symptoms based on what the patient states
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29
Q

What other symptoms may accompany “dizziness” that may determine a different dx?

A
  • hearing changes
  • weakness
  • dysarthria
  • nausea
  • fatigue
  • anxiety
  • fogginess
30
Q

Describe what dizziness is.

A
  • a non-specific term
  • encompasses feelings of imbalance, spinning, and lightheadedness
  • can have a multitude of vestibular and non-vestibular causes
31
Q

What is vertigo?

A
  • a false sense of self-motion which can be rotational or linear
  • a dysfunction of the VOR
32
Q

What are the causes of vertigo?

A
  • an imbalance of tonic neural activity to the vestibular cortex
  • peripheral or central vestibular damage
33
Q

What is oscillopsia?

A
  • gaze instability

- an illusionary sensation that a stationary visual world is moving

34
Q

What are the causes of oscillopsia?

A
  • Bilateral > unilateral vestibulopathy

- central vestibular dysfunction

35
Q

What is disequilibrium?

A
  • an imbalance or unsteadiness while standing or walking

- a dysfunction of the otoliths (saccule and utricle)

36
Q

What are common causes of disequilibrium?

A
  • visual changes
  • vestibular dysfunction
  • proprioceptive deficits
37
Q

What are less common causes of disequilibrium?

A
  • neuromotor deficits
  • joint pain
  • psychological factors
38
Q

What causes lightheadedness?

A

a brief decrease in blood flow to the brain

aka: pre-syncope

39
Q

What is motion sickness?

A

episodic dizziness, tiredness, pallor, diaphoresis, salivation, and N/V

40
Q

What is motion sickness induced by?

A
  • passive locomotion (car)

- motion in visual surroundings while standing still

41
Q

What causes motion sickness?

A

a sensory mismatch between visual and vestibular systems

42
Q

Name the RED FLAGS for the vestibular exam. (9)

A
  • severe headache
  • rapid hearing decline
  • dysarthria
  • discoordination
  • diplopia
  • decreased mentation & urinary incontinence
  • acute weakness
  • decreased consciousness
  • additional cranial nerve dysfunction
43
Q

Name the 4 steps of the vestibular examination

A
  1. Auditory screen
  2. Gaze stability assessment
  3. Cervical dizziness tests
  4. Balance and postural control assessment
44
Q

What are the components of the gaze stability assessment?

A
  • spontaneous nystagmus
  • evoked nystagmus
  • smooth pursuit
  • saccades
  • optokinetics
  • dynamic visual acuity
  • head impulse test
  • head shake test
  • skew deviation
45
Q

What are the 4 normal eye movements?

A
  1. Smooth pursuit
  2. Saccades
  3. VOR
  4. Optokinetic reflex
46
Q

Which normal eye movements are mediated by central structures?

A
  • smooth pursuit

- saccades

47
Q

Which eye movement is technically not a vestibular based function?

A

the optokinetic reflex

48
Q

What is smooth pursuit?

A

a voluntary eye movement in which the eyes slowly follow a target (1-2Hxz)

49
Q

What are saccades?

A

voluntary eye movements consisting of rapid repositioning to and from a target

50
Q

What is VOR?

A
  • vestibulo-ocular reflex

- an involuntary reflex in which the eye position moves in relation to head movement

51
Q

What is the optokinetic reflex?

A
  • an involuntary reflex
  • functions to produce rhythmic involuntary eye movements in response to a dynamic moving visual environment
  • supplements VOR to stabilize vision
52
Q

What is nystagmus?

A
  • an abnormal visual finding

- repetitive, to-and-fro movement of the eyes characterized by a fast and slow phase of movement

53
Q

What causes nystagmus?

A

an imbalance between vestibular apparatus signaling

54
Q

How is nystagmus defined/characterized?

A

by the direction of the fast phase of movement

- upwards, downwards, horizontal, torsional

55
Q

What can nystagmus lead to?

A
  • vertigo
  • oscillopsia
  • abnormal head positioning
  • can be asymptomatic
56
Q

What are the 3 main types of nystagmus?

A
  • Spontaneous nystagmus
  • Evoked nystagmus
  • Non-pathological nystagmus
57
Q

What are the types of spontaneous nystagmus?

A
  • peripheral vestibular imbalance
  • congenital
  • central
58
Q

What are the types of evoked nystagmus?

A
  • gaze-evoked
  • head shaking
  • optokinetic
  • positional
  • caloric
  • pressure-induced
  • sound-induced
59
Q

Define spontaneous nystagmus

A

the onset of nystagmus without any cognitive, visual, or vestibular stimulus

  • it occurs in the absence of any purposeful eye or head motion
60
Q

What are the characteristics of spontaneous peripheral nystagmus?

A
  • mixed horizontal/torsional directions
  • present with acute lesions, rarely with chronic stable lesions (up to 7-10 days)
  • more prominent with fixation removed
61
Q

What are the characteristics of spontaneous central nystagmus?

A
  • vertical or torsional direction
  • present with acute or chronic lesions
  • more prominent with fixation present
62
Q

Which direction do the fast phases of horizontal and torsional components of spontaneous peripheral nystagmus move the eye?

A

AWAY from the involved ear

63
Q

Name the 2 main outcome measures for vestibular dysfunction

A
  • motion sensitivity quotient (MSQ)

- dizziness handicap inventory (DHI)

64
Q

What does the MSQ measure?

A
  • position-dependent clinical examination that evaluates symptom response
  • determines what positions evoke symptoms and monitors how they respond to rehab
65
Q

What is the specificity and sensitivity of the MSQ?

A

Sp: 80%
Sn: 100%

66
Q

What are the scores for the MSQ?

A

0-10: mild vestibular dysfunction
11-30: moderate vestibular dysfunction
31-100: severe vestibular dysfunction

67
Q

How is each individual position scored for the MSQ?

A 
intensity + duration of symptoms
Intensity (0-5 scale)
Duration (0-3 scale)
- <5s = 0
- 5-10s = 1
- 11-30s = 2
- >30s = 3
68
Q

Describe the DHI

A

a 25-item self-assessment inventory designed to evaluate self-perceived handicap from dizziness
- 0-100 scale (higher=worse)

69
Q

What are the subscales of the DHI?

A
  • physical
  • emotional
  • functional
70
Q

What are the cut-off scores and MCID for the DHI?

A

0-30: mild
31-60: moderate
61-100: severe

MCID: 18

Neuro 2 (3 decks)

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