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Vestibular Exam Flashcards

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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
Name some other causes of vestibular-like symptoms (13)
- 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
26
What are the four main topics we want to address during the subjective history?
- type of dizziness/description of symptoms - triggers - onset/duration - frequency also associated symptoms
27
Why is the subjective history so important?
Literature suggests that >80% of the information needed to confidently identify a specific vestibular dx over another is determined during the subjective history
28
Determining an accurate diagnosis depends on what four things?
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
29
What other symptoms may accompany "dizziness" that may determine a different dx?
- hearing changes - weakness - dysarthria - nausea - fatigue - anxiety - fogginess
30
Describe what dizziness is.
- a non-specific term - encompasses feelings of imbalance, spinning, and lightheadedness - can have a multitude of vestibular and non-vestibular causes
31
What is vertigo?
- a false sense of self-motion which can be rotational or linear - a dysfunction of the VOR
32
What are the causes of vertigo?
- an imbalance of tonic neural activity to the vestibular cortex - peripheral or central vestibular damage
33
What is oscillopsia?
- gaze instability | - an illusionary sensation that a stationary visual world is moving
34
What are the causes of oscillopsia?
- Bilateral > unilateral vestibulopathy | - central vestibular dysfunction
35
What is disequilibrium?
- an imbalance or unsteadiness while standing or walking | - a dysfunction of the otoliths (saccule and utricle)
36
What are common causes of disequilibrium?
- visual changes - vestibular dysfunction - proprioceptive deficits
37
What are less common causes of disequilibrium?
- neuromotor deficits - joint pain - psychological factors
38
What causes lightheadedness?
a brief decrease in blood flow to the brain aka: pre-syncope
39
What is motion sickness?
episodic dizziness, tiredness, pallor, diaphoresis, salivation, and N/V
40
What is motion sickness induced by?
- passive locomotion (car) | - motion in visual surroundings while standing still
41
What causes motion sickness?
a sensory mismatch between visual and vestibular systems
42
Name the RED FLAGS for the vestibular exam. (9)
- severe headache - rapid hearing decline - dysarthria - discoordination - diplopia - decreased mentation & urinary incontinence - acute weakness - decreased consciousness - additional cranial nerve dysfunction
43
Name the 4 steps of the vestibular examination
1. Auditory screen 2. Gaze stability assessment 3. Cervical dizziness tests 4. Balance and postural control assessment
44
What are the components of the gaze stability assessment?
- spontaneous nystagmus - evoked nystagmus - smooth pursuit - saccades - optokinetics - dynamic visual acuity - head impulse test - head shake test - skew deviation
45
What are the 4 normal eye movements?
1. Smooth pursuit 2. Saccades 3. VOR 4. Optokinetic reflex
46
Which normal eye movements are mediated by central structures?
- smooth pursuit | - saccades
47
Which eye movement is technically not a vestibular based function?
the optokinetic reflex
48
What is smooth pursuit?
a voluntary eye movement in which the eyes slowly follow a target (1-2Hxz)
49
What are saccades?
voluntary eye movements consisting of rapid repositioning to and from a target
50
What is VOR?
- vestibulo-ocular reflex | - an involuntary reflex in which the eye position moves in relation to head movement
51
What is the optokinetic reflex?
- an involuntary reflex - functions to produce rhythmic involuntary eye movements in response to a dynamic moving visual environment - supplements VOR to stabilize vision
52
What is nystagmus?
- an abnormal visual finding | - repetitive, to-and-fro movement of the eyes characterized by a fast and slow phase of movement
53
What causes nystagmus?
an imbalance between vestibular apparatus signaling
54
How is nystagmus defined/characterized?
by the direction of the fast phase of movement | - upwards, downwards, horizontal, torsional
55
What can nystagmus lead to?
- vertigo - oscillopsia - abnormal head positioning - can be asymptomatic
56
What are the 3 main types of nystagmus?
- Spontaneous nystagmus - Evoked nystagmus - Non-pathological nystagmus
57
What are the types of spontaneous nystagmus?
- peripheral vestibular imbalance - congenital - central
58
What are the types of evoked nystagmus?
- gaze-evoked - head shaking - optokinetic - positional - caloric - pressure-induced - sound-induced
59
Define spontaneous nystagmus
the onset of nystagmus without any cognitive, visual, or vestibular stimulus - it occurs in the absence of any purposeful eye or head motion
60
What are the characteristics of spontaneous peripheral nystagmus?
- mixed horizontal/torsional directions - present with acute lesions, rarely with chronic stable lesions (up to 7-10 days) - more prominent with fixation removed
61
What are the characteristics of spontaneous central nystagmus?
- vertical or torsional direction - present with acute or chronic lesions - more prominent with fixation present
62
Which direction do the fast phases of horizontal and torsional components of spontaneous peripheral nystagmus move the eye?
AWAY from the involved ear
63
Name the 2 main outcome measures for vestibular dysfunction
- motion sensitivity quotient (MSQ) | - dizziness handicap inventory (DHI)
64
What does the MSQ measure?
- position-dependent clinical examination that evaluates symptom response - determines what positions evoke symptoms and monitors how they respond to rehab
65
What is the specificity and sensitivity of the MSQ?
Sp: 80% Sn: 100%
66
What are the scores for the MSQ?
0-10: mild vestibular dysfunction 11-30: moderate vestibular dysfunction 31-100: severe vestibular dysfunction
67
How is each individual position scored for the MSQ?
``` intensity + duration of symptoms Intensity (0-5 scale) Duration (0-3 scale) - <5s = 0 - 5-10s = 1 - 11-30s = 2 - >30s = 3 ```
68
Describe the DHI
a 25-item self-assessment inventory designed to evaluate self-perceived handicap from dizziness - 0-100 scale (higher=worse)
69
What are the subscales of the DHI?
- physical - emotional - functional
70
What are the cut-off scores and MCID for the DHI?
0-30: mild 31-60: moderate 61-100: severe MCID: 18

Neuro 2 (3 decks)

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