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Vestibular System Flashcards

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1
Q

Vestibular Pathologies: Peripheral: Labyrinth related

A
  • BPPV
  • Vestibular neuritis
  • Labyrinthitis
  • Acoustic neuroma
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2
Q

Vestibular Pathologies: Central: Brain-related

A
  • CVA
  • Cerebellar disorder
  • MS
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3
Q

Labyrinth =

A

Semicircular canal + otolith organs

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4
Q

Semicircular Canals:

A

anterior (vertical)
posterior (vertical)
horizontal (lateral)

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5
Q

otolith organs:

A
  • Saccule
  • Utricle
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6
Q

Benign Paroxysmal Positional Nystagmus/Vertigo (BPPN/V)

A

Most common disorder resulting in dizziness in older population

Mechanical disorder caused by otoconia displaced from the macula of the utricle

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7
Q

Benign Paroxysmal Positional Nystagmus/Vertigo (BPPN/V) causes:

A
  • Infection
  • Head trauma
  • Vestibular weakness
  • Advancing age
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8
Q

BPPV – Signs and Symptoms

A

Vertigo with change in head position, such as when turning over in bed, getting into or out of bed, or when
bending over/coming up

Nystagmus (involuntary, rapid and repetitive movement of the eyes) – Most important symptom

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9
Q

BPPV affects which canal:

A

can happen in any of the 3 semicircular
canals (posterior is most common)

can be one two types : CANALithiasis or
CUPULOlithiasis

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10
Q

Canalithiasis:

A

otoconia floating in canal

symptoms < 1 min

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11
Q

Cupulolithiasis:

A

otoconia stuck in cupula

> 1 min

tricky to treat - have to unstick otoconia first + then treat

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12
Q

most common BPPV

A

Posterior Canal

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13
Q

least common BPPV

A

Anterior Canal

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14
Q

Assessment of Vertical Canals:

A

Dix-Hallpike Test

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15
Q

Dix-Hallpike Test Positioning:

A

(A) The patient’s head is turned (45 degrees) toward her affected ear while she is in a sitting position.

(B) The patient is quickly moved into a supine position with her head extended (20-30 degrees off the table) and rotated 45 degrees toward her ear.

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16
Q

Dix-Hallpike Test Result Interpretation:

A

Posterior Canal - Upbeating torsional Nystagmus

Anterior Canal - Downbeating torsional Nystagmus

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17
Q

A patient presents with chief concerns of dizziness with rolling in bed
and bending forward to load the dishwasher. On assessment, the
patient tests positive for the Dix-Hallpike test on the right side for
posterior canalithiasis. Which of the following is MOST LIKELY expected
to be present in this patient?
A. Downbeating torsional nystagmus for 120 seconds
B. Upbeating torsional nystagmus for 70 seconds
C. Downbeating torsional nystagmus for 10 seconds
D. Upbeating torsional nystagmus for 40 seconds

A

D. Upbeating torsional nystagmus for 40 seconds

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18
Q

Treatment: Posterior Canal BPPV -

A

CANALITHIASIS
(Canalith Repositioning Maneuver) - The “Epley” Maneuver

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19
Q

“Epley” Maneuver

A

series of four head positions – Maintain each position for 1 to 2 minutes or until the vertigo and nystagmus has
stopped to ensure otoconia low through the canal

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20
Q

“Epley” Maneuver positions:

A
  1. Turn head 45° to the more symptomatic side and 30° below horizontal (the Dix-Hallpike exam position)
  2. Rotate 45° to the other side keeping 30° declination
  3. Roll to sidelying (uninvolved side), nose down
  4. (Slowly sit up, maintaining head position flexed (chin tucked) and rotated

Slowly return the head to upright and remain sitting 3-4 minutes, then repeat until no symptoms are seen

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21
Q

___ Maneuver for CUPULOLITHIASIS

A

Semont or Liberatory

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22
Q

Liberatory (Semont) Maneuver for right posterior SCC BPPV:

A

(A) The head is rotated 45° to the left side

(B) With assistance, the patient is then moved from sitting to right side-lying and stays in this position for 1 minute

(C) The patient is then rapidly moved 180°, from right side-lying to left side-lying

The head should be in the original starting position, left rotated (nose down in final position) in this example.

Note that the otoconia have been dislodged from the cupula.

After 1 minute in this position, (D) the patient returns to sitting.

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23
Q

Brandt Daroff Exercise:

Study These Flashcards
A

NOT 1st choice treatment = plan B (similar to semont but you turn your head 2x)

24
Q

Brandt Daroff Exercise - uses:

Study These Flashcards
A
  • Mild vertigo (even after Canalith Repositioning Maneuver (CRM))
  • For the patient who may not tolerate CRM
  • Home Exercise Program
25
Dix -Hallpike Test side: R nystagmus: Torsional UPbeating duration: <60 sec diagnosis = treatment =
Diagnosis: Right Posterior Canal Canalithiasis Treatment: Epley Maneuver (Right)
26
Dix -Hallpike Test side: R nystagmus: Torsional UPbeating duration: >60 sec diagnosis = treatment =
Diagnosis: Right Posterior Canal Cupulolithiasis Treatment: Semont Liberatory Maneuver (Right) or Brandt-Daroff
27
Dix -Hallpike Test side: R nystagmus: Torsional DOWNbeating duration: <60 sec diagnosis = treatment =
Diagnosis: Right Anterior Canal Canalithiasis Treatment: Deep Head Hanging Maneuver
28
Dix -Hallpike Test side: R nystagmus: Torsional DOWNbeating duration: >60 sec diagnosis = treatment =
Diagnosis: Right Anterior Canal Cupulolithiasis Treatment: Modified Deep Head Hanging or Semont (Anterior variation)
29
Dix -Hallpike Test side: L nystagmus: Torsional UPbeating duration: <60 sec diagnosis = treatment =
Diagnosis: Left Posterior Canal Canalithiasis Treatment: Epley Maneuver (Left)
30
Dix -Hallpike Test side: L nystagmus: Torsional UPbeating duration: >60 sec diagnosis = treatment =
Diagnosis: Left Posterior Canal Cupulolithiasis Treatment: Semont Liberatory Maneuver (Left) or Brandt-Daroff
31
Dix -Hallpike Test side: L nystagmus: Torsional DOWNbeating duration: <60 sec diagnosis = treatment =
Diagnosis: Left Anterior Canal Canalithiasis Treatment: Deep Head Hanging Maneuver
32
Dix -Hallpike Test side: L nystagmus: Torsional DOWNbeating duration: >60 sec diagnosis = treatment =
Diagnosis: Left Anterior Canal Cupulolithiasis Treatment: Modified Deep Head Hanging or Semont (Anterior variation)
33
Horizontal Canal:
Oriented 30° above horizontal; needs slight head flexion to align it during testing 2 main types: Canalithiasis: Free-floating otoconia in the canal Cupulolithiasis: Otoconia stuck on the cupula
34
Supine Roll Test (aka Pagnini-McClure Test) Purpose:
To identify Horizontal Canal BPPV (canalithiasis or cupulolithiasis).
35
Supine Roll Test:
Position the patient supine on a flat surface. Flex the head 30° forward — this aligns the horizontal semicircular canals parallel to the floor. Quickly turn the head 90° to one side (e.g., right) and observe for: Nystagmus direction (geotropic or ageotropic) Duration Intensity of vertigo or symptoms Bring the head back to neutral. Repeat the maneuver to the other side (e.g., left) and observe again.
36
Supine Roll Test: suspect right horizontal canal involvement
You turn their head 90° to the right: > They get intense vertigo > You see geotropic nystagmus You bring their head back to center, then turn it 90° to the left: > They still have vertigo, but it's less intense > Still geotropic nystagmus
37
Geotropic Nystagmus
(beats toward the ground) → Canalithiasis → Affected Side = More Intense
38
Ageotropic Nystagmus
(beats away from the ground) → Cupulolithiasis → Affected Side = Less Intense
39
BBQ Roll Maneuver
Indication: Horizontal Canal Canalithiasis (more intense geotropic nystagmus on affected side)
40
BBQ Roll Maneuver Steps:
Start Supine Turn Head 90° Toward Affected Side Roll Head & Body 90° Toward Unaffected Side Roll Body Another 90° Toward Unaffected Side Continue Roll Another 90° Sit Up Slowly
41
BBQ Roll Assuming Right Horizontal Canal is Affected:
Head flexed 30°, lying flat on back turn head to the right Wait 15–30 seconds or until symptoms subside Roll Head & Body 90° Toward Unaffected Side = Now facing up to facing left Wait again for symptoms to settle Roll Body Another 90° Toward Unaffected Side = Now you're lying prone (face down) Head turned slightly downward Wait 15–30 seconds Continue Roll Another 90°= Patient is now on left side, almost back to sitting Sit Up Slowly = End the maneuver seated with head still flexed slightly forward
42
A physical therapist is treating a patient with presence of geotropic nystagmus on head turns in the supine position. The nystagmus was weaker on the right side. Which of the following is the MOST APPROPRIATE sequence of administering the intervention for these symptoms? A. Canalith repositioning maneuver with head in 20 deg extension, head turn to 90 deg to right, then moved to the left, then get the patient in prone position with neck in flexion and finally sit the patient up B. Canalith repositioning maneuver with head in 20 deg flexion, head turn to 90 deg to left, then moved to the right, then get the patient in prone position with neck in flexion and finally sit the patient up C. Canalith repositioning maneuver with head in 20 deg extension, head turn to 90 deg to left, then moved to the right, then get the patient in prone position with neck in flexion and finally sit the patient up D. Canalith repositioning maneuver with head in 20 deg flexion, head turn to 90 deg to right, then moved to the left, then get the patient in prone position with neck in flexion and finally sit the patient up
B. Canalith repositioning maneuver with head in 20 deg flexion, head turn to 90 deg to left, then moved to the right, then get the patient in prone position with neck in flexion and finally sit the patient up
43
Anterior or Posterior Canal BPPV due to Canalithiasis (Dix-Hallpike duration < 60sec) treatment =
Epley/CRM Posterior SCC canalithiasis is the most common
44
Anterior or Posterior Canal BPPV due to Cupulolithiasis (Dix-Hallpike duration > 1 min) treatment =
Semont/Liberatory
45
* Persistent/residual or mild vertigo (even after CRM) * For the patient who may not tolerate CRM treatment =
Brandt-Daroff exercises
46
Horizontal Canal BPPV – Canalithiasis/Cupulolithiasis treatment =
Barbecue roll/CRM (Canal) Gufoni (Cupulolithiasis)
47
Assessments:
Cranial nerve and coordination Eye assessment: Smooth pursuits, Saccades, VOR (Head impulse test) Positional testing: Dix-Hallpike, supine roll test need to clear cranial nerves first then positional testing (+) smooth pursuits and saccades = central (+) VOR = peripheral HIT = not (+) in BPPV
48
Central Vestibular Pathology
Ataxia Abnormal smooth pursuit and saccades Diplopia and other red flags (dysarthria, dysphagia) Usually, no hearing loss Nystagmus : - Pendular nystagmus (eyes oscillate at equal speeds) - Persistent vertical nystagmus Visual fixation does not improve symptoms
49
Peripheral Vestibular Pathology
Normal smooth pursuit and saccades Hearing loss Fullness in ears, tinnitus Nystagmus : - Jerk Nystagmus (has a slow and fast phases) Visual fixation improves symptoms
50
Oculomotor Examination
Smooth Pursuit: “Follow my finger with your eyes” Saccade: “Look at my --- nose- finger- nose-finger-nose- finger” Abnormal Smooth Pursuits and Saccades >>>> Central Vestibular Pathology
51
Vestibulo-Ocular Reflex (VOR)
VOR: Responsible for maintaining focus on an image during rapid head movements Remember: VOR is intact in BPPV turn head one direction -> eyes turn to opp. direction = normal
52
Head Impulse Test (Head Thrust Test)
Purpose: To assess VOR integrity in patients with dizziness or vertigo Helps differentiate peripheral vestibular loss from central causes
53
How to Perform: Head Impulse Test (Head Thrust Test)
Have the patient sit upright and focus their gaze on your nose (or a fixed target). Gently hold their head in both hands, flexed slightly forward (~30°). Quickly and unpredictably turn the head ~15–20° to one side, then back to center. (You’re testing one side at a time.) Watch the eyes during the movement.
54
Head Impulse Test (Head Thrust Test) Result Interpretation:
Normal VOR: Eyes stay fixed on the target = VOR is intact (could be BPPV or central issue) Abnormal VOR: Eyes move with head, then make a quick corrective saccade back to target = Peripheral vestibular hypofunction on the side you turned to
55
So if you do the Head Impulse Test on someone with BPPV...
→ their eyes will stay on target → No corrective saccade → That’s a normal test result In Benign Paroxysmal Positional Vertigo (BPPV), the Vestibulo-Ocular Reflex (VOR) is normal
56
abnormal Head Impulse Test = peripheral lesion
Because we’re talking about a different type of peripheral lesion: Vestibular neuritis Unilateral vestibular hypofunction Labyrinthitis
57

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