Week 1- Vestibular Dysfunction: Examination

Question 1

PART 1: PATIENT REFERRAL AND LAB TESTING

Answer 1

PART 1: PATIENT REFERRAL AND LAB TESTING

Question 2

Misdiagnosis is VERY common and is often referred for ________.

Answer 2

-Dizziness

Question 3

What lab tests can be performed to help with diagnosing and treating vestibular patients?

Answer 3

• Audiogram
• ENG/VNG, Caloric testing
• Vestibular Evoked Myogenic Potential (VEMP) testing

Question 4

What are the 3 main things that audiograms will give us information on?

Answer 4

• Auditory Asymmetry
• Retrocochlear Pathology
• Ear Canal and Tympanic Membrane integrity

Question 5

Audiograms are largely used with vestibular patients for what reason?

Answer 5

-Used as screening tool to rule out any auditory pathology that may mimic vestibular pathology.

Question 6

• Auditory asymmetry indicates the possibility of __________ vestibular or __________ _______ pathology.
• What are some examples?

Answer 6

• Peripheral Vestibular or Auditory Nerve Pathology

- Meniere’s Disease, Acoustic Neuroma, Perilymph Fistula, Labyrinthitis

Question 7

• Retrocochlear pathology refers to site of lesion at the CN ____, ____________ angle, or CN ____ nerve root.
• Retrocochlear pathology presents with unilateral __________ hearing loss and impaired ______ recognition.
• What are some examples?

Answer 7

• CN VIII, cerebellopontine angle, or CN VIII nerve root
• sensorineural, speech
• Acoustic Neuroma, MS, variety of brainstem lesions

Question 8

ENG and VNGs aren’t done as commonly as audiograms but specifically looks at the integrity of what?

Answer 8

-VOR integrity

Question 9

What is the difference between ENG and VNG?

Answer 9

The way they measure VORs. ENG looks at muscular activity of extraoccular movements while VNG measures eye movement.

Question 10

• ENGs and VNGs also allow us to look at what subtest?

- What is this?

Answer 10

• Caloric Testing

- Cold water is squirted into ear canal to evaluate integrity of unilateral vestibular apparatus.

Question 11

Caloric testing is a comparative exam of what canal?

Answer 11

-Horizontal Canal

Question 12

Describe what happens with caloric testing of the L ear normally.

Answer 12

• Elicits cooling effect on canal which affects endolymph inside which reduces activity of said canal.
• By inhibiting our L ear the brain thinks the head is moving to the right.
• VOR kicks in gear and moves eyes left but recognizes that the head isn’t moving and corrects back to right. (NYSTAGMUS)

Question 13

What happens when warm water is used with caloric testing of the L ear normally?

Answer 13

-Warm water excites that side and will cause the opposite response.

Question 14

What is a good way to remember caloric testing?

Answer 14

COWS

-COLD irrigations generate nystagmus in OPPOSITE direction, WARM irrigations in the SAME direction function bilaterally

Question 15

What will we see with caloric testing with vestibular pathologies involving horizontal canal?

Answer 15

Blunted response unilaterally

-Significant Asymmetry = ~25% difference in peak slow component eye movement velocities obtained bilaterally.

Question 16

What are Vestibular Evoked Myogenic Potentials (VEMP)?

Answer 16

-Short latency muscle reflexes typically recorded from the neck (cVEMP) or eye (oVEMP) muscles with surface electrodes in response to loud sounds.

Question 17

What does cVEMP evaluate the integrity of?

Answer 17

-Otoliths (specifically saccule)

Question 18

What muscle does the saccule project down to specifically?

Answer 18

-Sternocleidomastoid (SCM)

Question 19

How does abnormal saccule function present when performing cVEMP?

Answer 19

• No muscular response (relaxation) to sound

- Asymmetrical response R vs L

Question 20

How does structural abnormality present when performing cVEMP?

Answer 20

-Evoked response from softer sound waves (as sound turns down, SCM stays inhibited)

Question 21

PART 2: SUBJECTIVE INTERVIEW

Answer 21

PART 2: SUBJECTIVE INTERVIEW

Question 22

What do we want to do first in the systems review when assessing for vestibular dysfunction?

Answer 22

-Rule out other causes of vestibular-like symptoms.

Question 23

More than 80% of the information needed to identify a specific vestibular diagnosis is made when?

Answer 23

-Subjective History/Patient Interview

Question 24

What are (4) things that you can ask during a subjective history to help narrow down “Dizziness” diagnosis?

Answer 24

• Type of dizziness/ description of symptoms
• Triggers/ Relieving Factors
• Onset/Duration
• Frequency

-And other associated symptoms

Question 25

_________ presents with a false sense of self-motion, can be rotational or linear, is due to imbalances of toxic neural activity to vestibular cortex, and can be caused by peripheral or central vestibular damage.

Answer 25

-Vertigo

Question 26

___________ presents with gaze instability and illusionary sensation that a stational visual world is moving, and can be seen with bilateral>unilateral vestibulopathy and central vestibular dysfunction.

Answer 26

-Oscillopsia

Question 27

____________ presents with imbalance or unsteadiness while standing or walking. Common causes are visual changes, vestibular dysfunction, and proprioceptive deficits.

Answer 27

-Disequilibrium

Question 28

____________ is also referred to as pre-syncope and is caused from brief decrease in blood flow to the brain.

Answer 28

-Lightheadedness

Question 29

____________ is episodic dizziness, tiredness, pallor, diaphoresis, salivation, and N/V. It is induced by passive locomotion (car) OR motion in visual surroundings while standing still. It is caused by sensory mismatch between visual and vestibular system.

Answer 29

Motion Sickness

Question 30

What are the RED FLAGS with vestibular pathologies? (9)

Answer 30

- Severe headache - Rapid hearing decline - Dysarthria - Discoordination - Diplopia - Decreased mentation & Urinary Incontinence - Acute weakness - Decreased consciousness - Additional Cranial Nerve Dysfunction

Question 31

PART 3: NYSTAGMUS AND OUTCOME MEASURES

Answer 31

PART 3: NYSTAGMUS AND OUTCOME MEASURES

Question 32

What are the (4) main components of the vestibular examination?

Answer 32

- Auditory Screen - Gaze Stabilization Assessment - Cervical Dizziness Tests - Balance and Postural Control Assessment

Question 33

What is one of the most common S/Sx of vestibular dysfunction?

Answer 33

-Gaze Stability

Question 34

What are some things to look at when assessing Gaze Stability? (9)

Answer 34

- Spontaneous Nystagmus - Evoked Nystagmus - Smooth Pursuit - Saccades - Optokinetics - Dynamic Visual Acuity - Head Impulse Test - Head Shake Test - Skew Deviation

Question 35

- What is smooth pursuit? - What is saccades? - What is VOR? - What is optokinetic? - What is nystagmus?

Answer 35

- Smooth Pursuit = Voluntary slow following of a target. - Saccades = Voluntary rapid repositioning of target. - VOR = Involuntary eye stabilization in relation to head movement. - Optokinetic = Involuntary, perceives motion in visual field, and supplements VOR to stabilize vision. - Nystagmus = Involuntary eye movement which may cause the eye to rapidly move from side to side, up and down, or in a circle, and may slightly blur vision.

Question 36

________ is an abnormal visual finding that can occur spontaneously.

Answer 36

-Nystagmus

Question 37

- Nystagmus is a repetitive, to- and fro- movement of the eyes characterized by a _____ and _____ phase of movement. - It is caused by imbalance between vestibular apparatus signaling and defined by the direction of the _____ phase of movement.

Answer 37

- fast and slow | - fast

Question 38

- Nystagmus is the ________ diagnostic indicator used in identifying most peripheral and central vestibular lesions. - It can be ___________ and can lead to vertigo, oscillopsia, and/or abnormal head positioning.

Answer 38

- primary | - asymptamotic

Question 39

Are vertical and horizontal nystagmus the only forms?

Answer 39

No, can sometimes see torsional nystagmus.

Question 40

What are the 2 major ways we classify nystagmus?

Answer 40

- Spontaneous | - Evoked

Question 41

What is the 5% of nystagmus that may be normal?

Answer 41

When bringing to end range and hanging there, can see some nystagmus in normal.

Question 42

____________ Nystagmus is the onset of nystagmus without any cognitive, visual or vestibular stimulus and occurs in the absence of any purposeful eye or head motion. -How does this happen?

Answer 42

- Spontaneous - When one side is not working correctly it will present as inhibited and cause an imbalance (Ex: R side inhibited, reflex thinks head is moving to L, eyes correct and go R).

Question 43

What are the (3) primary things that define peripheral spontaneous nystagmus?

Answer 43

- Mixed horizontal/torsional (same direction). - Presents with acute lesions, rarely w/ chronic stable lesions. - More prominent with fixation removed.

Question 44

What are the (3) primary things that define central spontaneous nystagmus?

Answer 44

- Vertical/torsional. - Acute or chronic. - More prominent w/ fixation present.

Question 45

- How do we test for fixation removed/present? | - What do we do if we don't have these items?

Answer 45

-Visual fixation blockers. (Frenzel Lenses, Video Infrared Goggles) -Private treatment room w/ lights off and shining light into patients eyes.

Question 46

What are 2 outcome measures used?

Answer 46

- Motion Sensitivity Quotient | - Dizziness Handicap Inventory

Question 47

- What is Motion Sensitivity Quotient (MSQ)? | - With this, symptoms are scored off of ________ and ________.

Answer 47

- Objective examination tool bringing patient through 16 potential provocative head/body movements that can elicit motion sensitivity. - intensity and duration

Question 48

What is the scoring for MSQ?

Answer 48

- Mild Vestibular Dysfunction = 0-10 - Modderate Vestibular Dysfunction = 11-30 - Severe Vestibular Dysfunction = 31-100

Question 49

- Dizziness Handicap Inventory is a 25-item self-assessment designed to evaluate ______-__________ handicap from dizziness. - It is on a 0-100 scale with _______ scores indicating higher perceived handicap. - What are the 3 subscales of questions?

Answer 49

- self-perceived - higher - physical, emotional, functional

Question 50

- What is the scoring for the Dizziness Handicap Inventory? | - What is the MCID?

Answer 50

- Mild = 0-30 - Moderate = 31-60 - Severe = 61-100 -MCID = 18