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DESCRIPTION
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A LOGICAL APPROACH TO THE DIZZY PATIENT
Dizziness and balance disorders center
www.susqneuro.com
Conditions
Vertigo– BPPV– Labyrinthitis– Other Conditions: MS, migraine, Meniere’s etc
Non-Vertigo– Gait Dysfunction (countless neurological oto, ortho conditions
Elderly:– PD, frontal lobe disease, neuropathy, multi-deficit, stroke
Post-Injury Psych
A philosopher in the vestibule
We move An unmoving earth is our base of operation If our base moves we have no hope of orientation:
hopelessly lost. Discomfort comes from shift in orientation. Need an absolute set of coordinates. Problem of shifting base. Developed from lateral line system in fish Which way is down??
Oscillopsia
Bilateral vestibular dysfunction Shows function of vestibular system When the world moves with your head it drives
you crazy We need a solid base of operations Result: “Visual Dependence” Foam Pad Romberg positive.
VESTIBULO-OCULAR REFLEX (VOR)
KEEP YOUR EYES ON THE PRIZE
Our world seems not to move thoughWe Do
Dizziness- Logical Approach -strategy for lecture Go into some basic principles applications and testing get into a few prominent diagnoses
DIZZINESS EIGHT MILLION PHYSICIAN VISITS/YR AVERAGE: 5 VISITS WITHOUT
RESOLUTION OF PROBLEM Dizziness affects 10% of adults over 40 LOSS OF LIVLIHOOD, FALLS INJURIES SYSTEMATIC APPROACH
DIZZINESS VERTIGO LIGHT-HEADEDNESS DYSEQUALIBRIUM GAIT DYSFUNCTION NEAR SYNCOPE ANXIETY
Dizziness: Pointed questions
Vertigo or Not? Standing or Seated? Isolated or ass’d with Other symptoms? Constant or paroxysmal? Caused by positional change?
DIZZINESS: A MULTIDIMENSIONAL
APPROACH AREAS OF EXPERTISE
– NEUROLOGIST– OTOLOGIST– REHAB SPECIALIST
2
COWS: Fast Phase of Nystagmus
Cold – Opposite Warm – Same Each vestibule tonically pushes eyes to opposite
side Cold inhibits, warm stimulates and ear Fast phase of nystagmus: cortical correction
Nystagmus
Pitch, Roll, Yaw
MODULAR VIEW OF VESTIBULAR SYSTEM
Vertigo or not?
=Nystagmus or no nystagmus
semicircularcanals
(movement)
utricle & saccule(gravity)
cochlea
(hearing)
Inner ear teleology
Utricle and Saccule – Gravity receptors– Which way is down??
Semicircular Canals - Planar angular accelerometers– What’s moving what is still??– Which Way is down??
Why Vertigo?? conditions
Converting accelerometer (semi-circular canals) into gravitometers – BPPV
Stimulating accelerometer: Meniere’s, labyrinthitis
“central” mechanism: hallucination in CNS – much less potent
Something stimulates accelerometer (SCC)
Vertigo DDx
BPPV Meniere’s Vestibular neuritis Bilateral vestibular Loss Post-traumatic vertigo (labyrinthine concussion) Perilymph fistula Migraine and epilepsy Cerebro-vascular Disease
Dizziness Battery
Orthostatics and both arms Hallpike Fukada Head Thrust Head Shake Romberg (conventional, tandem, foam pad) Fistula test
Benign Paroxysmal Positional Vertigo Recurrent One ear down position Positive Hallpike Transitory positional vertigo “Vertigo induced by postional change” Unique
BPPV History
Variable history: Many patients complain of waxing and waning dizziness, not always vertiginous and aren’t aware of episodic nature
Classic: In bed when turn, looking up, or down– Tie shoelace or put clothes on line
Remits and exacerbates
BPPV predispositions
Age Post vestibular neuritis Post trauma Ear infections
BPPV
Canalithiasis: By far majority. Set up eddy currents in fluid filled canal
Cupulolithiasis: otoliths adherent to walls
Posterior nystagmus are delayed by approximately 15 seconds (latency), peak in 20-30 seconds, and then decay, with complete resolution of symptoms.
Symptoms and reversed nystagmus may recur when the patient is brought to a sitting position.Nystagmus fatigues on repeated trials. Peripheral nystagmus is latent, paroxysmal, geotropic, reversible, and fatigable.
Horizontal canal BPPV nystagmus is purely horizontal and asymmetric, with its stronger component beating toward the diseased canal.
Anterior canal nystagmus is rotary, with its vertical component beating downward. The vertical component of benign paroxysmal positioning nystagmus (BPPN) is best observed by asking the patient to move the eyes away from the down-most (tested) ear.
BPPV Variants – Eye Movements
Posterior SCC: Canalith or cupulo – Torsional to side down and upbeat
Horizontal SCC: Canalith– Horizontal geotropic
Horizontal SCC: Cupulolithiasis– Horizontal ageotropic
Anterior SCC: Canalith or Cupulo:– Downbeat and torsional to side down
BPPV
Logroll maneuver for horiz canal
CANALITH REPOSITIONING (EPLEY)
Semont Maneuver
Brandt Daroff
Paroxysmal psychological Vertigo
Form of Panic Attack Sensory overload “Supermarket Syndrome” Complication of untreated BPPV + Anxiety Computation of position and movement Worst in Aisles and small spaces: comparator of near and
distant movement: Car +claustophobia?? Your life depends on it: Therefore intense fear “Phobic positional vertigo”
Vestibular Neuritis
Sudden Vertigo and vomiting Emergency room Extreme motion sensitivity: Pts lay like a rock. Kinetophobia Viral or ischemic
– Herpes simplex and other viruses. Bell’s palsy of the vestib n. Rarely recurs Look for other signs that may relate to VB system or
posterior fossa.
Vestibular neuritis, neuronitis or labyrinthitis No loss of hearing indicates inflammation of vestibular
nerve or scarpa’s ganglion (neuronitis)– Inferior vestib nerve goes to posterior canal– Superior nerve goes to utricle, sup, lat canal– Herpes virus?
Hearing loss: may be labyrinthitis Any pain or inflammation: ? Bacterial or other treatable
infection Can’t distinguish 100% from brainstem stroke
Vestibular Neuritis: Findings
Spontaneous horizontal or horizonto-rotatory nystagmus– You may have to block fixation to see it.
Fast phase away from the offending ear Veer to slow phase ENG suppressed on offending side 5% or so cases may be recurrent BPPV is frequent sequel
Meniere’s
Severe vertigo and vomiting Fluctuating Hearing Loss Fullness unilateral Tinnitus Endolymphatic Hydrops
Meniere’s
Vertigo + Vomiting last hours– Few disorders are paroxysmal in just this way
Patients need not have entire tetrad Most common: Severe vertigo, vomiting and
tinnitus A number of “Meniere-like” syndromes
– Previous insults to inner ear
Meniere’s treatment
Avoid Salt and Caffeine Diuretic Surgeries
– Gentamycin injection– Vestibular nerve section– Hearing sparing operations
Perilymph fistula
Dizziness with change in pressure Nose-blowing dizziness Sound sensitivity “Tullio Phenomenon” Dizziness with exertion Sensori-neural loss on audiogram
Perilymph Fistula
Breach of Round window Superior canal dehiscence Cholesteatoma Trauma Post-surgical esp fenestration for otosclerosis Scuba diving
Perilymph Fistula: breach of round window.
From Tim Hain
Fistula
Strain against closed glottis– Upbeat nystagmus CW for right ear CCW for left ear
Pull in thru closed nostrils– Downbeat nystagmus CW for left ear, CCW for right
ear OR do fistula test with bulb OR Test for Tullio phenonenon
Cholesteatoma
cholesteatoma
Hearing loss and loss of balance or vertigo Chronic infection or congenital Basically tumor in middle ear and petrous bone
3
INPUTS TO BALANCE
Construct Program. Elements:
Clinicians to Evaluate– PM&R, Neurology
Diagnosis Therapeutic Recommendations
– Gait Analysis
Treatment– Vestibular (habituation, exercise, Canalith)– Gait and Balance– Devices trial and recommendation
Vestibular Rehabilitation
Compensations– Avoidance (BPPV)– Substitution (Bilateral Vestibular Loss)– Plasticity (Vestibular Neuritis)– Massed practice to retune CNS and compensate– “habitutation”– Repositioning– Gait retraining
Vestibular Rehab
Habituation Canalith repositioning Balance Retraining Exercises and retraining Conditioning Compensation Strategies
– As in visual dependence Assistive devices Bracing Muscle strengthening
Vestibular Rehabilitation
VOR Stimulation Exercises Oculomotor Exercises Balance Exercises Gait exercise Obstacle course
www.emedicine.com/ent/topic666.htm#target1
Cawthorne-Cooksey Exercises In bed or sitting
– Eye movements -- at first slow, then quick up and down from side to side focusing on finger moving from 3 feet to 1 foot away from face
– Head movements at first slow, then quick, later with eyes closed bending forward and backward turning from side to side
Sitting
– Eye movements and head movements as above – Shoulder shrugging and circling – Bending forward and picking up objects from the ground
Standing
– Eye, head and shoulder movements as before – Changing form sitting to standing position with eyes open and shut – Throwing a small ball from hand to hand (above eye level) – Throwing a ball from hand to hand under knee – Changing from sitting to standing and turning around in between
Moving about (in class)
– Circle around center person who will throw a large ball and to whom it will be returned – Walk across room with eyes open and then closed – Walk up and down slope with eyes open and then closed – Walk up and down steps with eyes open and then closed – Any game involving stooping and stretching and aiming such as bowling and basketball
VESTIBULAR REHABILITATION
HABITUATION ADAPTATION OF OTHER SENSORY
SYSTEMS
Neurologic Syndromes
MS PD NPH Stroke Aging Multi-sensory Deficit
Normal Gait
Sitting Balance Leans or slides in chairSteady, safe= 0= 12. Arises Unable without helpAble, uses arms to helpAble without using arms= 0= 1= 23. Attempts to arise Unable without helpAble, requires > 1 attemptAble to rise, 1 attempt= 0= 1= 2
Tinetti
Tinetti (2) 4. Immediate standing balance (first 5 seconds) Unsteady (swaggers, moves feet, trunk sway) Steady but uses walker or other support Steady without walker or other support0,1,2 5. Standing Balance Unsteady Steady but wide stance (medial heels > 4 inches apart) and uses cane or other support Narrow stance without support0,1,2 6. Nudged (subject at max position with feet as close together as possible, examiner pushes lightly on subject’s sternum with palm of hand 3 times. Begins to fall Staggers, grabs, catches self Steady0,1,2
Tinetti (3)
7. Eyes closed (at maximum position #6) Unsteady Steady0,1 8. Turning 360 degrees Discontinuous steps Continuous steps Unsteady (grabs, swaggers) Steady0,1,2 9. Sitting Down Unsafe (misjudged distance, falls into chair) Uses arms or not a smooth motion Safe, smooth motion0,1,2
Tinetti Gait
10. Initiation of gait (immediately after told to “go”) Any hesitancy or multiple attempts to start No hesitancy0,1 11. Step length and height a. Right swing foot does not pass left stance foot with step b. Right foot passes left stance foot0,1 c. Right foot does not clear floor completely with step0,1 d. Right foot completely clears floor0,1 e. Left swing foot does not pass right stance foot with step0,1 f. Left foot passes right stance foot0.1 g. Left foot does not clear floor completely with Step0.1 h. Left foot completely clears floor 0.1
Tinetti Gait 2
12. Step Symmetry Right and left step length not equal (estimate) Right and left step appear equal0,1 13. Step Continuity Stopping or discontinuity between steps Steps appear continuous0,1,2 14. Path (estimated in relation to floor tiles, 12-inch diameter; observe excursion of 1 foot over about 10 feet of the course). Marked deviation Mild/moderate deviation or uses walking aid Straight without walking aid0,1,2 15. Trunk Marked sway or uses walking aid No sway but flexion of knees or back, or spreads arms out while walking No sway, no flexion, no use of arms, and no use of walking aid0,1,2 16. Walking Stance Heels apart Heels almost touching while walking0,1
Multiple Sclerosis
May present as typical peripheral vestibulpathy ? lesion at root entry zone
Multi-sensory deficit
Aging Loss of neurons in CNS
– degenerative– vascular
Arthritis Peripheral nerve dysfunction Vestibular dysfunction
Multi-sensory deficit
Physical therapy– falls prevention– muscle strengthening– trying out assistive devices– minimizing deficits
Acoustic Neuroma
Acoustic Neuroma
Unilateral Hearing Loss VII and V Unsteadiness rarely paroxysmal vertigo
Vertebrobasilar Insufficiency
Vertigo Diplopia Dysarthria Dysphagia Ataxia Sensory or Motor Loss Drop attack Most feared misdiagnosis in older vertiginous patient
Post-Traumatic Vertigo
BPPV Meniere’s “Cervical” vertigo Perilymph fistula Factitious (psychological) vertigo
Migraine Associated Vertigo
Headache Bickerstaff Vertigo occurs as aura or part of HA syndrome
Autoimmune Inner Ear Disease (AIED) Hearing Loss Vertigo Bilateral “meniere’s”
AIED
Anti HSP-70 Anti Raji Cell Sed, ANA, RF, C1Q, FTA, Lyme, Thyroids
Bilateral Vestibular Loss
Oscillopsia Visual Dependence Aminoglycosides Advanced Age + Chronic ear disease
Bilateral vestibular dysfunction
Advanced age Unsureness on feet. Symptomatic only when up Positive Romberg Foam Pad Romberg which diminishes
proprioception – hallmark Help by increasing proprioceptive feedback –
assistive device, practice.
MOTION SICKNESS
CHRONIC SENSITIVITY TO MOTION OTHER PERSON DRIVING DISCOMFORT WITH MOTION VESTIBULAR REHAB: HABITUATION
Mal de Debarquement
Persistence of perception of motion after a cruise Psychophysiological (?)
Bibliography
www.susqneuro.com– “Dizziness Explained”, “Benign Positional Vertigo”,
“Vertigo: A Logical Approach” www.thain.com. by Tim Hain, MD www.ivertigo.net by Todd Troost, MD www.onbalance.com: Posturography