vestibular disorders - herman kingmahermankingma.com › onewebmedia ›...
TRANSCRIPT
![Page 1: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/1.jpg)
vestibular disordersphysical examination
Permission of patients to show their videos for educational purposes
![Page 2: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/2.jpg)
“keep an eye on the eyes”
![Page 3: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/3.jpg)
goals
1. determining peripheral vestibular deficit:- head impulse test
- Dix-Hallpike and lateral roll
- head shake test
- other tests
2. differentiate peripheral vs. central vestibular:- stability eyes and gaze
- eye position, -movements and range
- saccades
- other tests
- (Romberg, etc.)
![Page 4: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/4.jpg)
RECOGNIZE FIRST, INTERPRETE LATER
PROBLEM CAN BE VERY SUBTLE
![Page 5: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/5.jpg)
physical examination:
peripheral vestibular
![Page 6: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/6.jpg)
goals
1. determining peripheral vestibular deficit:- head impulse test
- Dix-Hallpike and lateral roll
- head shake test
- other tests
2. differentiate peripheral vs. central vestibular:- stability eyes and gaze
- eye position, -movements and range
- saccades
- other tests
- (Romberg, etc.)
![Page 7: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/7.jpg)
head impulse test (HIT)
normal HIT:
![Page 8: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/8.jpg)
BE CAREFUL WITH NECK COMPLAINTS:
ROTATE INWARDS
![Page 9: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/9.jpg)
head impulse test (HIT)
the vestibulo-ocular reflex (VOR):
![Page 10: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/10.jpg)
head impulse test (HIT)
the vestibulo-ocular reflex (VOR):
![Page 11: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/11.jpg)
VOR
MVN
VI
III
head impulse test (HIT)
the vestibulo-ocular reflex (VOR):
![Page 12: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/12.jpg)
VOR
MVN
VI
III
head impulse test (HIT)
the vestibulo-ocular reflex (VOR):
![Page 13: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/13.jpg)
VOR
MVN
VI
III
head impulse test (HIT)
the vestibulo-ocular reflex (VOR):
![Page 14: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/14.jpg)
head impulse test (HIT)
the vestibulo-ocular reflex (VOR):
![Page 15: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/15.jpg)
head impulse test (HIT)
give instructions to the patient: look at my nose
![Page 16: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/16.jpg)
head impulse test (HIT)
HIT can be very clear sometimes:
![Page 17: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/17.jpg)
head impulse test (HIT)
Testing vertical canals:
LARP
RALP
![Page 18: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/18.jpg)
Head Impulse Test (HIT)
HIT Lateral canal after plugging:
![Page 19: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/19.jpg)
Head Impulse Test (HIT)
HIT Posterior canal right after plugging:
![Page 20: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/20.jpg)
Head Impulse Test (HIT)
HIT can “fool” the examiner:
![Page 21: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/21.jpg)
Head Impulse Test (HIT)
HIT can “fool” the examiner:
Normal Overt saccades Covert saccades
![Page 22: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/22.jpg)
Goals
1. Determining peripheral vestibular deficit:- Head impulse test
- Dix-Hallpike and lateral roll
- Head shake test
- Other tests
2. Differentiate peripheral vs. central vestibular:- Stability eyes and gaze
- Eye position, -movements and range
- Saccades
- Other tests
- (Romberg, etc.)
![Page 23: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/23.jpg)
Goals
1. Determining peripheral vestibular deficit:- Head impulse test
- Dix-Hallpike and lateral roll
- Head shake test
- Other tests
2. Differentiate peripheral vs. central vestibular:- Stability eyes and gaze
- Eye position, -movements and range
- Saccades
- Other tests
- (Romberg, etc.)
![Page 24: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/24.jpg)
BPPV
BPPV is systematically not recognized- Radiating rather than repositioning
Dizziness: >20% is BPPV- Always perform Dix-Hallpike: Often unexpected BPPV
- Combine with lateral roll (15%)
![Page 25: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/25.jpg)
BPPV
Use Frenzel or Video goggles (fixation suppression ↓)
![Page 26: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/26.jpg)
BPPV
Dix-Hallpike with BPPV AD:
![Page 27: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/27.jpg)
BPPV
Dix-Hallpike with BPPV AD:
![Page 28: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/28.jpg)
BPPV
Direction of the fast-phases of VOR:
![Page 29: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/29.jpg)
BPPV
Direction of the fast-phases of VOR:
Not the expected eye movements? reconsider diagnosis
![Page 30: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/30.jpg)
BPPV
Which canal?
![Page 31: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/31.jpg)
BPPV
Reconsider diagnosis?
![Page 32: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/32.jpg)
BPPV
Canalolithiasis Cupulolithiasis
Otoliths in long arm Otoliths near cupula / short arm
Longer latency Short latency
Exhaustible reaction Inexhaustible reaction
Often response to therapy Therapy more difficult
Supine position
![Page 33: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/33.jpg)
BPPV
BPPV horizontal canals: 2 types of nystagmus possible
- Eyes to the ground (geotropic): Canalolithiasis
- Eyes away from ground (apogeotropic): Cupulolithiasis
Strongest nystagmus points to affected labyrinth
![Page 34: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/34.jpg)
BPPV
BPPV horizontal canals: 2 types of nystagmus possible
- Eyes to the ground (geotropic): Canalolithiasis
- Eyes away from ground (apogeotropic): Cupulolithiasis
Strongest nystagmus points to affected labyrinth
![Page 35: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/35.jpg)
BPPV
2 Questions:
- Geo- or apogeotropic?
- Which side is affected?
Lateral roll to the left
Lateral roll to the right
![Page 36: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/36.jpg)
BPPV
Doubt about affected side lateral roll: Bown and lean
- Geotropic (Bow):
- Sitting patient bends head forewards 90º
- Nystagmus points to affected side
- Apogeotropic (Lean):
- Sitting patient bends head backwards 45º
- Nystagmus points to affected side
![Page 37: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/37.jpg)
Goals
1. Determining peripheral vestibular deficit:- Head impulse test
- Dix-Hallpike and lateral roll
- Head shake test
- Other tests
2. Differentiate peripheral vs. central vestibular:- Stability eyes and gaze
- Eye position, -movements and range
- Saccades
- Other tests
- (Romberg, etc.)
![Page 38: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/38.jpg)
Goals
1. Determining peripheral vestibular deficit:- Head impulse test
- Dix-Hallpike and lateral roll
- Head shake test
- Other tests
2. Differentiate peripheral vs. central vestibular:- Stability eyes and gaze
- Eye position, -movements and range
- Saccades
- Other tests
- (Romberg, etc.)
![Page 39: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/39.jpg)
Head Shake Test
Head shake test: Charging velocity storage (3Hz)
![Page 40: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/40.jpg)
Head Shake Test
Head shake test: Charging velocity storage (3Hz)
![Page 41: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/41.jpg)
Head Shake Test
Head shake test: Charging velocity storage (3Hz)
VOR
MVN
VI
III
![Page 42: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/42.jpg)
Head Shake Test
Head shake test: Charging velocity storage (3Hz)
VOR
MVN
VI
III
Velocity
storage
![Page 43: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/43.jpg)
Head Shake Test
Head shake test: Charging velocity storage (3Hz)
VOR
MVN
VI
III
Velocity
storage
![Page 44: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/44.jpg)
Head Shake Test
Head shake test: Charging velocity storage (3Hz)
VOR
MVN
VI
III
Velocity
storage
Velocity
storage
![Page 45: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/45.jpg)
Head Shake Test
Head shake test: Charging velocity storage (3Hz)
VOR
MVN
VI
III
Velocity
storage
Velocity
storage
![Page 46: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/46.jpg)
Head Shake Test
Head shake test: Charging velocity storage (3Hz)
VOR
MVN
VI
III
Velocity
storage
Velocity
storage
![Page 47: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/47.jpg)
Head Shake Test
Head shake test: Charging velocity storage (3Hz)
![Page 48: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/48.jpg)
Head Shake Test
Head shake test: Charging velocity storage (3Hz)
![Page 49: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/49.jpg)
Head Shake Test
Head shake test: Recovery nystagmus
VOR
MVN
VI
III
Velocity
storage
Velocity
storage
Adaptation
![Page 50: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/50.jpg)
Head Shake Test
Head shake test: Perverted nystagmus
VOR
MVN
VI
III
Velocity
storage
Velocity
storage
![Page 51: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/51.jpg)
Head Shake Test
Head shake test: Perverted nystagmus
![Page 52: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/52.jpg)
Head Shake Test
Head shake test: Perverted nystagmus
![Page 53: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/53.jpg)
Other: Provocational testing
Provocational testing:
- Tragal compression (Hennebert)
- Valsalva / Coughing
- Barany-drum / Politzer balloon
![Page 54: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/54.jpg)
Other: Provocational testing
Politzer balloon:
![Page 55: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/55.jpg)
Other: Provocational testing
Politzer balloon:
![Page 56: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/56.jpg)
Physical examination:
Differentiate peripheral vs. central
![Page 57: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/57.jpg)
Peripheral vs. Central
Why so many tests?
![Page 58: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/58.jpg)
Goals
1. Determining peripheral vestibular deficit:- Head impulse test
- Dix-Hallpike and lateral roll
- Head shake test
- Other tests
2. Differentiate peripheral vs. central vestibular:- Stability eyes and gaze
- Eye position, -movements and range
- Saccades
- Other tests
- (Romberg, etc.)
![Page 59: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/59.jpg)
Goals
1. Determining peripheral vestibular deficit:- Head impulse test
- Dix-Hallpike and lateral roll
- Head shake test
- Other tests
2. Differentiate peripheral vs. central vestibular:- Stability eyes and gaze
- Eye position, -movements and range
- Saccades
- Other tests
- (Romberg, etc.)
![Page 60: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/60.jpg)
Stability eyes and gaze
Stability eyes:
![Page 61: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/61.jpg)
Stability eyes and gaze
Abnormality can be very subtle:
![Page 62: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/62.jpg)
Stability eyes and gaze
Peripheral vestibular nystagmus: Alexander’s law
![Page 63: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/63.jpg)
Stability eyes and gaze
Peripheral vestibular nystagmus: Alexander’s law
Peripheral
Nystagmus suppressed by fixation
Nystagmus with mixed components
Nystagmus according to Alexander’s law
No gaze evoked nystagmus
![Page 64: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/64.jpg)
Stability eyes and gaze
2 types of nystagmus:
- Peripheral
- Central
Peripheral Central
Nystagmus suppressed by fixation No effect of fixation
Nystagmus with mixed components Purely vertical (e.g. downbeat) or horizontal
Nystagmus according to Alexander’s law Not according to Alexander’s law
No gaze evoked nystagmus Gaze evoked nystagmus
![Page 65: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/65.jpg)
Central nystagmus increases with fixation:
Stability eyes and gaze
Without fixation
With fixation
![Page 66: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/66.jpg)
Central nystagmus increases with fixation:
Stability eyes and gaze
Without fixation
With fixation
![Page 67: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/67.jpg)
Stability eyes and gaze
Some types of nystagmus:
1. Vestibular (peripheral and central):
2. Gaze evoked:
3. ….Other, e.g.:
![Page 68: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/68.jpg)
Stability eyes and gaze
Which nystagmus is not central?
A B
C D
![Page 69: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/69.jpg)
Stability eyes and gaze
Testing gaze + sidepockets (!)
![Page 70: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/70.jpg)
Stability eyes and gaze
Importance of sidepockets:
![Page 71: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/71.jpg)
Stability eyes and gaze
Watch out for physiological end-point nystagmus:
![Page 72: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/72.jpg)
Stability eyes and gaze
Some types of nystagmus:
1. Vestibular (peripheral and central):
2. Gaze evoked:
3. ….Other, e.g.:
![Page 73: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/73.jpg)
Stability eyes and gaze
Some types of nystagmus:
1. Vestibular (peripheral and central):
2. Gaze evoked:
3. ….Other, e.g.:
![Page 74: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/74.jpg)
Stability eyes and gaze
Gaze evoked nystagmus: Changes with direction of gaze
![Page 75: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/75.jpg)
Stability eyes and gaze
All-in one: Alexander’s law - Sidepockets
![Page 76: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/76.jpg)
Goals
1. Determining peripheral vestibular deficit:- Head impulse test
- Dix-Hallpike and lateral roll
- Head shake test
- Other tests
2. Differentiate peripheral vs. central vestibular:- Stability eyes and gaze
- Eye position, -movements and range
- Saccades
- Other tests
- (Romberg, etc.)
![Page 77: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/77.jpg)
Goals
1. Determining peripheral vestibular deficit:- Head impulse test
- Dix-Hallpike and lateral roll
- Head shake test
- Other tests
2. Differentiate peripheral vs. central vestibular:- Stability eyes and gaze
- Eye position, -movements and range
- Saccades
- Other tests
- (Romberg, etc.)
![Page 78: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/78.jpg)
Eye position, -movements, -range
Eye position:
![Page 79: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/79.jpg)
NOT EACH EYE CONDITION IS DIRECTLY VISIBLE
![Page 80: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/80.jpg)
Eye position, -movements, -range
Eye position: 2 types of abnormalities (hypo, hyper, eso, exo)
1. Tropia: misalignment always present
- Including cover- uncover test
2. Phoria: misalignment when synchronization is interrupted
- Cross-cover test
![Page 81: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/81.jpg)
Eye position, -movements, -range
Eye position: Tropia (www.opthobook.com)
1. In primary position: e.g. Hirschberg’s test
Exotropia OS Esotropia OD
Hypertropia OS Hypotropia OS
![Page 82: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/82.jpg)
Eye position, -movements, -range
Eye position: Tropia (www.opthobook.com)
2. With gaze: make a “box”
Exotropia OS Esotropia OD
Hypertropia OS Hypotropia OS
![Page 83: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/83.jpg)
Eye position, -movements, -range
Subtle tropia: Cover-uncover test
![Page 84: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/84.jpg)
Eye position, -movements, -range
Eye position: Tropia (www.ophthobook.com)
3. More subtle: Cover-uncover test
Exotropia OS
![Page 85: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/85.jpg)
Eye position, -movements, -range
Eye position: Tropia (www.ophthobook.com)
3. More subtle: Cover-uncover test
Practice 1
![Page 86: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/86.jpg)
Eye position, -movements, -range
Eye position: Tropia (www.ophthobook.com)
3. More subtle: Cover-uncover test
Practice 2
![Page 87: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/87.jpg)
Eye position, -movements, -range
Eye position: Tropia (www.ophthobook.com)
3. More subtle: Cover-uncover test
Practice 3
![Page 88: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/88.jpg)
Eye position, -movements, -range
When phoria: Cross-cover test
![Page 89: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/89.jpg)
Eye position, -movements, -range
Eye position: Phoria (www.ophthobook.com)
Only evident when interrupting synchronization: Cross-cover
Exophoria
![Page 90: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/90.jpg)
Eye position, -movements, -range
Eye position: Phoria (www.ophthobook.com)
Only evident when interrupting synchronization: Cross-cover
Practice
![Page 91: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/91.jpg)
AND NOW MORE DIFFICULT…
![Page 92: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/92.jpg)
Eye position, -movements, -range
Normal eye position:
![Page 93: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/93.jpg)
Eye position, -movements, -range
Earth verticalNormal eye position:
![Page 94: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/94.jpg)
Eye position, -movements, -range
Disorder utriculus pathway:
“New” vertical
![Page 95: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/95.jpg)
Eye position, -movements, -range
Disorder utriculus pathway:
“New” vertical
![Page 96: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/96.jpg)
Eye position, -movements, -range
Skew deviation and ocular tilt reaction:
![Page 97: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/97.jpg)
Eye position, -movements, -range
Skew deviation and ocular tilt reaction:
![Page 98: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/98.jpg)
Eye position, -movements, -range
Testing eye movements (smooth pursuit):
![Page 99: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/99.jpg)
Eye position, -movements, -range
Testing eye movements (smooth pursuit):
MVN
VI
III
NPH
Cerebellum
![Page 100: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/100.jpg)
Eye position, -movements, -range
Testing eye movements (smooth pursuit):
![Page 101: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/101.jpg)
Eye position, -movements, -range
Testing eye movements (smooth pursuit):
![Page 102: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/102.jpg)
Goals
1. Determining peripheral vestibular deficit:- Head impulse test
- Dix-Hallpike and lateral roll
- Head shake test
- Other tests
2. Differentiate peripheral vs. central vestibular:- Stability eyes and gaze
- Eye position, -movements and range
- Saccades
- Other tests
- (Romberg, etc.)
![Page 103: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/103.jpg)
Goals
1. Determining peripheral vestibular deficit:- Head impulse test
- Dix-Hallpike and lateral roll
- Head shake test
- Other tests
2. Differentiate peripheral vs. central vestibular:- Stability eyes and gaze
- Eye position, -movements and range
- Saccades
- Other tests
- (Romberg, etc.)
![Page 104: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/104.jpg)
Saccades
Testing saccades:
NPH
Cerebellum- Vermis
- Fastigial nucleus
VI
III riMLF
PPRF RIP Pons
Midbrain+
+
-
-
Motor Burst Omnipause
![Page 105: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/105.jpg)
Saccades
Testing saccades: Close and wide
NPH
![Page 106: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/106.jpg)
Saccades
Testing saccades: Close and wide
NPH
![Page 107: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/107.jpg)
Saccades
Testing saccades:
NPH
![Page 108: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/108.jpg)
Saccades
Testing saccades:
NPH
![Page 109: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/109.jpg)
Saccades
Testing saccades:
NPH
![Page 110: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/110.jpg)
Saccades
Testing saccades:
NPH
Hypermetria
![Page 111: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/111.jpg)
Saccades
Testing saccades:
NPH
![Page 112: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/112.jpg)
Saccades
Testing saccades:
NPH
![Page 113: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/113.jpg)
Saccades
Testing saccades:
NPH
![Page 114: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/114.jpg)
Saccades
Testing saccades:
NPH
![Page 115: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/115.jpg)
Saccades
Testing saccades:
NPH
![Page 116: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/116.jpg)
Saccades
Testing saccades:
NPH
Hypometria
![Page 117: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/117.jpg)
Saccades
Testing saccades:
NPH
![Page 118: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/118.jpg)
Saccades
Testing saccades:
NPH
![Page 119: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/119.jpg)
Saccades
Testing saccades:
NPH
![Page 120: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/120.jpg)
Saccades
Testing saccades:
NPH
Slowing
![Page 121: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/121.jpg)
Other tests
Hyperventilation test:
NPH
Demyelinization nerve: Vestibular schwannoma, microvascular
Demyelinization central: MS
Canalopathy: FHM, SCA-6, EA-2, epilepsia
Other: Migraine, post-neuritis, fistula, craniocervical
![Page 122: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/122.jpg)
Other tests
Hyperventilation test:
NPH
Demyelinization nerve: Vestibular schwannoma, microvascular
Demyelinization central: MS
Canalopathy: FHM, SCA-6, EA-2, epilepsia
Other: Migraine, post-neuritis, fistula, craniocervical
![Page 123: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/123.jpg)
Other tests
Hyperventilation test:
NPH
Demyelinization nerve: Vestibular schwannoma, microvascular
Demyelinization central: MS
Canalopathy: FHM, SCA-6, EA-2, epilepsia
Other: Migraine, post-neuritis, fistula, craniocervical
![Page 124: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/124.jpg)
Other tests
Hyperventilation test:
Positional testing: Eye movements not always BPPV!
NPH
Demyelinization nerve: Vestibular schwannoma, microvascular
Demyelinization central: MS
Canalopathy: FHM, SCA-6, EA-2, epilepsia
Other: Migraine, post-neuritis, fistula, craniocervical
Peripheral: Cupulolithiasis, SCDS, fistula, Meniere’s
Central: MS, cerebellair tumor/infarction/hematoma, ischemiabrainstem, migraine, whiplash/head trauma, alcohol
![Page 125: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/125.jpg)
Other tests
Positional nystagmus cerebellar tumor:
NPH
![Page 126: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/126.jpg)
Other tests
Testing fixation suppression:
NPH
![Page 127: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/127.jpg)
Other tests
Testing fixation suppression:
NPH
![Page 128: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/128.jpg)
Other tests
Testing fixation suppression:
NPH
![Page 129: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/129.jpg)
Other tests
Testing fixation suppression:
NPH
![Page 130: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/130.jpg)
The acute problem!
What to do?
![Page 131: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/131.jpg)
Differential diagnosisTiming Trigger Diagnosis benign Diagnosis dangerous
Episodic Trigger BPPV
Orthostatic
CPPV/Tumor
Internal bleeding
Vascular stenosis
Vertebral artery
Spontaneous Meniere’s
Migraine
SCDS
Paroxysmia
Vasovagal
Panic
Arrhythmia/MI
TIA
Pulmonary embolus
Hypoglycemia
Acute Postexposure Perilymphatic fistula Skull base fracture
Vertebral dissection
Drugs (genta, AED)
Carbon monoxide, etc.
Spontaneous Neuritis
Labyrinthitis
CVA/Vertebral
Wernicke’s/encephalitis
..Other internal/neuro
Chronic Context e.g. Vestibular hypofunction
Spontaneous e.g. Cerebellar degeneration
![Page 132: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/132.jpg)
Differential diagnosisTiming Trigger Diagnosis benign Diagnosis dangerous
Episodic Trigger BPPV
Orthostatic
CPPV/Tumor
Internal bleeding
Vascular stenosis
Vertebral artery
Spontaneous Meniere’s
Migraine
SCDS
Paroxysmia
Vasovagal
Panic
Arrhythmia/MI
TIA
Pulmonary embolus
Hypoglycemia
Acute Postexposure Perilymphatic fistula Skull base fracture
Vertebral dissection
Drugs (genta, AED)
Carbon monoxide, etc.
Spontaneous Neuritis
Labyrinthitis
CVA/Vertebral
Wernicke’s/encephalitis
..Other internal/neuro
Chronic Context e.g. Vestibular hypofunction
Spontaneous e.g. Cerebellar degeneration
![Page 133: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/133.jpg)
Central or peripheral?: HINTS
HINTS:
- Head Impulse
- Nystagmus
- Test Skew deviation
NPH
+ +
![Page 134: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/134.jpg)
Central or peripheral?: HINTS
HINTS:
- Head Impulse
- Nystagmus
- Test Skew deviation
Importance:
- Acute phase: HINTS more sensitive than MRI (88%)
NPH
+ +
![Page 135: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/135.jpg)
Central or peripheral?: HINTS
HINTS: Head impulse test
NPH
![Page 136: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/136.jpg)
Central or peripheral?: HINTS
HINTS: Nystagmus
NPH
![Page 137: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/137.jpg)
Central or peripheral?: HINTS
HINTS: Testing Skew deviation
NPH
![Page 138: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/138.jpg)
Central or peripheral?: HINTS
HINTS: Testing Skew deviation
NPH
CENTRAL OR PERIPHERAL?
![Page 139: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/139.jpg)
Central or peripheral?: HINTS
HINTS: Peripheral nystagmus
NPH
![Page 140: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/140.jpg)
Conclusions
![Page 141: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/141.jpg)
Conclusions
1. Collect as much information as possible• Central tests
• Peripheral tests
2. Keep an eye on the eyes: often subtle abnormalities- Other neurological examination can be normal
3. Acute problem: HINTS
![Page 142: vestibular disorders - Herman Kingmahermankingma.com › onewebmedia › 8ClinicalExamination2.pdf · vestibular disorders physical examination Permission of patients to show their](https://reader033.vdocument.in/reader033/viewer/2022042402/5f11ac9aae4ad24545420321/html5/thumbnails/142.jpg)
Questions