16. History Vestibular Not Vestibular Sudden onset Gradual onset Spinning Ill defined symptoms Hearing loss Passing out Aural fullness Can’t ambulate Tinnitus Numbness/weakness
59. Nicole A. Walstein M.S., PA-C [email_address] ENTACC 80 West Welsh Pool Rd. Suite 103 Exton, PA 19341 (610) 363-2532
Editor's Notes
Get 5 volunteers to read the mini case studies, get a volunteer for PE
Flip lecture over!
8 th cranial nerve Guess DDx?
-How do you test for syphilis? -Glomus jugulare tumors are rare, slow-growing, hypervascular tumors that arise within the jugular foramen of the temporal bone. Otoscopic examination reveals a characteristic, pulsatile, reddish-blue tumor behind the tympanic membrane that is often the beginning of more extensive findings (ie, the tip of the iceberg). Audiologic examination reveals mixed conductive and sensorineural hearing loss. CT and MRI -Labyrinthine artery- The cochlea is an end organ in terms of its blood supply with no collaterals. It is supplied by the labyrinthine artery, a branch of AICA. Its tortuous course predisposes it to the effects of hyperviscocity. In addition, it is extremely sensitive to changes in blood supply. Thus, the time course of hearing loss correlates well with a vascular event such that an acute hearing loss is most likely caused by hemorrhage, thrombosis, embolism or hypotension.
Otospongiosis- early otosclerosis- is a disease of the bones of the middle ear. The ossicles become knit together into an immovable mass, and do not transmit sound as well as when they are more flexible. Osteopetrosis , literally "stone bone", also known as marble bone disease and Albers-Schonberg disease is an extremely rare inherited disorder whereby the bones harden, becoming denser , ??? We conclude that MDD is typically a prolonged rocking vertigo which usually is triggered by a sea-going voyage. MDD is almost exclusively found in Caucasian females. Most cases of MDD have onset in their 40's. Anticholinergic medications are typically ineffective. The cause of MDD remains uncertain. Mal de Debarquement (MDD) refers to prolonged sensations of movement that typically follow exposure to an ocean cruise.
B3-niacin-Palegra
Wallenburg lateral medullary syndrome- clinical manifestation resulting from occlusion of the posterior inferior cerebellar artery (PICA) or one of its branches or of the vertebral artery , in which the lateral part of the medulla oblongata infarcts, resulting in a typical pattern.
What is Usher syndrome???
Vestibulopathy- Any abnormality of the vestibular apparatus (recurrent or bilateral- can be caused by ototoxic drugs); inflammation of the vestibular nerve
For example, in a patient with syncope or presyncope, the cause of the sensation is probably cardiovascular and not inner ear. In contrast, in a patient with a sensation of spinning or whirling, the pathology probably involves the inner ear or vestibular nerve on one side, although insults to the cerebellum and brainstem may also produce true vertigo. Therefore, the cause in a patient with true vertigo cannot be assumed to be peripheral.) (This will help to pinpoint whether it is true vertigo {vestibular cause} or non vestibular {CNS, cardiovascular, or systemic}).
Dizziness- all encompassing term Dysequilibrium- a sense of poor coordination with erect posture or during purposeful movement; usually continuous (vertigo episodic) Imbalance- implies an orthopedic or neurologic problem Lightheadedness- sensation of unsteadiness and falling or the symptoms similar to those preceding syncope (usually non vestibular)
– How much is it affecting the patient’s ADL’s? Acute attack- patient is walking with help and/or holding onto a wall
Where is the headache? Fistula- leakage of perilymphatic fluid from the inner ear into the tympanic cavity via the round or oval window results from physical injury (blunt head trauma), extreme barotrauma (scuba diving), or vigorous valsalva maneuver (wt lifting). Tullio phenomenon
Trauma resulting in damage to an ear often manifests as unilateral hearing loss, which may be the cause of episodic vertigo even years later (posttraumatic hydrops). The most common cause fo vertigo from trauma is labyrinthine concussion. Basilar skull fx that traverse the inner ear usually result in severe vertigo lasting several days to a week and results in hearing loss in the affected ear. Cervical vertigo- results from closed head or whiplash injury, vertigo due to neck disorders (ex. aminoglycosides, antineoplastic drugs [cisplatin]) These medications can damage vestibular hair cells and typically lead to progressive ataxia and/or oscillopsia. When ototoxic patients describe vertigo, the condition almost always is related to head movement and is described as an uncomfortable sense of shifting or bobbing of viewed objects (oscillopsia). patients with agoraphobia may describe their symptoms as dizziness (psychogenic).
Diabetes (can cause visual and proprioceptive problems)
Tympanomastoidectomy???
Labyrinthine causes of vertigo usually are not inherited; however, rare exceptions (eg, Usher syndrome) are reported.] Some clinical researchers believe that Ménière disease may have a hereditary predilection. Usher syndrome is the most common cause of autosomal recessive syndromic SNHL. Usher syndrome results in both hearing and visual impairments, and it is the etiology in at least 50% of persons with deafness and blindness. Medications- BP meds common culprit; Can occur as a side effect to anticonvulsants (phenytoin), antibiotics (aminoglycosides, doxycycline, metronidazole), hypnotics (diazepam), analgesics (aspirin), and tranquilizing drugs or of alcohol
Balance involves the overlapping function of several systems, namely, the visual system, the proprioceptive system, and the vestibular system. Together, these systems maintain equilibrium. For patients whose symptoms are episodic, physical examination findings may be normal between episodes.
CNIII , IV, VI - Test the 6 cardinal positions, lid lag and accommodation. Check for nystagmus. Then test 4 visual fields by confrontation. Check for direct and consensual papillary response. Perform the funduscopic exam on each eye CN V - Cotton wisp to pts cornea on each eye. (absent reflex- acoustic neuroma)- unilateral. Then ask the pts to bite down and palpate the masseter and temporalis muscles CN VII (facial)- Ask the pt to close their eyes tightly and then attempt to open the eyelids. Ask the pt to smile, frown, puff out the cheeks, and raise the eyebrows Test hearing and discrimination by using a tuning fork and by whispering and asking the patient to repeat heard words.
Acute otitis media What is cholesteatoma? (Has nothing to do with cholesterol), CT of temporal bone
Important to characterized nystagmus as specifically as possible to make correct diagnosis
Postural control tests Romberg- This test detects abnormalities in younger patients
The Dix-Hallpike maneuver is one of the most important tests for patients who experience true vertigo.
Head-shake test- eyes “beat” toward the normal (or better performing) labyrinth Head thrust- normal –eyes remain fixed on the target; abnormal- the eyes make a compensatory movement after the head is stopped to reacquire the target
Fistula test- The direction of nystagmus depends on the site of the fistula Can also have pt bear down (valsalva) Fukuda test- Rotation of the patient may indicate a unilateral loss of vestibular tone
Oscillopsia is the result of bilateral vestibulopathy, which most commonly is observed in ototoxicity. Heel to shin test- Positive if poor coordination
VNG- videonystagmography Bithermic calorics- warm/cold air in ears- will cause dizziness Help differentiate between peripheral and central vertigo Performed by audiologist
Performed by audiologists ABR- screening test for retrocochlear pathology (ie. Aucoustic neuroma) VEMP- helps to diagnose Ménière’s disease, superior canal dehiscence, and vestibular schwannomas
Specific to your working differential diagnosis list- CT- more for conductive HL, MRI- more for SNHL CT temporal bones without contrast- superior canal dehiscience Blood test: thyroid, fasting glucose, CBC, electrolytes, FTA, Lyme
The goals of pharmacotherapy are to relieve vertigo, reduce morbidity, and prevent complications. Vestibular suppressants should be used for a few days at most because they delay the brain's natural compensatory mechanism for peripheral vertigo. Zofran ODT Vestibular rehab- good for anyone who is a falls risk; "balance rehabilitation”; helps with compensation; vertiginous individuals are provided with a series of tasks to perform that require them to use their eyes while their head is moving, and possibly when their body is also moving. Works for: BPPV, vestibular neuritis, acoustic neuroma, ototoxicity, Meniere’s, peri;ymphatic fistula, post traumatic vertigo, multifactorial dysequilibrium of the elderly, psychogenic vertigo, central vertigo, idiopathic
Most common
1 in 10 patients who present to the ER for vertigo get the correct referral. May have a residual sensation of disequilibrium between episodes. Medication is usually not helpful “ I turned over in bed.” Vibrator
A brief course of antiemetic and vestibular suppressants is usually needed in the acute phase, but should be withdrawn as soon as possible to facilitate the process of central vestibular compensation. Corticosteroids may improve long-term outcomes Vestibular suppressants- meclizine (antivert)
In labyrinthitis, there is an acute onset of continuous, usually severe vertigo lasting several days to a week, hearing loss, and tinnitus. During the recovery period, rapid head movements may bring on transient vertigo. Hearing may return to normal or remain permanently impaired in the involved ear. Vestibular suppressants- antivert (meclizine)
A precise cause cannot be established, two causes are syphilis and head trauma. All 4 symptoms not necessary for diagnosis. 1 or 2 symptoms may be present for months. Test for syphilis with FTA, because patients who have late tertiary syphilis can present with identical symptoms.
Endolymphatic hydrops (Meniere’s syndrome) results from distention of the endolymphatic compartment of the inner ear; the primary lesion appears to be in the endolymphatic sac, which filters and excretes endolymph.
Diuretic of choice- Dyazide (HCTZ and Triamterene) Vestibular suppressants- meclizine (antivert) If untreated, severe hearing loss and unilateral vestibular paresis are inevitable The role of surgical therapy, such as shunting the endolymphatic sac, is controversial. The literature demonstrates wide variation in the effectiveness, or lack thereof, of surgery.
Not all symptoms need to be present -Acoustic neuromas are intracranial, extra-axial tumors that arise from the Schwann cell sheath investing either the vestibular or cochlear nerve. Unilateral hearing loss is overwhelmingly the most common symptom present at the time of diagnosis and is generally the symptom that leads to diagnosis. Assume that any unilateral sensorineural hearing loss is caused by an acoustic neuroma until proven otherwise. Although tinnitus is most commonly a manifestation of hearing loss, a few individuals with acoustic tumors (around 10%) seek treatment for unilateral tinnitus without associated subjective hearing loss. Vertigo and disequilibrium are uncommon presenting symptoms among patients with acoustic tumors. Decrease in the corneal reflex generally occurs earlier and more commonly than objective facial hypoesthesia. MRI with gadolinium
MRI of a 26-year-old woman with progressive disequilibrium and bidirectional horizontal nystagmus shows the periventricular areas of demyelination that are characteristic of multiple sclerosis.
MRI of a 56-year-old woman with right cerebellar ischemia. Her history included brief episodes of vertigo and a sensation of turning to the right. The brief episodes were followed by prolonged episodes of vertigo, nausea and vomiting, and truncal ataxia.
MRI of a 48-year-old woman with progressive unsteadiness, projectile vomiting, and headache. She was referred for an evaluation of vertigo. Pathology proved the posterior fossa mass to be a medulloblastoma.
MRI of a 26-year-old woman with unsteadiness and vertical nystagmus. Arrow points to an Arnold-Chiari malformation. ??? -What is Arnold-Chiari malformation?
Hint: It only lasts for a few seconds and then dissipates. Answer: BPPV
Vestibular Neuritis Labyrinthitis- also be complaint of sudden onset unilateral hearing loss and tinnitus
