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| Pregunta | Respuesta |
| Most common vestibular disorder in the elderly? | Benign Paroxysmal Positional Vertigo |
| Label the following on a picture: | 1. endolymph 2. ampulla 3. cupula 4. cilia 5. crista ampullaris 6. axons of vestibular ganglion 7. otoliths 8. gelatinous layer 9. hair cells 10. macula |
| Resting output of the vestibular nerve is _______. | About 6o mV. |
| In an intact system, eye movement in VOR is a result of _______ in signal sent from vestbular nerve on each side. | Difference |
| Key subjective questions regarding onset of dizziness? | 1. sudden or insidious onset? 2. is it episodic? 3. how long does it last? 4. any association with postural/ head position changes? |
| What are the characteristics of vertigo? | 1. sensation of movement in the absence of stimuli 2. spinning, rocking, tilting |
| Specific follow-up questions regarding vertigo | 1. episodic? 2. duration? 3. changes with the head position? 4. nausea and vomiting? 5. constant- associated disequilibrium |
| Disequilibrium is the sense of unsteadiness or _______. It occurs mainly during ________ or _______ and gets better when _______ or ________. | Disequilibrium is the sense of unsteadiness or [imbalance]. It occurs mainly during [walking] or [standing] and gets better when [sitting] or [lying down]. |
| What are some key follow-up questions for disequilibrium? | 1. associated neurological symptoms 2. difficulty ambulating in the dark 3. other types of vestibular symptoms |
| What are some common symptoms of hypotension-related dizziness? | 1. presyncope 2. light-headedness 3. foggy head 4. spatial disorientation |
| What are some follow-up questions if patient has hypotention-related dizziness? | 1. associated heart disease 2. posture-related dizziness 3. palpitation 4. medication 5. anxiety 6. hyperventilation |
| Name some associated symptoms with vestibular problems. | Ear-related: tinnitus, hearing loss, phonophobia Eye-related: visual changes, aural fullness, photophobia Others: nausea, vomiting, headache 4Ds |
| Name the 4 Ds | Diplopia Dysarthria Dysphagia Dysmetria |
| What some special tests for vestibular disorders? | 1. MRI 2. CT 3. Audiometric exam |
| Rationale for MRI? | 1. Brain and internal auditory canals (with or without gadolinium) 2. Identification of infarction, tumor |
| Rationale for CT? | 1. Have a good visual of the temporal bones, brain, internal auditory canals 2. assist in identification of hemorrhage, infarction, tumor |
| What is auditormetric exam trying to differentiate? | 1. distinction between conductive or sensorineural loss 2. see if there is word distinction (ability to understand speech) |
| T/F: Unilateral hearing loss is a sign of aging. | F. Need further evaluation. |
| What is ENG/ VNG? | ENG: electronystagmography (electrodes around eye muscles) VNG: videonystagmography |
| Name the tests that can assess inner ear responses. | 1. vestibular evoked myogenic potentials (VEMP) 2. Spontaneous eye movement 3. position testing 4. visual tracking 5. vestibular testing (caloric or rotary chair testing) |
| Nystagmus is a (reflexive/voluntary) oscillation of the eyes. | Reflexive |
| The fast beat is in the direction of the ear with (increased/decreased) neural activity. | Increased. |
| T/F: Nystagmus at visual end range and during optokinetic stimulation is normal. | T. |
| T/F: Nystagmus suggests central dysfunction. | F. Can be either central or peripheral. |
| Direction fixed nystagmus is (peripheral/central) | Peripheral. (horizontal nystagmus) |
| If the lesion is peripheral, nystagmus (increases/decreases) with visual fixation. | Decreases. |
| If the patient has peripheral vestibular problem and is experiencing left-beating nystagmus, having him/her looking to the left will (increase/decrease) the nystagmus. | Increase. |
| General direction of nystagmus caused by central vestibular dysfunction: | direction-changing. pure vertical or pure torsional. |
| Nystagmus caused by peripheral vestibular dysfunction is (pure/mixed) in direction. | mixed pattern with torsion and vertically. |
| What are some non-vestibular causes of dizziness? | 1. multi-factorial 2. panic attack 3. anxiety 4. orthostatic hypotension 5. arrhythmia 6. diabetes 7. hypoglycemia 8. infection 9. medications |
| match the following with peripheral/ central vestibular dysfunctions. 1. BPPV 2. Cerebellar disorders 3. acoustic neuroma 4. tumors 5. Migraines 6. vestibular neuritis/ labrynthitis 7. MS 8. TBI/ Concussion 9. Meniere disease 10. TIA/ stroke 11. ototoxicity | Peripheral: BPPV, Meniere disease, vestibular neuritis/ labyrinthitis, ototoxicity, acoustic neuroma Central: TBI/ concussion, TIA/ stroke, cerebellar disorders, tumors, MS, migraines |
| What is the pathology of BPPV? | The crystals on saccule and utricle break off and interfere with endolymph signals. (when brain is stopped, crystals keep moving) |
| Other than idiopathic BPPV, what are some etiologies? | 1. post-traumatic 2. viral neurolabyrinthitis 3. vertebrobasilar ischemia 4. Meniere's |
| What are the two forms of BPPV? | 1. Canalithiasis 2. Cupulolithiasis |
| Mechanism of canalithiasis | Calcium carbonate crystals (otoliths) in canal |
| Mechanism of cupulolisthiasis | The otoliths are stuck on the cupula (sail-like membrane) |
| If BPPV lasts for <60sec, it is more likely ____________ while if it lasts more than 60 sec, it is more likely _________. | < 60 sec: canalithiasis > 60 sec: cupulolithiasis |
| Briefly describe the timeline of BPPV. | 1. sudden onset of vertigo with nystagmus upon positional changes 2. lasts seconds to minutes 3. episodic |
| If you suspect BPPV involving anterior and posterior canals, what test should you do? | Dix Hallpike |
| If you suspect BPPV involving horizontal/lateral canals, what test should you do? | Roll test |
| T/F: BPPV symptoms remain the same intensity with repeated testing. | F. The symptoms will likely fatigue. |
| BPPV is central or peripheral? | Peripheral |
| BPPV involves labyrinth or nerve? | Labyrinth |
| Age of population commonly affected by vestibular neuritis/ labyrinthitis | 30 - 60 |
| Women are usually affected by vestibular neuritis/ labyrinthitisin their _____s while men are usually affected in their ____s. | women 40s. Men 60s. |
| Possible causes of vestibular neuritis and labyrinthitis? | 1. viral infection of upper respiratory tract 2. viral infection of GI tract 3. Autoimmune 4. vascular 5. bacterial infection |
| T/F: neuritis and labyrinthitis are usually bilateral. | F. Unilateral. |
| How may the symptoms of unlateral vestibular dysfunction be exacerbated? | head movement due to inaccurate VOR. |
| Outline the general timeline of vestibular neuritis/ labyrinthitis. | 1. sudden onset of vertigo. may experience nausea/vomiting/nystagmus. 2. Lasts 1-3 days (think acute infection) 3. Vertigo decreases after 3 days, but dizziness and disequilibrium continue. 4. Symptoms will be improving, but still remain worse with quick movements. |
| T/F: There is no change in hearing due to vestibular neuritis/labyrinthitis. | F. May have sensory neural hearing loss. |
| How is VOR affected by neuritis/labyrinthitis? | unilateral VOR with a positive HIT test. (remains after 3 days) |
| Diagnostic test to confirm/rule out vestibular neuritis/ labyrinthitis: | VNG/ENG Reduced unilateral response to caloric stimulation. Ipsilateral hypo- or non-responsive. |
| Short-term treatment for vestibular neuritis. | Vestibular suppressants (to reduce symptoms. |
| Long-term treatment for neuritis/ labyrinthitis. | Vestibular rehabilitation (good prognosis). |
| Is vestibular neuritis/ labyrinthitis central or peripheral? | Peripheral. |
| T/F: Meniere's disease is usually inulateral. | F. Can be either unilateral or bilateral. |
| The onset of Meniere's disease is usually ____ years old. | 40 - 60 years old. |
| Pathogenesis fo Meniere's disease: | 1. trauma 2. infection 3. immunie-mediated 4. genetic predisposition |
| When patients have Meniere's disease, they are likely experiencing _________________, increased pressure and volume causing abdominal firing of hair cells. | malabsorption or endolympe. |
| Is Meniere's disease episodic? How long can it last? | Episodic. Lasts hours to days. |
| Is prognosis better for acute or chronic Meniere? | Acute. (higher risk of permanent damage to vestibular and cochlear organs. |
| What is the general timeline like for Meniere's Disease? | 1. sudden onset of vertigo (> 20min, <24 hours), tinnitus, fullness, hearing loss 2. lasts for minutes to hours 3. resolution of symptom followed by sudden again. 4. fluctuating and progressive 5. Eventual permanent hearing loss and disequilibrium. |
| Spectrum of hearing loss. | Low frequency |
| Diagnostic tests for Meniere's disease | Audiogram (low frequency hearing loss) VNG/ENG (loss of vestibular function) |
| Treatment options for Meniere's disease. | 1. diet (low sodium, alcohol, nicotine, caffeine) 2. Diuretics 3. Suppressive medications 4. Surgery (vestibular nerve section/ labyrinthectomy) 5. Gentamicin perfusion 6. Psychological support 7. Vestibular rehabilitation |
| What is the 3rd most common intracranial tumor? | Acoustic neuroma |
| Which part of the vestibular system is mostly affected by ototoxicity? | Hair cells in vestibular system |
| Which part of CN VIII is affected by acoustic neuroma? | Schwann cells |
| What are some common locations of tumors for acoustic neuroma? | 1. vestibular portion of CN VIII 2. Labyrinth 3. Brainstem 4. Cerebellum |
| T/F: Symptoms of acoustic neuroma is usually bilateral. | F. Usually inilateral. |
| General timeline of acoustic neuroma | 1. insidious onset 2. unilateral hearing loss, may have tinnitus 3. may experience dizziness, and/or disequilibrium 4. gradual worsening 5. central involvement if left untreated |
| Gold standard to dx acoustic neuroma | MRI with gadolinium of internal auditory canals |
| What are the top 3 medications that cause ototoxicity? | Gentamicin Tobramycin Vancomycin |
| Is ototoxicity usually unilateral or bilateral? | Bilateral. |
| T/F: HIT is positive in ototoxicity. | T. (bilaterally positive!) |
| What are some signature symptoms of ototoxicity? | 1. severe disequilibrium 2. oscillopsia 3. falls |
| Diagnostic test for ototoxicity: | ENG/VNG Rotary chair |
| T/F: Ototoxicity has a faster and better prognosis compared to unilateral vestibular hypofunction. | F. Slower and worse prognosis |
| T/F: With good PT, pt. with ototoxicity can regain previous balance. | F. (postural control will NEVER return to normal) |
| Which situations should your patient avoid if they are diagnosed with ototoxicity? | 1. low light situations 2. uneven terrain 3. fatigue |
| What are some possible reasons that may trigger central vestibular dysfunction? | 1. vestibular migraine 2. multiple sclerosis 3. TIA/stroke 4. TBI/ concussion 5. Vertebrobasilar ischemia 6. cerebellar disorders 7. tumors 8. drug intoxication |
| What is oscillopsia? | objects in visual field seem to be oscilating |
| What are some symptoms of central vestibular dysfunction? | 1. disequilibrium 2. nausea 3. lightheadedmess 4. headache 5. falls 6. oscillopsia 7. occasionally vertigo |
| What are some signs of central vestibular dysfunction? | 1. incoordination 2. ataxia 3. disequilibrium 4. abnormal convergence 4. nystagmus (vertical/directional changing) 5. impaired VOR cancellation 6. saccadic smooth pursuit 7. abnormal saccades 8. 4Ds (diplopia, dysphagia, dysarthria, dysmetria) |
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