Neuro 12 - Vestibular

11

100

- Past medical history
- Past surgical history -
- Setting 

Impact of other factors 

200

- Fixation REDUCES nystagmus
- Direction is FIXED; MIXED HORIZONTAL OR TORSIONAL
- Nystagmus INCREASES with gaze directed towards FAST phase
- Unidirectional
- Tinnitus or deafness may occur 

Peripheral nystagmus *** 

300

- Observation
- Smooth pursuits
- Saccades
- Gaze holding 

Action: screening 

400

- Dizziness in an established CNS or PNS dysfunction
- Dizziness of unknown origin: screen CNS/PNS
- Positional dizziness: think peripheral vertigo
- Cervicogenic dizziness/MSK sign
- Disuse deconditioning 

Dizziness and giddiness (referrals) 

500

- Nystagmus lasts, oscillopsia and imbalance
- TIA/stroke, cerebellar degeneration, Arnold Chiari, MS, TBI, concussion 

Central vestibular disorders 

12

100

Illusion of movement, false sense of rotation or linear movement 

Vertigo 

200

- Any of the 5 D's
- Pure upbeat or pure torsional nystagmus
- True impairment in smooth pursuit or saccades without known CNS dysfunction 

Red flags -- Refer, do not treat ***

300

Sensation of being off balance, not observable 

Disequilibrium 

400

- Fixation ENHANCES nystagmus (or unchanged)
- Direction is PURE VERTICAL OR TORSIONAL
- Nystagmus may change direction with gaze
- Unidirectional or multidirectional 

Central nystagmus 

500

- No definitive test, eval upper quarter if no apparent neurological or otologic causes for the symptoms
- Address impaired cervical kinesthesia along with MSK impairments
- The cervical spine plays a role in gaze stability and postural control, focus on pain reduction and restoration of cervical mobility (not largely on VRT), most dont complain of vertigo but of imbalance/lightheadedness/disequalibrium
- Cervical ROM, pain
   - Limit positional testing
   - Impact VOR movement "head thrust"
   - Fear avoidance behaviors
   - Clear VBI 

Cervicogenic dizziness 

13

100

- Abnormal smooth pursuit or saccades
- Pure upbeat or torsional nystagmus
- 5Ds

Interpretation: findings 

200

Unsteadiness, observable 

Imbalance 

300

- CNS or PNS
- Unknown CNS 

Decision: Treat or Refer 

400

- Vestibular neuritis
- Anterior vestibular artery ischemia
- Labyrinthitis 

Unilateral hypofunction (stable) 

500

- Dilated (swollen) labyrinth
- Progressive hearing loss
- Tinnitus
- Imbalance
- Fullness
- Auditory symptoms (hearing loss)
- Spontaneous not positional vertigo (but can have secondary BPPV)
- Difficult to diagnosis; drop attacks in late stages

Meniere's disease 

14

100

Moving objects in the environment, subjective 

Oscillopsia 

200

- Hypofunction
- Concussion
- Stroke, MS (CNS disorder) 

Vestibular rehab (referrals) 

300

Fainting feeling 

Lightheadedness/presyncope 

400

- Event lasts DAYS then compensation occurs
- Unilateral hypofunction: stable: weak VOR. This is what we treat!
   - Vestibular neuritis
   - Anterior vestibular artery ischemia
   - Labyrinthitis
- Unilateral hypofunction: unstable
   - Menieres disease
   - Acoustic neuroma
   - Superior canal dehiscence (SCD)
   - Research shows PT is not effective in unstable, fluctuating conditions 

Peripheral vestibular disorders 

500

- Deconditioning with fear of falling
- Functional effects of aging nervous system = skeletal mm atrophy, less precise control of movement, decreased sensitivity of somatosensory system, processing speeds slow
- Can be age-related 

Disuse disequilibrium 

15

100

- Menieres disease
- Acoustic neuroma
- Superior canal dehiscence 

Unilateral hypofunction (unstable) 

200

Diaphoresis, emesis 

Autonomic signs 

300

Which virus usually causes/sparks neuritis? 

Herpes simplex II 

400

- Ototoxicity, meningitis, sequential vestibular neuritis, progressive disorders, autoimmune disorders, CIDP, congenital loss, and neurofibromatosis
- Most commonly idiopathic (underlying cause not known)
- Treatment: challenging, compensation for lost vestibular function 

Bilateral hypofunction -- peripheral vestibular disorders 

500

Symptoms are vague and vestibular tests normal, can be frustrating as a clinician
- Vestibular migraine
- Cervicogenic dizziness
- Disuse disequalibrium (deconditioning)
- Cardiac
- Psychological
- Chronic subjective dizziness
- Medication induced dizziness
- Persistent postural perceptual dizziness
- Visual vertigo 

Non-otogenic dizziness