Vestibular Disorders

Benign Paroxysmal Positional Vertigo (BPPV)

  • Symptoms:
    • Feeling that you are spinning or moving
    • Usually takes about 5 seconds for symptoms to manifest (symptom delay)
    • Last for 30 seconds to 2 minutes
  • Theories for the cause:
    • Otoconia get dislodged from the Vestibules and travel into the ampulla and semicircular canals
    • Cupulolithiasis – otoconia adherent to the cupula of the affected semicircular canal causing the cupula to be weighted down.  Usually lasts for minutes.  Would not be if a patient has symptoms for a couple seconds
    • Canalithiasis – free floating otoconia within the semicircular canal results in abnormal endolymphatic flow with affected canal and lasts from 3-5 seconds and nystagmus will last for 5-45 seconds.  Anterior canal BPPV is very rare to nonexistent
    • This is common in people with osteoporosis and osteopenia as they will affect the calcium deposits in the inner ear
  • Causes:
    • Being in a position for a long period of time as things get settled such as the ear that they sleep down with
    • A fall, motor vehicle accident, or quick movement of the body and head
  • Prevalence in 10% of the population of geriatric patients 
  • Assessment
    • Can use Hallpike-Dix, or right side lying for anterior and posterior canals and the roll test for horizontal canals
      • Posterior canal BPPV canalithiasis – torsion ipsilateral to the ear down and upbeat
      • Horizontal canal BPPV canalithiasis – horizontal geotropic toward the ground
      • Horizontal canal bppv cupulothiasis – horizontal ageotropic away from the ground
    • Can also use Sidelying test and Roll Test
  • Treatment
    •  Eply maneuver
    • Modified Gufonis maneuver – horizontal maneuver to the opposite side of the problem and hold for 2 minutes

Unilateral vestibular disorders (fixed) – better outcome than unstable

  • Vestibular neuritis – 2nd or 3rd most common vestibular disorder
    • May be viral insult such as having a respiratory or GI infection or reactivation of Herpes virus (usually the superior nerve is the problem)
    • No auditory symptoms
    • Insidious onset
    • Nystagmus always beats to the unaffected side
    • HINTS = Head Impulse Test is normal (labyrinth good), Nystagmus (unpredictable and spontaneous), and Test for Skew
      • Skew is the eye opposite lesion is elevated
    • Symptoms usually last a couple days to a week then will have a feeling of unsteadiness and oscillopsia
    • Prednisone helps in most cases
    • Prognosis is excellent and physical therapy will be used to help with central nervous system adaptation
  • Anterior vestibular artery ischemia
    • Vascular risk problems and diagnosed from exclusion
    • Spontaneous onset of vertigo typically for days with nausea and vomiting and imbalance
    • No associated auditory symptoms
    • Treat with vestibular compensation and excellent prognosis
    • May have to treat like a stroke and see if they have atrial fibrillation
  • Labyrinthitis
    • Infection to labyrinth
    • Spontaneous onset of vertigo for days with nausea/vomiting, imbalance, and auditory symptoms such as hearing loss and ringing in ears
    • Antibiotics or steroids if bacterial or viral
    • Prognosis is good and work on vestibular compensation
    • Hearing test to diagnose to see if there is a difference
      • Weber or Rinne Tests
    • Can also diagnose with caloric testing

Unilateral Vestibular Disorders (fluctuant/unstable)

  • Meniere’s Disease – 2 or more episodes of spontaneous vertigo of at least 20 minutes to 24 hours
    • Audiometrically documented hearing loss
    • Tinnitus or aural fullness/pressure
    • Exclusion of other causes
    • Positive Fukuda Step test = >30 degrees turn
    • Unknown cause and duration can last for up to about 7 years
    • Diagnose with audiogram with low frequency hearing loss
    • Can have episodes of drop attacks and are conscious on the way to the floor as opposed to fainting and usually last only seconds
    • Treated with vestibular suppressants, limit sodium/salt in diet, diuretic, steroids or finally surgical ablation (if they are going to lose their hearing then might as well get the ablation so no vertigo or attacks)
    • Rehab will work on fluctuant imbalances
  • Acoustic neuroma (vestibular schwannoma)
    • Tumor on vestibular nerve most commonly on the inferior than superior nerve
    • Symptoms of progressive sensorineural hearing loss, tinnitus, and imbalance
      • More common are hearing loss and tinnitus
      • Rarely with facial paralysis due to tumor pressing on facial nerve
    • Vertigo attacks are not common
    • Diagnosed with MRI with enhancement
    • Hyperventilation for 40 seconds and watch for eye movements to see if nystagmus kicks in
    • After surgery then a candidate for rehab but if not resected then not a candidate for rehab
  • Superior Canal Dehiscence
    • Opened bone over superior portion of the anterior canal
    • Abnormal communication of the anterior/superior canal and brain
    • Onset from Trauma 
      • Head trauma
      • Barotrauma due to pressure changes
      • Mastoid and stapes surgery
      • Penetration of tympanic membrane
      • Vigorous straining
      • Will usually experience a pop in the ear after the event
      • May be from sneezing, coughing, blowing nose, straining
    • Congenital defect that can worsen with age
      • Pressure sensitivity with sneezing, coughing, Valsalva, lifting and bowel movement will cause dizziness
      • Imbalance (exertional imbalance) sound sensitivity
        • Internal with heel strike, eye movement, heart beat (people tend to be soft talkers because of the sound they create when talking)
        • External phone ring, music
    • Tests
      • Bone conduction is better than air conduction stimuli
      • Tulios phenomena – torsional nystagmus with a high tone
      • Valsalva – nystagmus evoked with bearing down
      • Bone conduction velocity – tuning fork and can hear it in their affected ear
    • Treatment
      • Rehab will not help and refer to medical doctor
      • Can live with it or pursue surgery
      • Bed rest for 5-10 days
      • Medication for sedation
      • Avoid straining
      • Surgery warranted if hearing loss worsens or symptoms last longer than 4 weeks

Bilateral Disorders – caused by ototoxic agents and common with renal impairment and complaints of oscillopsia and imbalance; on gentamycin/-mycin if in the hospital for awhile

  • Oscillopsia – head thrust test positive bilaterally for eyes moving with head instead of being able to right their eyes; will also see this with caloric stimulation causing weakness
  • Bilateral disorders will not have significant vertigo because it is bilateral
  • No medications for bilateral loss
  • Rehab will improve postural control and gaze stability with predictable head movements

Central Vestibular Disorders

  • Transient Ischemic Attack (TIA) of the posterior circulation
    • Vertigo with vertebrobasilar insufficiency
    • Double vision and visual field defects
    • hypertension, smoking, diabetes, hyperlipidemia
    • Duration tends to be minutes
    • Vertebral Artery Compression Test
      • Supine with the neck extended and rotated near end range and positive with signs of TIA
      • Very poor test
  • Cerebral Vascular Accident (CVA)
    • Brainstem strokes and cerebellum strokes
    • Headaches, nausea, inability to walk, vertigo
    • Spontaneous nystagmus without provocation causes torsional nystagmus
      • Can be seen with just maintaining eye movement either right or left
      • Gaze causes not head movements
    • Ocular lateral pulsion
      • Close eyes and they drift to the side when they are opened and they have to right their eyes again
  • Cerebellar degenerative disorders
    • Alcohol induced – cerebellar atrophy
    • Spino-cerebellar ataxias
    • Paraneoplastic from remote cancers
  • Arnold-Chiari malformation
    • Cerebellar tonsils are protruding through the foramen magnum
    • Symptoms include HA, imbalance, aural fullness, tinnitus, vertigo
    • Symptoms of the cerebellum
    • Tests
      • Cerebellar dysfunctional is pure vertical nystagmus which will not occur with other disorders
      • Rebound nystagmus – nystagmus with looking to the side and then return to central will have a rebound of nystagmus
  • Multiple Sclerosis
    • Complaints of vertigo, imbalance, in 30-40 years old
    • Eye movement dysfunctional
    • Affects brain related eye movements – eyes do not move together with saccades and will not have smooth pursuit
  • Traumatic Brain Injury (TBI)
    • Concussion – Increase in motion hypersensitivity, sensitivity to sound, HA, nausea
    • BPPV
    • Temporal bone fracture – loss of hearing can occur due to the fracture which will include compensation training
    • Increase in migraines
    • Superior canal dehiscence

References:

Herdman SJ, Clendaniel R. (2014). Vestibular Rehabilitation. F.A. Davis

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