1- vestibular disorders 1-13-16

7/25/2019 1- Vestibular Disorders 1-13-16

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Vestibular Disorders

Chad Lairamore, PT, PhD

Physical TherapyUniversity of Central Arkansas


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Incidence Dizziness

5.5% or 15 million peopleyear

!ne of most common complaints todoctors "ith increasin# a#e

$ain reason to see $D for those 5 andover

&% of those "ith initial complaints have

no resol'tion in ( "eeks )*% "ith persistent dizzinessreport

rec'rrent symptoms +eyond * months


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Pro+lems in "hich of the follo"in# areas"o'ld !T ca'se verti#o and di--iness

A. Peripheral vesti+'lar system

/. Central vesti+'lar system

C. Cere+ell'mD. 0nner ear

E. Lower extremity peripheral

nervous system


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Anatomy of the ear

!'ter ar Pinna

Tra#'s

2ternal A'ditory Canal 3meat's4

Tympanic mem+rane

'nction6 Collect 7 direct so'nd "aves


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!'ter ar Patholo#ies

Perforated eardr'm

Ca'ses6 2plosions, tra'ma,ac'te middle ear infections

Can +e s'r#ically corrected


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$iddle ar

Components6

A'ditory !ssicles6 $alle's, 0nc's, 8tapes

Tensor tympani 7 8tapedi's m'scles.

'stachian t'+e

'nction6 Comm'nicates so'nd "aves viavi+ration to inner ear

Patholo#ies6 $iddle ear infections

The middle ear is dry, 'stachian t'+e drainsanythin# o't of the middle ear


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0nner ar

/ony 7 $em+rano's La+yrinth6 Utricle, 8acc'le, 8emicirc'lar canals,

cochlea

9o'nd and oval "indo"s Areas "here the tiss'e is thinner, can +e

r'pt'red easily, "hich "ill ca'se symptoms.

Perilymph 3s'rro'nds semicirc'larcanal4, ndolymph 3:'id inside Utricle,

8acc'le, semic'rc'lar canals4

'nction6 Sensory info forequilibrium and hearin


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0nner ar Patholo#ies

/eni#n Paro2ysmal Positional ;erti#o3/PP;4

La+yrithitis

$eniere


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Anatomy of Central ;esti+'lar

8ystem

Central ;esti+'lar 8ystem Areas "ithin the +rain that comm'nicate "ith and

inte#rate vesti+'lar information.

/rain stem

Controls vesti+'lar re:e2es ;esti+'lar corte2, Thalam's, 9etic'lar ormation

Aro'sal

A"areness of the +ody

Discrimination +et"een movement of environment vs. self

Cere+ell'm

!aintain vestibulo"ocular re#ex $V%&'

Post're

Coordination


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Central ;esti+'lar 8ystem

2tensive connections +et"een vesti+'lar n'clei andretic'lar formation, thalam's and cere+ell'm

;esti+'lar system contri+'tes to aro'sal, conscio'sa"areness of +ody, a+ility to discriminate +et"eenmovement of self and environment.

=hat happens if a pt does not o+tain an 'pri#htpositionThink a+o't retic'lar formation.

!rthostatic hypertension can happen.

Pts. =ill +e "oo-y #ettin# 'p +'t is not al"ays related toorthostatic hypertension.


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Central ;esti+'lar Cont.

Cere+ellar connections

(elp maintain calibration of Vestibulo"%cular &e#ex

Contri+'te to post're in static and dynamic

0n:'ence coordination of lim+ movement

;esti+'lo>!c'lar 9e:e2 3;!94

$aintains sta+ility of an ima#e on thefovea of the retina d'rin# rapid head

movements 9apid movement of the eye opposite the

direction of head movement

video
http://www.youtube.com/watch?v=j_R0LcPnZ_whttp://www.youtube.com/watch?v=j_R0LcPnZ_w


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Patholo#y

Central system

/rainstem infarctiono 8ymptoms6 Transient cl'msiness, =eakness, Loss

of vision, Diplopia, Drop attacks, Dysarthria

Cere+ellar infarctiono A0CA

$ay ca'se verti#o, also associated "ith hearin# loss

Lesion here mimics a peripheral disorder

o P0CA infarcts Ac'te, severe verti#o, mimickin# la+yrinthine d-

o ;erte+ral artery infarct6 typically only e?ects thecere+ell'm 3perf'se cere+ellar iss'es like ata2ia,etc.4

T/0 "ith la+yrinthine or sk'll fract'reo A+normal central processin# res'ltin# in verti#o


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Patholo#y Central 8ystem

;erte+ro+asilar ins'@ciency Posterior circ'lation s'pplies +lood to +rainstem,

cere+ell'm and peripheral vesti+'larapparat'sverte+ro+asilar ins'@ciency 3;/04

Drop attacks, transient +lindness, dysarthria ot as common.

$'ltiple 8clerosis 3$84 Demyelinatin# disease

Can a?ect C ;0006 ca'sin# identical symptoms as'nilateral peripheral vesti+'lar hypof'nction 3$90re'ired for d24

Aco'stic ne'roma, menin#ioma, metastatic

t'mor, or hematoma in the posterior fossa


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$edical Treatment for Central

Disorders

$ana#e as those "itho'taccompanyin# symptoms ofdyse'ili+ri'm

8'r#ical 9emoval of t'mors

PT to incl'de6 Adaptation 7 fall prevention strate#ies


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Anatomy of Peripheral ;esti+'lar 8ystem

Peripheral ;esti+'lar 8ystem3located "ithin the inner ear4

* primary f'nctions 3Associated "ith

;!94 8ta+ili-ation of vis'al ima#es on the fovea of

the retina d'rin# head movement to allo"clear vision

$aintain post'ral sta+ility, especially "ithhead movement

Provide info for spatial orientation


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Anatomy Peripheral ;esti+'lar8ystem

ach ear has6

) Semicircular canals $S**' Anterior, posterior, hori-ontal

B06 anterior is also called s'perior

ori-ontal canal is also called lateral

+ otolith orans

8acc'le Utricle


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8emicirc'lar Canals

ach has acontralateralcoplanar mate

ori-ontal

8CC pair Posterior and

contralateralanterior 8CC


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8emicirc'lar Canals

ndolymph l'id that moves freely "ithin the

canals

Amp'lla nlar#ement at one end of the

8CC


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8emicirc'lar Canals

C'p'la6 "ithin amp'lla elatino's +arrier

Contains sensory hair cells and proEectin#

cilia 8tereocilia 3small4 and Finocilia 3lar#er4

$ovement of the cilia Ca'se an e2citation or inhi+ition in the hair cell

"hich in t'rn leads to a depolari-ation orhyperpolari-ation of a?erent vesti+'lar nerves.

Dependant 'pon direction of motion 8terocilia to"ard Finocilia6 e2citation

8terocilia a"ay from Finocilia6 inhi+ition


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C'p'la is a#elatino's or#an


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8emicirc'lar Canals

9espond to motion ino"n plane +est

Coplanar pair6 p'sh>p'll dynamic

/rain detectsmovement +y

comparin# ( 8CC


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!tolith !r#ans

8acc'le 7 Utricle Linear acceleration

8tatic head tilt

!tolyth 8ensory hair cells proEect into #elatino's

material

!toconia 3ear rocks4

Utricle e2citation

ori-ontal linear acceleration andor statichead tilt

8acc'lar e2citation ;ertical linear acceleration


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!toconia and 'nderlyin#hair cells


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0f a person t'rns their head to the90T. =hat vesti+'lar or#an "as

primarily activated

A. sacc'le

/. 'triclesC. anterior canal

D. posterior canal

E. horizontalcanal


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Patholo#yUnilateral Peripheral system

/eni#n Paro2ysmal Positional ;erti#o 3/PP;4

Displacement of otoconia

5& G &% of the cases are idiopathic

Under the a#e of Hfty tra'ma s'ch as a fall, T/0, or "hiplash inE'ry

!ver the a#e of Hfty De#eneration or dehydration of the #elatino's

mem+rane

$i#rate into 8CC ree :o"in# in the endolympth > canalithiasis

or adhere to c'p'la G c'p'lolithiasis


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A (5 yr old is +ein# treated for "hiplash after


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A (5 yr old is +ein# treated for "hiplash aftera car accident. 8he reports neck pain andintermittent di--iness "ith head movements.

=hat is the +est co'rse of action

A. Teach the patient to limit all neckran#e of motion.

/. 9efer her to a physician for a centralvesti+'lar disorder

C. Treat her "hiplash hopin# that the

di--iness "ill s'+side on its o"nD. ,reat her whiplash and evaluate

her for a peripheral vestibulardisorder


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Patholo#y

Unilateral Peripheral system

;esti+'lar ne'ronitisTypically ca'sed +y a viral infection

0f assoc. "ith hearin# lossentire la+yrinth

ass'med to +e involved

Labyrinthitis ;erti#o provoked +y head movement, +'t not

necessarily head position

Ac'tely

8'dden severe verti#o, 7;, no hearin loss orfacial wea-ness

Typically resolves in I 1 "eek

Physician may prescri+e anti>viral meds


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Patholo#y

Unilateral Peripheral system

9amsay 'nt syndrome 3viral infection4 orm of la+rynthitis

erpes -oster 3chicken po24 in e2ternal ear

;000 and ;00 C a?ected, facial "eakness, hearin#loss, verti#o

Tends to resolve on its o"n, can +e treated "ithantivirals.

Post>Tra'matic ;erti#o 0mmediately follo"in# head tra'ma

9espond "ell to repositionin# techni'esand vesti+'lar e2ercise most nota+ly for ;!9


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Patholo#y

ilateral /eripheral systems

Dr'# To2icity

8econdary e?ect

Amino#lycosidesJconcentrated in endo and perilymph :'ids,

e2posin# hair cells to hi#h concentrations Streptomycin 0 entamycin most detrimental

Can a?ect the hair cells

9eport pro#ressive 'nsteadiness, especially "ith decreased vis'alinp't

/ilateral loss of vesti+'lar f'nction, l'ct'atin# attacks of verti#o3depends 'pon symmetry of hypof'nction4, tinnit's, :'ct'atin#hearin# loss and ill>descri+ed a'ral sensations of f'llness

8pontaneo's recovery in ho'rs to "eeks "hen the dr'# isdiscontin'ed

Bo' are a PT st'dent in ac'te care Bo' are treatin#


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Bo' are a PT st'dent in ac'te care. Bo' are treatin#a K& yo male patient "ho has an endocarditis andis takin# 8treptomycin. The patient complains oflosin# his +alance and hearin# a hi#h pitchedso'nd. 0f yo' "ant to impress yo'r C0, yo' "o'lds'##est6

A. A disc'ssion "ith the $D re#ardin# possi+le$eniere


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Patholo#y

/ilateral Peripheral systems

$eniere5&

Pro#ressive hearin# loss and tinit's "ith fre'ency of attacks

Comes and #oes, #ets "orse over time. 5&% +ecome +ilateral

earin# loss pro#resses to moderate de#ree and sta+ili-es

$edically mana#ed +y controllin# :'id intake


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$edical $ana#ement

Dru ,ype 2ame Indications

Antihistamine andAnticholiner#ic

$ecli-ineM Antivert Ac'te ;est. e'ritisLa+yrinthitis9amsay>'nt

Phenothia-ine Phener#an Ac'te ;est. e'ritis

La+yrinthitis9amsay>'nt

Anti>in:ammatory Prednisone Ac'te ;est. e'ritisLa+yrinthitis9amsay>'nt

Antiviral Acyclovir 9amsay>'nt

Dont have to memorize this chart.


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N'estion6 A person "ith symmetrical+ilateral vesti+'lar dysf'nction "ill

likely !T e2perience

1.Vertio and nystamus

,his is usually a unilateral 3 centralproblem

/. Tinnit's and f'llness in the ears

C. Unsteadiness

D. earin# loss


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ysta#m's

ysta#m's D'e to im+alance in tonic Hrin# rate of

vesti+'lar ne'rons

amed for fast component of eye movement Us'ally a central patholo#y.

ye movement that typically occ'r6 Com+ined hori-ontal and rotational 3torsional4

8in#le planarJhori-ontal or vertical

Direction chan#in#

Discernin# peripheral vs central


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Discernin# peripheral vs centralpatholo#y +ased on nysta#m's

Symptom or Sin /eripheral *entralysta#m's direction $i2ed plane 3hori-ontal

and torsionalDirection chan#in#,varia+le

?ect of H2ation onnysta#m's

Decreases 8ame or increases

ati#a+ility Bes o

D'ration3sin#le episode4

Less than 1 min'te 8ymptoms may persist

0ntensity of si#ns andsymptoms

8evere verti#o, markednysta#m's, systemic

symptoms s'ch asna'sea

Us'ally mild verti#o,less intense nysta#m's,

rare nausea

/alance $ay +e mild O5& yearsof a#e5& may have 34

9om+er#

34 9om+er#, deviateL9 d'rin# #ait


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ysta#m's video

ori-ontal and rotationalnysta#m's

ori-ontal nysta#m's

;ertical nysta#m's

=hat is the di?erence +et"eenthe di?erent types ofnysta#m's
http://www.youtube.com/watch?v=fBDXQchKapU&feature=relatedhttp://www.youtube.com/watch?v=fBDXQchKapU&feature=relatedhttp://www.youtube.com/watch?v=PNSK8q40ax0&feature=fvwhttp://www.youtube.com/watch?v=_KtMS7hx5c4http://www.youtube.com/watch?v=_KtMS7hx5c4http://www.youtube.com/watch?v=_KtMS7hx5c4http://www.youtube.com/watch?v=PNSK8q40ax0&feature=fvwhttp://www.youtube.com/watch?v=PNSK8q40ax0&feature=fvwhttp://www.youtube.com/watch?v=fBDXQchKapU&feature=relatedhttp://www.youtube.com/watch?v=fBDXQchKapU&feature=related


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8ymptoms associated "ith centralvs peripheral patholo#y

*entral /atholoy /eripheral /atholoy

Ata2ia often seen Ata2ia mild or not present

A+normal smooth p'rs'its anda+normal saccadic eyemovements

8mooth p'rs'its and saccades's'ally normal. Positional testin#may prod'ce nysta#m's

Do not typically incl'de hearin#loss

$ay incl'de hearin# loss, f'llnessin ears, tinnit's

Ac'te verti#o is not 's'allys'ppressed +y vis'al H2ation

Ac'te verti#o is 's'ally moreintense, +'t can +e s'ppressed"ith vis'al H2ation

yes oscillate at e'al speeds3pend'lar nysta#m's4

ysta#m's e2hi+its slo" and fastphase 3Eerk nysta#m's4

P're persistent verticalnysta#m's re#ardless ofpositional testin#

8pontaneo's hori-ontalnysta#m's

Bo'


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Bo' re takin# the history of a Q5 yo female"ho is active. 8he presents "ith6 verti#o"ith movement, na'sea and vomitin#, and

nysta#m's "ith head movements. =hich ofthe follo"in# do yo' !T e2pect to Hndd'rin# yo'r e2amination6

A. A positive 9om+er#/. A fati#'in# nysta#m's

*.1taxia

All others are Peripheral,a'sea is mostly peripheral,and rare in central

D. ormal smooth p'rs'its


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Case 8t'dy 1

Bo'r patient has complaints of intermittent severedi--iness. The symptoms are a##ravated +yrollin# over in +ed and #ettin# 'p in the mornin#.

=hen o+servin# the patient yo' notice a torsional

hori-ontal nysta#m's "ith head movement thats'+sides after K5 seconds

The patient states that foc'sin# on an o+Eectmakes the di--iness +etter.


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0s the lesion likely central orperipheral

1. Central

+./eripheral


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=hat is a likely dia#nosis

A. ;esti+'lar ne'ronitis 3no hearin#

loss or facial "eakness4. //V

Intermittent

C. $eniere


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0f the patient has persistentsymptoms after m'ltiple

treatments "hat sho'ld +er'led o't

1. entamycin

to2icity(. /PP;

*. $eniere


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Case 8t'dy (

Bo'r patient is admitted "ith a dia#nosis of/PP; from a local physician. =heno+servin# the patient yo' note an irre#'lar

vertical nysta#m's that is persistent. The patient states that he is al"ays a little

di--y and is havin# di@c'lty foc'sin# hisvision.


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0s the physician dia#nosiscorrect

1. Bes

+. 2o


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=here is the lesion likelylocated

1. Posterior canal

(. Anterior canal

). *entral vestibular system

K. Peripheral vesti+'lar system


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Case 8t'dy *

Bo'r patient has complaints of intermittentdi--iness "ith a feelin# of f'llness andrin#in# in +oth ears, also mild hearin# loss.

The symptoms have persisted on and o?for m'ltiple years 3only lastin# 1>( ho'rs4.


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=hat is the likely dia#nosis

1. ;esti+'larne'ronitis

(. /PP;

*. $eniere


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8ho'ld a physician +econs'lted

5. 6es(. o


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N'estions

9eadin# Assi#nment !

1- vestibular disorders 1-13-16

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