vestibular disorders - herman kingmahermankingma.com › onewebmedia ›...

vestibular disordersphysical examination

Permission of patients to show their videos for educational purposes

“keep an eye on the eyes”

goals

1. determining peripheral vestibular deficit:- head impulse test

- Dix-Hallpike and lateral roll

- head shake test

- other tests

2. differentiate peripheral vs. central vestibular:- stability eyes and gaze

- eye position, -movements and range

- saccades

- other tests

- (Romberg, etc.)

RECOGNIZE FIRST, INTERPRETE LATER

PROBLEM CAN BE VERY SUBTLE

physical examination:

peripheral vestibular

goals

1. determining peripheral vestibular deficit:- head impulse test

- Dix-Hallpike and lateral roll

- head shake test

- other tests

2. differentiate peripheral vs. central vestibular:- stability eyes and gaze

- eye position, -movements and range

- saccades

- other tests

- (Romberg, etc.)

head impulse test (HIT)

normal HIT:

BE CAREFUL WITH NECK COMPLAINTS:

ROTATE INWARDS

head impulse test (HIT)

the vestibulo-ocular reflex (VOR):

head impulse test (HIT)

the vestibulo-ocular reflex (VOR):

VOR

MVN

VI

III

head impulse test (HIT)

the vestibulo-ocular reflex (VOR):

VOR

MVN

VI

III

head impulse test (HIT)

the vestibulo-ocular reflex (VOR):

VOR

MVN

VI

III

head impulse test (HIT)

the vestibulo-ocular reflex (VOR):

head impulse test (HIT)

the vestibulo-ocular reflex (VOR):

head impulse test (HIT)

give instructions to the patient: look at my nose

head impulse test (HIT)

HIT can be very clear sometimes:

head impulse test (HIT)

Testing vertical canals:

LARP

RALP

Head Impulse Test (HIT)

HIT Lateral canal after plugging:

Head Impulse Test (HIT)

HIT Posterior canal right after plugging:

Head Impulse Test (HIT)

HIT can “fool” the examiner:

Head Impulse Test (HIT)

HIT can “fool” the examiner:

Normal Overt saccades Covert saccades

Goals

1. Determining peripheral vestibular deficit:- Head impulse test

- Dix-Hallpike and lateral roll

- Head shake test

- Other tests

2. Differentiate peripheral vs. central vestibular:- Stability eyes and gaze

- Eye position, -movements and range

- Saccades

- Other tests

- (Romberg, etc.)

Goals

1. Determining peripheral vestibular deficit:- Head impulse test

- Dix-Hallpike and lateral roll

- Head shake test

- Other tests

2. Differentiate peripheral vs. central vestibular:- Stability eyes and gaze

- Eye position, -movements and range

- Saccades

- Other tests

- (Romberg, etc.)

BPPV

BPPV is systematically not recognized- Radiating rather than repositioning

Dizziness: >20% is BPPV- Always perform Dix-Hallpike: Often unexpected BPPV

- Combine with lateral roll (15%)

BPPV

Use Frenzel or Video goggles (fixation suppression ↓)

BPPV

Dix-Hallpike with BPPV AD:

BPPV

Dix-Hallpike with BPPV AD:

BPPV

Direction of the fast-phases of VOR:

BPPV

Direction of the fast-phases of VOR:

Not the expected eye movements? reconsider diagnosis

BPPV

Which canal?

BPPV

Reconsider diagnosis?

BPPV

Canalolithiasis Cupulolithiasis

Otoliths in long arm Otoliths near cupula / short arm

Longer latency Short latency

Exhaustible reaction Inexhaustible reaction

Often response to therapy Therapy more difficult

Supine position

BPPV

BPPV horizontal canals: 2 types of nystagmus possible

- Eyes to the ground (geotropic): Canalolithiasis

- Eyes away from ground (apogeotropic): Cupulolithiasis

Strongest nystagmus points to affected labyrinth

BPPV

BPPV horizontal canals: 2 types of nystagmus possible

- Eyes to the ground (geotropic): Canalolithiasis

- Eyes away from ground (apogeotropic): Cupulolithiasis

Strongest nystagmus points to affected labyrinth

BPPV

2 Questions:

- Geo- or apogeotropic?

- Which side is affected?

Lateral roll to the left

Lateral roll to the right

BPPV

Doubt about affected side lateral roll: Bown and lean

- Geotropic (Bow):

- Sitting patient bends head forewards 90º

- Nystagmus points to affected side

- Apogeotropic (Lean):

- Sitting patient bends head backwards 45º

- Nystagmus points to affected side

Goals

1. Determining peripheral vestibular deficit:- Head impulse test

- Dix-Hallpike and lateral roll

- Head shake test

- Other tests

2. Differentiate peripheral vs. central vestibular:- Stability eyes and gaze

- Eye position, -movements and range

- Saccades

- Other tests

- (Romberg, etc.)

Goals

1. Determining peripheral vestibular deficit:- Head impulse test

- Dix-Hallpike and lateral roll

- Head shake test

- Other tests

2. Differentiate peripheral vs. central vestibular:- Stability eyes and gaze

- Eye position, -movements and range

- Saccades

- Other tests

- (Romberg, etc.)

Head Shake Test

Head shake test: Charging velocity storage (3Hz)

Head Shake Test

Head shake test: Charging velocity storage (3Hz)

Head Shake Test

Head shake test: Charging velocity storage (3Hz)

VOR

MVN

VI

III

Head Shake Test

Head shake test: Charging velocity storage (3Hz)

VOR

MVN

VI

III

Velocity

storage

Head Shake Test

Head shake test: Charging velocity storage (3Hz)

VOR

MVN

VI

III

Velocity

storage

Head Shake Test

Head shake test: Charging velocity storage (3Hz)

VOR

MVN

VI

III

Velocity

storage

Velocity

storage

Head Shake Test

Head shake test: Charging velocity storage (3Hz)

VOR

MVN

VI

III

Velocity

storage

Velocity

storage

Head Shake Test

Head shake test: Charging velocity storage (3Hz)

VOR

MVN

VI

III

Velocity

storage

Velocity

storage

Head Shake Test

Head shake test: Charging velocity storage (3Hz)

Head Shake Test

Head shake test: Charging velocity storage (3Hz)

Head Shake Test

Head shake test: Recovery nystagmus

VOR

MVN

VI

III

Velocity

storage

Velocity

storage

Adaptation

Head Shake Test

Head shake test: Perverted nystagmus

VOR

MVN

VI

III

Velocity

storage

Velocity

storage

Head Shake Test

Head shake test: Perverted nystagmus

Head Shake Test

Head shake test: Perverted nystagmus

Other: Provocational testing

Provocational testing:

- Tragal compression (Hennebert)

- Valsalva / Coughing

- Barany-drum / Politzer balloon

Other: Provocational testing

Politzer balloon:

Other: Provocational testing

Politzer balloon:

Physical examination:

Differentiate peripheral vs. central

Peripheral vs. Central

Why so many tests?

Goals

1. Determining peripheral vestibular deficit:- Head impulse test

- Dix-Hallpike and lateral roll

- Head shake test

- Other tests

2. Differentiate peripheral vs. central vestibular:- Stability eyes and gaze

- Eye position, -movements and range

- Saccades

- Other tests

- (Romberg, etc.)

Goals

1. Determining peripheral vestibular deficit:- Head impulse test

- Dix-Hallpike and lateral roll

- Head shake test

- Other tests

2. Differentiate peripheral vs. central vestibular:- Stability eyes and gaze

- Eye position, -movements and range

- Saccades

- Other tests

- (Romberg, etc.)

Stability eyes and gaze

Stability eyes:

Stability eyes and gaze

Abnormality can be very subtle:

Stability eyes and gaze

Peripheral vestibular nystagmus: Alexander’s law

Stability eyes and gaze

Peripheral vestibular nystagmus: Alexander’s law

Peripheral

Nystagmus suppressed by fixation

Nystagmus with mixed components

Nystagmus according to Alexander’s law

No gaze evoked nystagmus

Stability eyes and gaze

2 types of nystagmus:

- Peripheral

- Central

Peripheral Central

Nystagmus suppressed by fixation No effect of fixation

Nystagmus with mixed components Purely vertical (e.g. downbeat) or horizontal

Nystagmus according to Alexander’s law Not according to Alexander’s law

No gaze evoked nystagmus Gaze evoked nystagmus

Central nystagmus increases with fixation:

Stability eyes and gaze

Without fixation

With fixation

Central nystagmus increases with fixation:

Stability eyes and gaze

Without fixation

With fixation

Stability eyes and gaze

Some types of nystagmus:

1. Vestibular (peripheral and central):

2. Gaze evoked:

3. ….Other, e.g.:

Stability eyes and gaze

Which nystagmus is not central?

A B

C D

Stability eyes and gaze

Testing gaze + sidepockets (!)

Stability eyes and gaze

Importance of sidepockets:

Stability eyes and gaze

Watch out for physiological end-point nystagmus:

Stability eyes and gaze

Some types of nystagmus:

1. Vestibular (peripheral and central):

2. Gaze evoked:

3. ….Other, e.g.:

Stability eyes and gaze

Some types of nystagmus:

1. Vestibular (peripheral and central):

2. Gaze evoked:

3. ….Other, e.g.:

Stability eyes and gaze

Gaze evoked nystagmus: Changes with direction of gaze

Stability eyes and gaze

All-in one: Alexander’s law - Sidepockets

Goals

1. Determining peripheral vestibular deficit:- Head impulse test

- Dix-Hallpike and lateral roll

- Head shake test

- Other tests

2. Differentiate peripheral vs. central vestibular:- Stability eyes and gaze

- Eye position, -movements and range

- Saccades

- Other tests

- (Romberg, etc.)

Goals

1. Determining peripheral vestibular deficit:- Head impulse test

- Dix-Hallpike and lateral roll

- Head shake test

- Other tests

2. Differentiate peripheral vs. central vestibular:- Stability eyes and gaze

- Eye position, -movements and range

- Saccades

- Other tests

- (Romberg, etc.)

Eye position, -movements, -range

Eye position:

NOT EACH EYE CONDITION IS DIRECTLY VISIBLE

Eye position, -movements, -range

Eye position: 2 types of abnormalities (hypo, hyper, eso, exo)

1. Tropia: misalignment always present

- Including cover- uncover test

2. Phoria: misalignment when synchronization is interrupted

- Cross-cover test

Eye position, -movements, -range

Eye position: Tropia (www.opthobook.com)

1. In primary position: e.g. Hirschberg’s test

Exotropia OS Esotropia OD

Hypertropia OS Hypotropia OS

Eye position, -movements, -range

Eye position: Tropia (www.opthobook.com)

2. With gaze: make a “box”

Exotropia OS Esotropia OD

Hypertropia OS Hypotropia OS

Eye position, -movements, -range

Subtle tropia: Cover-uncover test

Eye position, -movements, -range

Eye position: Tropia (www.ophthobook.com)

3. More subtle: Cover-uncover test

Exotropia OS

Eye position, -movements, -range

Eye position: Tropia (www.ophthobook.com)

3. More subtle: Cover-uncover test

Practice 1

Eye position, -movements, -range

Eye position: Tropia (www.ophthobook.com)

3. More subtle: Cover-uncover test

Practice 2

Eye position, -movements, -range

Eye position: Tropia (www.ophthobook.com)

3. More subtle: Cover-uncover test

Practice 3

Eye position, -movements, -range

When phoria: Cross-cover test

Eye position, -movements, -range

Eye position: Phoria (www.ophthobook.com)

Only evident when interrupting synchronization: Cross-cover

Exophoria

Eye position, -movements, -range

Eye position: Phoria (www.ophthobook.com)

Only evident when interrupting synchronization: Cross-cover

Practice

AND NOW MORE DIFFICULT…

Eye position, -movements, -range

Normal eye position:

Eye position, -movements, -range

Earth verticalNormal eye position:

Eye position, -movements, -range

Disorder utriculus pathway:

“New” vertical

Eye position, -movements, -range

Disorder utriculus pathway:

“New” vertical

Eye position, -movements, -range

Skew deviation and ocular tilt reaction:

Eye position, -movements, -range

Skew deviation and ocular tilt reaction:

Eye position, -movements, -range

Testing eye movements (smooth pursuit):

Eye position, -movements, -range

Testing eye movements (smooth pursuit):

MVN

VI

III

NPH

Cerebellum

Eye position, -movements, -range

Testing eye movements (smooth pursuit):

Eye position, -movements, -range

Testing eye movements (smooth pursuit):

Goals

1. Determining peripheral vestibular deficit:- Head impulse test

- Dix-Hallpike and lateral roll

- Head shake test

- Other tests

2. Differentiate peripheral vs. central vestibular:- Stability eyes and gaze

- Eye position, -movements and range

- Saccades

- Other tests

- (Romberg, etc.)

Goals

1. Determining peripheral vestibular deficit:- Head impulse test

- Dix-Hallpike and lateral roll

- Head shake test

- Other tests

2. Differentiate peripheral vs. central vestibular:- Stability eyes and gaze

- Eye position, -movements and range

- Saccades

- Other tests

- (Romberg, etc.)

Saccades

Testing saccades:

NPH

Cerebellum- Vermis

- Fastigial nucleus

VI

III riMLF

PPRF RIP Pons

Midbrain+

+

-

-

Motor Burst Omnipause

Saccades

Testing saccades: Close and wide

NPH

Saccades

Testing saccades: Close and wide

NPH

Saccades

Testing saccades:

NPH

Saccades

Testing saccades:

NPH

Saccades

Testing saccades:

NPH

Saccades

Testing saccades:

NPH

Hypermetria

Saccades

Testing saccades:

NPH

Saccades

Testing saccades:

NPH

Saccades

Testing saccades:

NPH

Saccades

Testing saccades:

NPH

Saccades

Testing saccades:

NPH

Saccades

Testing saccades:

NPH

Hypometria

Saccades

Testing saccades:

NPH

Saccades

Testing saccades:

NPH

Saccades

Testing saccades:

NPH

Saccades

Testing saccades:

NPH

Slowing

Other tests

Hyperventilation test:

NPH

Demyelinization nerve: Vestibular schwannoma, microvascular

Demyelinization central: MS

Canalopathy: FHM, SCA-6, EA-2, epilepsia

Other: Migraine, post-neuritis, fistula, craniocervical

Other tests

Hyperventilation test:

NPH

Demyelinization nerve: Vestibular schwannoma, microvascular

Demyelinization central: MS

Canalopathy: FHM, SCA-6, EA-2, epilepsia

Other: Migraine, post-neuritis, fistula, craniocervical

Other tests

Hyperventilation test:

NPH

Demyelinization nerve: Vestibular schwannoma, microvascular

Demyelinization central: MS

Canalopathy: FHM, SCA-6, EA-2, epilepsia

Other: Migraine, post-neuritis, fistula, craniocervical

Other tests

Hyperventilation test:

Positional testing: Eye movements not always BPPV!

NPH

Demyelinization nerve: Vestibular schwannoma, microvascular

Demyelinization central: MS

Canalopathy: FHM, SCA-6, EA-2, epilepsia

Other: Migraine, post-neuritis, fistula, craniocervical

Peripheral: Cupulolithiasis, SCDS, fistula, Meniere’s

Central: MS, cerebellair tumor/infarction/hematoma, ischemiabrainstem, migraine, whiplash/head trauma, alcohol

Other tests

Positional nystagmus cerebellar tumor:

NPH

Other tests

Testing fixation suppression:

NPH

Other tests

Testing fixation suppression:

NPH

Other tests

Testing fixation suppression:

NPH

Other tests

Testing fixation suppression:

NPH

The acute problem!

What to do?

Differential diagnosisTiming Trigger Diagnosis benign Diagnosis dangerous

Episodic Trigger BPPV

Orthostatic

CPPV/Tumor

Internal bleeding

Vascular stenosis

Vertebral artery

Spontaneous Meniere’s

Migraine

SCDS

Paroxysmia

Vasovagal

Panic

Arrhythmia/MI

TIA

Pulmonary embolus

Hypoglycemia

Acute Postexposure Perilymphatic fistula Skull base fracture

Vertebral dissection

Drugs (genta, AED)

Carbon monoxide, etc.

Spontaneous Neuritis

Labyrinthitis

CVA/Vertebral

Wernicke’s/encephalitis

..Other internal/neuro

Chronic Context e.g. Vestibular hypofunction

Spontaneous e.g. Cerebellar degeneration

Differential diagnosisTiming Trigger Diagnosis benign Diagnosis dangerous

Episodic Trigger BPPV

Orthostatic

CPPV/Tumor

Internal bleeding

Vascular stenosis

Vertebral artery

Spontaneous Meniere’s

Migraine

SCDS

Paroxysmia

Vasovagal

Panic

Arrhythmia/MI

TIA

Pulmonary embolus

Hypoglycemia

Acute Postexposure Perilymphatic fistula Skull base fracture

Vertebral dissection

Drugs (genta, AED)

Carbon monoxide, etc.

Spontaneous Neuritis

Labyrinthitis

CVA/Vertebral

Wernicke’s/encephalitis

..Other internal/neuro

Chronic Context e.g. Vestibular hypofunction

Spontaneous e.g. Cerebellar degeneration

Central or peripheral?: HINTS

HINTS:

- Head Impulse

- Nystagmus

- Test Skew deviation

NPH

+ +

Central or peripheral?: HINTS

HINTS:

- Head Impulse

- Nystagmus

- Test Skew deviation

Importance:

- Acute phase: HINTS more sensitive than MRI (88%)

NPH

+ +

Central or peripheral?: HINTS

HINTS: Head impulse test

NPH

Central or peripheral?: HINTS

HINTS: Nystagmus

NPH

Central or peripheral?: HINTS

HINTS: Testing Skew deviation

NPH

Central or peripheral?: HINTS

HINTS: Testing Skew deviation

NPH

CENTRAL OR PERIPHERAL?

Central or peripheral?: HINTS

HINTS: Peripheral nystagmus

NPH

Conclusions

Conclusions

1. Collect as much information as possible• Central tests

• Peripheral tests

2. Keep an eye on the eyes: often subtle abnormalities- Other neurological examination can be normal

3. Acute problem: HINTS

Questions