impact of the loss of vestibular function - herman...
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impact of the loss of vestibular function
Herman Kingma
Department of ORL, Head Vestibular Clinic, Maastricht University Medical Centre, The Netherlands
Faculty of Physics, Tomsk Research State University, Russian Federation
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vestibular pathology (traditional view)
• initial symptoms: vertigo, nausea and nystagmus
• central compensation
unilateral: the other labyrinth takes over
bilateral: sensory substitution takes care
• recovery in a few weeks to months
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vestibulopathy
two aspects
• vertigo, nausea and nystagmus
• sensory dysfunction or function loss
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acute unilateral loss or fluctuating function (neuritis, Ménière…)
acute severe vertigo, nausea, falling and imbalance
(the classical leading symptoms for diagnosis)
slow unilateral loss (vestibular schwannoma, aging):
no vertigo or nystagmus
what happens in case of acute bilateral loss ?
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Lidocaine 2 mg /ml
May 2008Mans Magnusson
Michael Karlberg
Lund, Sweden
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Topical prilocaine (EMLA)
on eardrums
Intratympanal injection
of lidocaine (spinal tap needle)
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1. Right side
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2. Left side
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3. Wait and see
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some time later when he wants to get up feeling a bit ….
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returning from the toilet after severe vomiting
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- duration 8 hours
- reproducible
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acute bilateral vestibular loss
no vertigo, no nystagmus
severe unsteadiness / ataxia
intolerance for voluntary head movements
clear neuro-vegetative symptoms
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in case of acute asymmetries
- vertigo and nystagmus
slow unilateral, slow or acute bilateral loss
- no vertigo or nystagmus
vertigo is only 1 aspect of vestibular loss
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vestibulopathy
aspects that require management:
- vertigo and nystagmus (occur in case of acute asymmetries)
- sensory dysfunction or function loss
- nausea
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let us focus now on the impact of the sensory deficit per se
what is the major impact of loss of vestibular loss ?
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image stabilisation
balance control
spatial orientation
interpretation
learning
adaptation
compensation
CNS
labyrinths
visiongravitoreceptors
blood pressure sensors in
large blood vessels
hearing
somatosensorye.g. foot sole pressure
circadian rhythmvestibular projections hypothalamus supra-chiasmatic nucleus
autonomic processes fast blood pressure regulationheart beat frequencynausea / vomiting
Vestibular effects on cerebral blood flowSerrador et al, BMC Neuroscience 2009
Vestibular modulation of circadian rhytmFuller et al, Neuroscience. 2004.
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consequence of slow or acute vestibular sensory loss:
- often persisting neuro-vegetative symptoms
(nausea, sweating, problems with blood pressure)
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image stabilisation
balance control
spatial orientation
interpretation
learning
adaptation
compensation
CNS
labyrinths
visiongravitoreceptors
blood pressure sensors in
large blood vessels
hearing
somatosensorye.g. foot sole pressure
circadian rhythmvestibular projections hypothalamus supra-chiasmatic nucleus
autonomic processes fast blood pressure regulationheart beat frequencynausea / vomiting
Vestibular effects on cerebral blood flowSerrador et al, BMC Neuroscience 2009
Vestibular modulation of circadian rhytmFuller et al, Neuroscience. 2004.
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consequence of slow or acute vestibular sensory loss:
- reduced perception of self motion and spatial orientation
(frequently intolerance to optokinetic stimuli)
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consequence of slow or acute vestibular sensory loss:
- reduced perception of self motion and spatial orientation
(frequently intolerance to optokinetic stimuli)
normal 24 months BVA 26 months
Sylvie Wiener-Vacher, 2013
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image stabilisation
balance control
spatial orientation
interpretation
learning
adaptation
compensation
CNS
labyrinths
visiongravitoreceptors
blood pressure sensors in
large blood vessels
hearing
somatosensorye.g. foot sole pressure
circadian rhythmvestibular projections hypothalamus supra-chiasmatic nucleus
autonomic processes fast blood pressure regulationheart beat frequencynausea / vomiting
Vestibular effects on cerebral blood flowSerrador et al, BMC Neuroscience 2009
Vestibular modulation of circadian rhytmFuller et al, Neuroscience. 2004.
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base of support
Centre Of Mass
vestibular impact
upon postural control
- regulation of muscle tone
relative to gravity
- regulation of COM
relative to base of support
balancing
correction steps
- labyrinths important for
detection of gravity-vector
fast vestibulo-spinal corrections to
maintain good posture and prevent falling
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vn
cer
hippocampus
basal ganglia
spinal pattern generator
visual
cortex
•Frontal cortex: initiation, dual tasks•Cerebellum: rhythm and velocity•Basal: ganglia modulation•Brainstem: start and stop•Spinal cord: automatic spinal patterns (running)•Labyrinth: fast detection and correction of imbalance (VSR)
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the labyrinths add
SPEED
to balance control
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otolith function especially relevant in case of:- motor learning (retardation in congenital areflexia)
- maintaining postures that need fast feed back (VSR)
- when other senses are compromised;
- soft surface (mud, sand, wind-surfing)
- in darkness
- in presence of confusing optokinetic stimuli
acquired bilateral areflexia leads to degeneration of
“head direction” and head “place” cells hippocampus
normal 11 months BVA 26 months
thank you Sylvie Wiener-Vacher
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severe bilateral loss
- 5 months after gentamycine intoxication
- intensive physiotherapy / training
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consequence of slow or acute vestibular sensory loss:
- often persisting neuro-vegetative symptoms
- reduced perception of self motion
- intolerance for strong optokinetic stimuli
- reduced ability for fast balance correction(need for visual anticipation: fear to fall)
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image stabilisation
balance control
spatial orientation
interpretation
learning
adaptation
compensation
CNS
labyrinths
visiongravitoreceptors
blood pressure sensors in
large blood vessels
hearing
somatosensorye.g. foot sole pressure
circadian rhythmvestibular projections hypothalamus supra-chiasmatic nucleus
autonomic processes fast blood pressure regulationheart beat frequencynausea / vomiting
Vestibular effects on cerebral blood flowSerrador et al, BMC Neuroscience 2009
Vestibular modulation of circadian rhytmFuller et al, Neuroscience. 2004.
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thalamus
visual
cortex
ponscerebellum
oculomotor
nuclei
vestibular image stabilisation: 8 msec
midbrain
vestibular
nuclei
visual image stabilisation: >75 msec
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head impulse test in left unilateral loss
standard video (50 Hz)
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why video registration? in 50% of the patients: the correction saccades occur during the head movement: overt saccades
right left
horizontal
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pathology: central compensation
the other labyrinth does NOT take over
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3D asymmetry
1st and 2nd law of Ewald
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simulation of oscillopsia reduced dynamic visual acuity
in case of bilateral vestibular areflexia
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Dynamic Visual Acuity (VA) measurement
treadmill: 2, 4 and 6 km/h
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decrease of VA during walking
- 0.2 - 0.2 - 0.3normal values (maximum VA decrease)
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Agrawal et al, 2013
HC
PC AC
DVA reduction (logMar)
<30 30-39 40-49 50-59 60-69 ≥70 years old
<30 30-39 40-49 50-59 60-69 ≥70 <30 30-39 40-49 50-59 60-69 ≥70
0.0
0.00.0
0.5
0.5
0.5
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which complaints are related to vestibular deficits ?
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what is the permanent impact of loss of the vestibular sense ?
for balance, vision and spatial orientation)
loss of speed
- poor dynamic vision (daily life)
- fear to fall and falls
loss of automatisation
- severe cognitive load:
anticipation constantly required to prevent falls
impaired double tasking
fatigue
- visual dependence: intolerance to optokinetic stimuli
no more shopping or parties
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a vestibular function loss implies
permanent impairmentanalogue to hearing and visual losses
examples
- Meniere’s disease when attacks are absent or disappeared
- neuritis vestibularis after central compensation
- bilateral vestibulopathy after central compensation
- vestibular loss schwannoma (also after extirpation)
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many vestibular syndromes where vertigo is the leading symptom
- Benign Paroxysmal Positioning Vertigo and Nystagmus
- vestibular neuritis or labyrinthitis / peripheral vestibular ischemia
- vestibular TIA or strokes
- vestibular migraine
- Meniere’s disease (MD)
- recurrent vestibulopathy
- benign paroxysmal vertigo of childhood
- vestibular paroxysms
- vestibular epilepsia
- fistula / superior canal dehiscence syndrome (SCDS)
- vertigo due to central vestibular pathology
- motion sickness / mal de debarquement
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take home messages
- vertigo occurs only in case of acute asymmetries
- many patients do not report vertigo at all, but report:
poor (dynamic) vision
fear to fall and falls
fatigue
- treatment of vertigo
reduction of symptoms due to acute loss
might impair compensation
- treatment of the sensory deficit because:
deficit is permanent
dynamic central compensation is poor
quality of life is severely decreased