Dr Zuraida ZainunMSc (Medical Audiology), MDMSc (Medical Audiology), MD

Senior lecturerSenior lecturerAudiology PrgrammeAudiology Prgramme

School of Helth SciencesSchool of Helth SciencesUniversiti Sains MalaysiaUniversiti Sains Malaysia

drzuraida@yahoo.comhttp://bal-exercise.blogspot.com/

Elicit history and evaluate dizziness

Understand vestibular testing

Knows differential diagnosis in dizziness

Understand management concepts

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‘’a disturbance that causes an individual to feel unsteady, giddy, woozy, or have a sensation of movement, spinning, or floating’’. http://www.nidcd.nih.gov/health/balance/balance_disorders.asp

Philip D. Sloane, MD, MPH; Remy R. Coeytaux, MD; Rainer S. Beck, MD; and John Dallara, MD Dizziness: State of the Science Ann Intern Med. 2001;134:823-832.

Dizziness subtype

Type of sensation

Temporal Characteristi

cs

Other Specification

Vertigo A feeling one that one or One’s surroundings are Moving (spinning)

Episodic vertigo (seconds to days) Continuous vertigo (most of the time for at least a week)

Characteristics, duration, and date of the first episode, length of episodes; and exacerbating factors.

Presyncope A lightheaded, faint feeling, as though one were about to pass out.

Typically occurs in episodes lasting seconds to hours.

1) Has syncope ever occurred during an episode2) Do episodes occur only when the patient is upright, or do they occur in other positions? 3) Are episodes associated with palpitations, medication meals, bathing, dyspnea, or chest discomfort?

Disequilibrium

Unsteadiness:- felt in lower limb- prominent when standing or walking- relieved by sitting or lying down

Usually present. Although it may fluctuate in intensity

Identify whether symptom occurs in isolation or accompanies another dizziness subtype; describe exacerbating factors.

Other dizziness; anxiety- related, ocular, tilting environment , other

A feeling not covered by the above definitions, may include swimming or floating sensations, vague lightheadedness, or feeling of dissociation.

Present all the time ~ days/weeks/years

-Is dizziness a/w anxiety or hyperventilation? - Was change in vision connected with dizziness onset? - Environment is tilting sideways (suggests an otolith problem?

http://www.aan.com/go/education/curricula/family/chapter5/section1

NatureNatureDurationDurationAssociated Associated symptomssymptomsPrecipitating Precipitating factorsfactors

OBJECTIVEOBJECTIVEVNGVNGVEMP (Ocul & Cer.)VEMP (Ocul & Cer.)V-HitV-HitEcohGEcohGPosturographyPosturographyRotating ChairRotating ChairSubjective vertical testSubjective vertical testSUBJECTIVESUBJECTIVEMalay Version VSSMalay Version VSSMalay version ModifiedMalay version Modified VSSVSS

Gen. exam.Gen. exam.Eye exam.Eye exam.Aural exam.Aural exam.Neurology Neurology exam.exam.Specific testSpecific test

*Chief complaints*Dizzy !! Lightheadacheness!! Headache!! Floating!!

Presyncope!!*Whirling !! Swaying!! Unsteadiness!!*True vertigo or not ? A) Nature*B) Duration of attack: BPPV-secondsTIA-minutesMeniere’s-hoursVestibular Neuronitis-Days

Ototoxins-years (See Hain, 1997) *C) Associated symptompositional related, hearing disturbance, headache, stress

D) Precipitating/ provoking factors

Spinning VestibularUnsteadiness Central lesionPresyncopal/ feeling faint Orthostatic Unspecific(dissociation) Psychology

•Otoconia exist within a part of the inner ear• crystals of calcium carbonate derived from a structure in the ear called the "utricle“

Duration of episode

Suggested diagnosis

Seconds Peripheral: unilateral loss of vestibular fx, late stage of acute vestibular neuronitis & MD

Seconds - minutes BPPV. perilymphatic fistula

Minutes – one hour

Posterior transient ischemic attack; perilymphatic fistula

Hours MD; perilymphatic; migraine. Acoustic neuroma

Days Early acute vestibular neuronitis*’stroke; migraine; Multiple sclerosis

Weeks Psychogenic (constant ~weeks w/o Improvement) *-Early acute vestibular neuritis can be two days or as long as one week or

more .

Symptom Suggested diagnosis

Aural fullness Acoustic neuroma;Meniere’s disease

Ear or mastoid pain

Acoustic neuroma; acute middle ear disease (e.g; otitis zoster oticus)

Facial weakness Acoustic neuroma; herpes zoster oticus

Facial neurologic

CPA tumour; CVA; MS

Headache Acoustic neuroma; migraine

Hearing loss MD; PLF; acoustic neuroma; cholesteatoma;otosclerosis;TIA or stroke involving anterior cerebella artery, herpes zoster oticus

Imbalance Acute vestibular neuronitis(usually moderate); CPA tumor (usually severe)

Nystagmus Peripheral or central vertigo

Phonophobia,photophobia

Migraine

Tinnitus Acute labyrinthitis; acoustic neuroma; Meniera’s disease

Provoking Factor Suggested diagnosis

Changes in head position

Acute labyrinthitis;BPPV; CPA Tumour ;multiple sclerosis (MS); PLF

Spontaneous episodes

AVN; CVA (stroke or TIA; MD ; migraine; MS

Recent URTI Acute vestibular neuronitis (AVN)

Stress Psychiatric or psychological causes; migraine

Changes in ear press., trauma, excess. straining, loud noises

Perilymphatic fistula (PLF)

Past medical history-vascular risk factors-ear surgery

Family History-Similar disorder ? -Migraine

Drug History-present and past exposures to ototoxins, antihypertensives.

Clinical Examination Clinical Examination

Aural Examination

otitis mediaear wax, perforated ear drumcholesteatoma

Eye ExaminationVisual acuityNystagmus

-saccadic, vestibular, pendular, congenital, alternating

Rebound nystagmus Saccades, pursuit,vergence, gaze

General Medical conditionBlood pressure (lying andsitting)Cardiac arrhythmias

Neurological Examinationcranial nerve palsies (Multiple sclerosis , acoustic neuroma, advanced brain stem tumor or basilar artery insufficiency

Neck examination

*Gait

*Cranial nerves

*Motor power and reflexes (e.g. Babinski)

*Sensory (proprioception)

Cerebellar sign ;a) Finger to noseb) Dysdiadokinesiac) Tandem gait (hell

to toe) with eye open and closed

*Romberg’s test Fall to one side:

- Posterior column lesion- Acute ipsilateral vestibular lesion

*Fukuda @ Unterberger test-Walk on the spot for 2 minutes with eye closed-Positive when patient turn > 45° -Ipsilateral peripheral lesion

l) Spontaneous nystagmus

MD, Vestibular Neuronitis, central disorders, to rule out Psychiatric (used Frenzel's goggles)

ii) Range of eye movements

Gaze paresis

Ocular paresis

iii) Cover test for strabismus : a deviation or misalignment eyes. strabism– eye muscle position ~ one or both

eyes may turn in (esotropia), out (exotropia), up

(hypertropia) or down (hypotropia). http://dewa-dony.blogspot.com/2008/10/strabismus.html

- to detect vestibular neuritis, acoustics, and to rule out psychiatric disturbance

Head-shake test - (Hain et al, 1987)75% sensitive but wrong side in 1/4 of the time.

Head Thrust test

http://cueflash.com/decks/CONTROL_OF_EYE_MOVEMENTS_-_57

Saccade when head turning toward lesion side

- to detect ototoxicity and other bilateral vestibulopathies

Dynamic illegible 'E' test or DIE

(Longridge, 87).

1. DIX-HALLPIKE TEST

-Rotatory upbeating; Post SCC

-Rotatory downbeating; Ant. SCC

video 1

video 2

video 3 cupulo

Treatment for Post. SCC- Epley’smenourve 2. ROLL TEST - horizontal nystagmus video 1

Treatment- Barbeque menourve

Video 1nystagmus

3) Fistula Test or Valsalva test- Occasionally helpful

4) Hyperventilation test – 30 seconds, look for nystagmus. Helpful when nystagmus changesdirection compared to vibration or head-shakingnystagmus.

5) Carotid Sinus Compression - for syncope patients.

6) Vertebral artery test - for persons with neck-

position induced vertigo (cervical vertigo).

Feature Peripheral Vertigo Central Vertigo

Nystagmus Mix horizontal & tensional;inhib. by fixation of eyes;Fades after a few days; notchange direction with gazeto either side

Purely vertical , horizontal, ortorsional; not inhibited byfixation of eyes ; last weeksto months; change directionWith gaze towards fast phaseOf Nystagmus

Imbalance Mild to moderate; able towalk

Severe; unable to stand orwalk

Nausea, vomiting

May be severe Varies

Hearing loss,tinnitus

Common Rare

NeurologicSx

Rare Common

Latency(follow. pro-vocative)

Longer (up to 20 seconds) Shorter (up to 5 seconds)

Indication; Assess vestibular function Locate the lesion organ/part Causative factor/etiology Vestibular rehabilitation assessment

*Videonystagmography (VNG)/Electronystagmograpy (ENG)

*Video Head impulsetTest (V-HIT)

*Vestibular evoked myogenic potential (VEMP) - Ocular & cervical

*Electrocochleargraphy (EcohG)

*Rotating chair

*Computerized Posturography (CDP)

*Subjective vertical test

*VNG – Horizontal SCC

*Rotatory Chair – Horizontal SCC

file:///F:/LECTURE%202007/posturography/Posturography.htmfile:///F:/LECTURE%202007/posturography/Posturography.htm

*Evaluation of the inner ear (cochlea) has an excessive amount of fluid pressure.

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Iran Audiology Congress 26-28 May 2011 Dr Iran Audiology Congress 26-28 May 2011 Dr Zuraida ZainunZuraida Zainun

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http://www.unmc.edu/physiology/Mann/mann9.html

Video nystagmography (VNG)Video Head impulsetTest (V-HIT)

Ocular VEMP

Cervical VEMP

Rotating chair

Bone-conducted cVEMP

*Others investigations

*Audiological test* PTA* Tympanometry* ABR

*Radiological test* CT Scan*MRI Scan* Vascular studies

*Laboratory investigations:* FBC* Blood sugar* Lipid profile* Thyroid profile

*MALAY VERSION VERTIGO SYMPTOM SCALE QUESTIONNAIRES (MVSS) ~ 22 questions (34 items)

*MALAY VERSION MODIFIED VERTIGO SYMPTOM SCALE QUESTIONNAIRES (MMVVSS) ~ 14 items

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1. Investigation and diagnosis2. Explanation3. Rehabilitation plan

- correction of remediable problems-General medical condition

- general fitness programmed- physical exercise regimens (i.e. Vestibular rehabilitation by

physiotherapist/ homebased)

Cawthorne cookseey exercise (CCE) Customised CCE Epley’s Menourve Brandt Daroff exercise

- psychological assessment -Psychological intervention i.e. CBT, Relaxation Rx.

- medication- realistic family/social/occupational goals

- surgery

4. Monitoring/feedback/follow up

5. Discharge

Reproduced with permission from Luxon LM, Davies RA, eds. Handbook of vestibular medicine. London: Whurr Publishers, 1997.

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Cawthorne cookseey exercise (CCE)

Customised CCE

Bal Ex : Homebased video module for balance exercises = customised CCE +Prayer movement

1. Kroenke K, Lucas CA, Rosenberg ML, et al. Causes of persistent dizziness: a prospective study of 100 patients in ambulatory care. Ann Intern Med. 1992;117:898-904.

2. LM Nashner, FO Black, and C Wall, 3d Adaptation to altered support and visual conditions during stance: patients with vestibular deficits J. Neurosci. 1982 2: 536-544.

3. Shupert CL, Black FO, Horak FB & Nashner LM (1988) Coordination of head and body in response to support surface translations in normals and patients with bilaterally reduced vestibular function. In Amblard B, Berthoz A, Clarac F (eds) Posture and gait: Development, Adaptation and Modulation. New York: Elsevier Science Publishers.

4. Allum, J.H.J., Honegger, F. and Pfaltz, C.R. (1989) The role of stretch and vestibulo-spinal reflexes in the generation of human equilibriating reactions. Progress in Brain Research 80, 399-409

5. Bles W, de Jong JMBV. Uni- and bilateral loss of vestibular function. In: Disorders of posture and gait.—Bles W, Brandt T, eds. (1986) Amsterdam: Elsevier, 1986, PP 127-139

6. Fregly AR (1974) Vestibular ataxia and its measurement in man. In: Kornhuber HH (ed) Handbook of Sensory Physiology,. vol VI. Springer, New York, pp 321–360

7. Handbook of Balance Function Testing by Gary P. Jacobson

(Author), Craig W. Newman (Author), Jack M. Kartush Singular; 1 edition (October 1, 1997)

8. http://www.neuroanatomy.wisc.edu/virtualbrain/BrainStem/13VNAN.html

9. http://www.utmb.edu/otoref/Grnds/Vestibular-2004-0414/Vestibular-2004-0414.htm

10. http://www.bcdecker.com/SampleOfChapter/1550092634.pdf