Dr Zuraida Zainun

MSc (Medical Audiology), MD

Senior lecturer
Audiology Prgramme
School of Helth Sciences
Universiti Sains Malaysia
drzuraida@yahoo.com
http://bal-exercise.blogspot.com/
*

Elicit history and evaluate dizziness
Understand vestibular testing
Knows differential diagnosis in dizziness
Understand management concepts

3
*What is a balance disorder?

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


*Dizziness

*Dizziness subtypes

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
Characteristics
Other Specification
Vertigo A feeling one that one or Ones
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
episode
2) 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?
Disequilibriu
m
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
VERTIGO
History
Clinical
Examination
Investigations
Nature
Duration
Associated
symptoms
Precipitating
factors

OBJECTIVE
VNG
VEMP (Ocul & Cer.)
V-Hit
EcohG
Posturography
Rotating Chair
Subjective vertical test
SUBJECTIVE
Malay Version VSS
Malay version Modified
VSS




Gen. exam.
Eye exam.
Aural exam.
Neurology
exam.
Specific test
*
*Chief complaints
*Dizzy !! Lightheadacheness!! Headache!! Floating!! Presyncope!!
*Whirling !! Swaying!! Unsteadiness!!
*True vertigo or not ?
A) Nature
*B) Duration of attack:
BPPV-seconds
TIA-minutes
Menieres-hours
Vestibular Neuronitis-Days
Ototoxins-years (See Hain, 1997)
*C) Associated symptom
positional related, hearing disturbance, headache,
stress
D) Precipitating/ provoking factors

Spinning Vestibular
Unsteadiness Central lesion
Presyncopal/
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;Menieres 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; Menieras 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
*


Aural Examination

otitis media
ear wax,
perforated ear drum
cholesteatoma
Eye Examination
Visual acuity
Nystagmus
-saccadic,
vestibular,
pendular,
congenital,
alternating
Rebound nystagmus
Saccades, pursuit,
vergence, gaze


General Medical condition
Blood pressure (lying and
sitting)
Cardiac arrhythmias
Neurological
Examination
cranial 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 nose
b) Dysdiadokinesia
c) Tandem gait (hell
to toe) with eye
open and closed
*Rombergs 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- Epleys
menourve

2. ROLL TEST

- horizontal nystagmus

video 1

Treatment- Barbeque menourve

Video 1
nystagmus
*

3) Fistula Test or Valsalva test- Occasionally helpful

4) Hyperventilation test 30 seconds, look for
nystagmus. Helpful when nystagmus changes
direction compared to vibration or head-shaking
nystagmus.

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; not
change direction with gaze
to either side
Purely vertical , horizontal, or
torsional; not inhibited by
fixation of eyes ; last weeks
to months; change direction
With gaze towards fast phase
Of Nystagmus
Imbalance Mild to moderate; able to
walk
Severe; unable to stand or
walk
Nausea,
vomiting
May be severe Varies
Hearing loss,
tinnitus
Common Rare

Neurologic
Sx
Rare Common
Latency
(follow. pro-
vocative)
Longer (up to 20 seconds) Shorter (up to 5 seconds)
*Objective Vestibular
Tests
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

*Computerized Dynamic
Posturography
file:///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
Zuraida Zainun
33
*
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


37
*


1. Investigation and diagnosis
2. Explanation
3. 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
Epleys 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.
40
*

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 321360

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