Differential Diagnosis: Vestibular Learning objective: The participant will identify the pathologies associated with complaints of imbalance and dizziness Anne K Galgon PT, PhD, NCS Vestibular and Related Disorders Main symptoms or complaints Symptoms of dizziness Oscillopsia visual perception that stationary objects are moving Postural disequilibrium or imbalance Hypersensitivity to movement Self provoked Environmental movement Differentiation of diagnosis based on the nature of the complaint of dizziness. Duration of dizziness (e.g. dizziness that last for minutes or hours) Type of dizziness (e.g. spinning vs. lightheadedness) Peripheral Sensory Neural vs. Central Nervous System disorders Are symptoms peripheral or central in nature? Peripheral Damage or irritation of the vestibular labyrinth or vestibular peripheral nerve. Central brainstem (vestibular nuclei), cerebellar, or cortical injury. Prognosis for recovery Examination summary results will help to reveal peripheral vs. central causes Neuro-Otologic Diseases Peripheral disorders Otosclerosis Autoimmune Meniere s disease Neuronitis BPPV Central disorders Degeneration Cerebellar Migraine Seizure Stroke Tumors Causes of Dizziness Adapted from Staab, JP. (2000) Diagnosis and treatment of psychologic symptoms and psychiatric disorders in patients with dizziness and imbalance, Otolyngologic Clinics of North America, 33:617-635 Cardiovascular-Pulmonary Illnesses Vertebrobasilar insufficiency Hyperventilation syndrome Orthostatic hypotension Cardiac dysrthymias Vasovagal syncope dysautonomia Psychologic Symptoms Demoralization Avoidance Worry Psychiatric disorders Panic/anxiety Somatization depression Symptoms Lasting Seconds to Minutes Benign Paroxysmal Positional Vertigo Perilymphatic Fistula Anterior Canal Dehiscence Presyncope Benign Paroxysmal Positional Vertigo Positional vertigo with lying down, turning over, looking up or bending over. Usually a complaint of severe spinning Othoconia, calcium carbonate crystals in semicircular canals Idiopathic, Trauma, previous vestibular events, aging Dix-Hallpike Maneuver- anterior and posterior canals Roll test- horizontal canals Canalith Repositioning, Brandt Daroff Exercises Anne Galgon, PT, PhD, NCS 1
Perilymphatic Fistula Barotrauma or head trauma Positional or pressure induce dizziness Hole or opening in round window difficult to diagnosis, pressure induced vertigo rule out dehiscence of bone of superior semicircular canal - rest, surgery Lundy-Ekman (2001) Fig 15.14 Superior (Anterior) Canal Dehiscence History: Positional, pressure or sound induced dizziness : loss of bone between anterior canal temporal shelf and the cranium Diagnosis: Pressure and Sound induced nystagmus MRI Treatment: Surgery (Possible vestibular rehab?) Minor et al, (1998) Presyncope Orthostatic hypotension Dizziness or light headiness with sitting or standing up Temporary reduction in perfusion of CNS after positional change Decrease in BP of greater than 10 mmhg with supine to standing cardiac halter, carotid sinus studies underlying cause, consider patient education for safety, LE strengthening and endurance exercise Symptoms Lasting Minutes to Hours TIA (transient ischemic attacks) Migraines Meniere s Disease Transient Ischemic Attacks Brief episode of neurological involvement with resolution of symptoms Short duration occlusion of CNS vascular structures (Vertebrabasal vascular structures) Cerebrovascular and cardiovascular studies Underlying causes, Multiple TIA may resulting in central vestibular signs, may benefit with Vestibular/Balance Rehabilitation Anne Galgon, PT, PhD, NCS 2
Migraines Headaches, personal or family history Photophobia, visual movement sensitivity Focal spasms or irritations of cranial vascular structure Neurotransmitter receptors Meets HIS criteria of migraine Reduce risk factors, serotonergic medications, exercise, vestibular rehabilitation Meniere s Disease Episodes of fluctuating hearing loss, aural fullness, tinnitus, vertigo Proposed Episodic increase in fluid in the vestibular/cholera apparatus May related inadequate fluid regulation in endolymphatic sac or duct Repeated audiograms Low salt, no caffeine, diuretics, ablative procedures; Vestibular rehabilitation, if there is long standing vestibular paresis Symptoms Lasting For Days Acute Unilateral Peripheral or Central Insult Severe vertigo with nausea lasting > 24 hours Severe loss of balance that resolves for static balance within ~ 72 hours Imbalance in sensory input, vestibular nuclei or central pathways Multiple causes: Neuritis, labyrinthitis, stroke, tumor, head trauma Clinical bedside evaluation Acute: 1-3 days rest, vestibular suppressant medications, steriods for neuronitis (Walker, 2009) Subacute: stop vestibular medications, vestibular rehab Imbalance in Vestibular Sensory Input Static input changes in first 3-day Directional fast beating nystagmus away from side of lesion Instability in sitting, standing, and walking Dynamic input disrupted chronically Unable to maintain gaze stability with head turns Instability with dynamic standing and walking Shepard & Solomon, (2000) Signs of Acute Unilateral Vestibular Involvement Unidirectional horizontal nystagmus Beats away from side of loss of function Loss of VOR reflex When moving toward side of loss of function Triad of head disorientation signs Head tilt to the side of loss of function Ocular tilt response (skew deviation) Ocular torsion response Instability in static sitting and standing Chronic Dizziness Acoustic Neuroma (Resection) Peripheral Vestibular Hypofunction Cervicogenic dizziness Central nervous system Psychological Anne Galgon, PT, PhD, NCS 3
Acoustic Neuroma : Gradual onset of instability and possible hearing loss, mild dizziness with rapid head movements : Benign tumor usually arising from sheath of superior division of CN VIII large tumors will create central signs : MRI : small tumors (monitored periodically with MRI) larger tumor- surgical resection or radiation, Vestibular Rehab, possible management for facial nerve palsy Peripheral Vestibular Hypofunction previous episode of prolonged vertigo and instability, followed by continued symptoms provoked by head movements or visual movements Unilateral peripheral hypofunction Vestibular function test, clinical examination Vestibular rehabilitation Peripheral Vestibular Hypofunction (Bilateral) Ototoxic drugs C/o chronic instability, oscillopsia with head movements Bilateral peripheral vestibular hypofunction IV- aminoglycoside antibiotic (Gentamicin) Oto-degenerative disease Vestibular function test Clinical examination oscillopsia and instability Vestibular rehabilitation Cervicogenic Dizziness Head or neck trauma Pain in c-spine and/or headache Head movement provoked dizziness (controversial) Muscle spasm in cervical spine results in aberrant sensory input to vestibular nuclei causing altered perception Clinical examination: cervical spine and neck movement provoked symptoms PT for c-spine and vestibular rehabilitation Central Nervous System Dizziness and balance complaints Acute or progressive disorders of Cerebellum Brainstem Basal ganglia H/O Concussion, Head injury, MS, Cancer, CVD Neurological Examination, and lab testing- MRI, EMG- nerve conduction velocity testing Balance and functional training Vestibular Rehab for symptoms of dizziness Wallenberg s Syndrome Lateral medullary stroke Blockage of the vertebral or posterior inferior cerebellar arteries Symptoms may vary: central and peripheral signs: Hoarsness, swallowing, (CN X,XII, paralysis of vocal cords) Dizziness and instability (nucleus of CN VIII) Loss of pain and temperature (nucleus of CN V) Facial paralysis (nucleus of CN VII) Abducens nerve palsy (nucleus of CN VI) Cerebellar signs Contralaterial Lower extremity weakness Anne Galgon, PT, PhD, NCS 4
Psychological/ Psychiatric Disorders Psychological Symptoms - demoralization, avoidance, worry Psychiatric Disorders - Panic, anxiety, somatization, depression Psych Fear Response Symptom Focus Mood State Referral? No referral None Noxious avoidance None Concern None Demoralization Possible Referral Definite Referral Clinical Presentation Phobic avoidance Agoraphopia Panic or Generalized Anxiety Preoccupation Somatization Disorder Adapted from Staab, 2000 Chronic Dysphoria Major Depression Chronic Subjective Dizziness : Chronic complaints of movement sensitivity May or may not relate to specific onset : Hypersensitivity to visual and/or vestibular information Anxiety- enhanced fear response : Complaints are vague or visual motion sensitivity Symptoms disproportional to physiological problem» Treatment: Behavior and/or Vestibular Rehab, Optokinetic Therapy Chronic Instability Without Significant Dizziness Primary balance complaints Multifactorial system changes Disease processes in multiple system Central CNS - Small vessel disease Peripheral neuropathy (somatosensory, vestibular, visual) Musculoskeletal changes Cardiopulmonary Aging Poly Pharmacology Multisystem medical management Reduction of intrinsic and extrinsic risk factors Balance and Functional training Summary of Age Related Changes in Balance and Ambulation Prolonged muscle latencies during reactive postural responses Dysmetric scaling of motor responses Ankle weakness Poor detection of dysequilibrum Poor perception of stability limits Abnormal sensory selection or weighting Abnormal response selection Temporal discoordination of motor responses Decreased gait speed and changes in gait parameters Increased attentional demands in balance and ambulation Shumway-Cook & Woollacott, 2007 Anne Galgon, PT, PhD, NCS 5
Falls Risk Factors Intrinsic Individual characteristics Drugs Sedatives Hypnotics 4 or more medication Extrinsic Environmental Poor lighting Objects in pathway Slippery rugs Behavioral Climbing on chair to reach high shelves Hurrying to the bathroom Multi-tasking Summary Differential diagnosis starts with a careful history: Symptoms classification Duration Type of symptoms Onset and progression Test and measures Selected to rule out and confirm diagnosis Anne Galgon, PT, PhD, NCS 6