Download - Peripheral vestibular disorders - Diagnostic tools

Common Peripheral Vestibular Disorders

Diagnostic Tools

Sasan Dabiri, MD, Assistant Professor

Department of Otorhinolaryngology – Head & Neck Surgery

Amir Alam Hospital – Tehran University of Medical Sciences

November 2016

Common Peripheral Vestibular Disorders – Diagnostic Tools

I n t r o d u c t i o n

Vertigo

Presyncope

Disequilibrium

Psychiatric

Not specific

Dizziness - Etiology


I n t r o d u c t i o n

Vertigo

Presyncope

Disequilibrium

Psychiatric

Not specific


Peripheral

Central



Ve r t i g o - D i a g n o s t i c To o l s

T h e a c c u ra te d i a g n o s i s o f t h e u n d e r l y i n g e t i o l o g y

i s a n i m p o r t a n t f i r s t s te p i n t h e t r e a t m e n t o f v e r t i g o



ImagingAudio-

Vestibular Tests

Physical Exam.

History





History

True or pseudo vertigo One attack or more Episodic or continuous Duration of each episode How starts in first time

(straining, trauma)

Effect of head movement, life style, environment

Effect of ear pressure changes Associated symptoms Associated histories

(medical, family, psychologic)



Physical Exam.

History

Otoscopic Examination (Normal) Nystagmus Vibration (SSCD, MD, VN) Hyperventilation (phobia, demyelination

[pressure by AN or vascular])

Sound/Pressure H I T test SVV (otolith dysfunction) Head shaking Positional testing (Hallpike)



Audio-Vestibular

Tests

Physical Exam.

History

VNG (saccade, pursuit, nystagmus) evaluation as evoked in VNG

• Caloric Test lower freq. • Head Shaking 1-2 Hz• V-HIT 3-5 Hz

VEMP Rotatory Chair C D P ECOG PTA-SRT-WRS, AR



ImagingAudio-

Vestibular Tests

Physical Exam.

History

C T :• SSCD Sx.• LVA Sx.

M R : • Meniere’s Disease• R/O CP Angle lesions & Other DDx


C o m m o n D i s o r d e r s

BPPVMeniere’s

Disease

SSCD Sx.Vestibular Neuritis


Robert BárányAustrian Anatomist

1876 - 1936


B e n i g n Po s i t i o n a l Pe r i p h e r a l Ve r t i g o

Short episodes of severe vertigo after specific movements of head rolling over in bed extreme posterior extension of head

• changing a light bulb• looking under a sink

Turning head to one side (Lt or Rt)

History of trauma, Vestibular Neuritis, Meniere’s D., Surgery (Stapes), Bed rest

Dix-Hallpike test + appropriate historythe most important factors for Diagnosis

History

Physical Exam.


B e n i g n Po s i t i o n a l Pe r i p h e r a l Ve r t i g o

Differential Diagnoses :

Vestibular Paroxysmia

(Dx Criteria , Carbamazepine responsive)

Differentiate with Clinical Findings (and Paraclinics if needed)

Central causes of Positional Nystagmus Demyelinating diseases (MS)

Cerebellar diseases

Around 4th Ventricle lesions

Differentiate with Nystagmus specifications

History

Physical Exam.


Prosper MeniereFrench Physician

1799 - 1862


M e n i e r e ’s D i s e a s e

Clinical Triad with special attention to : Incapacitating spinning vertigo, usually in the horizontal axis

Aural fullness as an equivalent to tinnitus

Life style effect (diet)

Environmental effect (weather, allergy)

Positive Family History

Tumarkin attack (sudden falling without vertigo or consciousness loss)

Lermoyes feature (unusual improvement of associated symptoms)

Horizontal nystagmus as the cardinal finding (during attacks)

Vibration induced nystagmus

History

Physical Exam.

Audio-Vestibular

Tests

Imaging



Caloric test Increased warm & Diminished cold response in affected ear (DP)

ECoG Amplitude : SP/AP more than 0.4

Duration : AP more than 3 ms

Limitations :• Variability in recording technique

• Variability in electrode placement

• Variability with age

• Not good reproducibility

• Under the effect of hearing loss

• Under the effect of stage of disease

• False positive (20%) & False Negative (40%)

History

Physical Exam.

Audio-Vestibular

Tests

Imaging



cVEMP Reduced amplitude

Higher threshold

Not good response to routine sound frequency (1000 Hz is better than 500 Hz)

Video HIT is rarely useful

MRI Axial 3T MRI of the inner ear, 3D Flair,

4 hours after double dose IV Gd (!)

History

Physical Exam.

Audio-Vestibular

Tests

Imaging



Differential Diagnoses :

Vestibular Migraine Diagnostic Criteria

Overlap with each other

Otosyphilis Related History

CT and MR findings

Extra temporal findings

History

Physical Exam.

Audio-Vestibular

Tests

Imaging


Antonio ScarpaItalian Anatomist

1752 - 1832


Ve s t i b u l a r N e u r i t i s

Sudden onset of severe vertigo (days) + Vegetative symptoms

Head Thrust (HIT)


Audiometry (not new changes)

Caloric test

Video HIT

VEMP is rarely useful

Central Mimickers : Brainstem lesions

Differentiation by clinical findings

History

Physical Exam.

Audio-Vestibular

Tests

used to identify the side of involvement


Josef HyrtlAustrian Anatomist

1810 - 1894


S u p e r i o r S e m i c i r c u l a r C a n a l D e h i s c e n c e S y n d .

Clinical findings : Autophony

Tullio phenomenon (not in all patients)

Hennebert Sign

Cough / Strain induced symptoms

Tinnitus (mostly pulsatile)

Conductive Hearing Loss (NL middle ear)

Bizzare symptoms (hearing of eye movement)

Easy Dizzy

Weber test to the lesion (even from foot !!!!! )


Sound / Pressure / Valsalva induced nystagmus

Variations of symptoms

between Patients

History

Physical Exam.

Audio-Vestibular

Tests

Imaging



Audiometry CHL (Change in Bone threshold) with preserved stapedial reflex

VEMP

lower thresholds for response & increased amplitude of response

oVEMP is better than cVEMP (bone stimulation is better)

ECoG May show some abnormalities ?????

History

Physical Exam.

Audio-Vestibular

Tests

Imaging



Temporal bone HRCT (bone window , reformatted view)

History

Physical Exam.

Audio-Vestibular

Tests

Imaging



Differential Diagnosis :

Perilymph Fistula

(to endolymph) or (to middle ear) Hx. of trauma, cholesteatoma, ear surgery (may be present)

Hx. from childhood

Direct disease related hearing loss is SNHL

History

Physical Exam.

Audio-Vestibular

Tests

Imaging

Large Vestibular Aqueduct Hyrtl’s fissure


R e f e r e n c e s• Rose BD et al. UpToDate. http://www.uptodate.com/contents/search (last seen: Oct. 2016)

• Approach to the patient with dizziness

• Evaluation of the patient with vertigo

• Pathophysiology, etiology, and differential diagnosis of vertigo

• Overview of nystagmus

• Pharmacologic use of glucocorticoids

• Flint PW et al. Cummings Otolaryngology - Head & Neck Surgery, 6th ed. (2015)

• Principles of applied vestibular physiology

• Evaluation of the patient with dizziness

• Peripheral vestibular disorders

• Surgery for vestibular disorders

• Bronstein AM et al. Oxford Textbook of Vertigo and Imbalance. 1st ed. (2013)

• Hain TC. MRI Imaging of Meniere's Disease/Syndrome. http://www.dizziness-and-balance.com/disorders/ menieres/mri-hydrops.html (last modified: Jul. 2016)

• Baráth K et al. Detection and Grading of Endolymphatic Hydrops in Meniere Disease Using MR Imaging. Am J Neuroradiol 2014; 35: 1-6

• Curthoys IS. The Interpretation of Clinical Tests of Peripheral Vestibular Function. Laryngoscope 2012; 122: 1342–52

• … and some web sources for photos

http://www.uptodate.com/contents/search

http://www.dizziness-and-balance.com/disorders/menieres/mri-hydrops.html

Current presentation content is available at: h t t p : / / t u m s . a c . i r / f a c u l t i e s / s - d a b i r i

Download - Peripheral vestibular disorders - Diagnostic tools

Top Related