peripheral vestibular disorders - diagnostic tools

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  • Common Peripheral Vestibular Disorders

    Diagnostic Tools

    Sasan Dabiri, MD, Assistant ProfessorDepartment 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

  • 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

    Peripheral

    Central

    Dizziness - Etiology

  • Common Peripheral Vestibular Disorders Diagnostic Tools

    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

  • Common Peripheral Vestibular Disorders Diagnostic Tools

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

    ImagingAudio-

    Vestibular Tests

    Physical Exam.

    History

    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

  • Common Peripheral Vestibular Disorders Diagnostic Tools

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

    ImagingAudio-

    Vestibular Tests

    Physical Exam.

    History

    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

  • Common Peripheral Vestibular Disorders Diagnostic Tools

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

    ImagingAudio-

    Vestibular Tests

    Physical Exam.

    History

    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

  • Common Peripheral Vestibular Disorders Diagnostic Tools

    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

  • Common Peripheral Vestibular Disorders Diagnostic Tools

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

    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)

  • Common Peripheral Vestibular Disorders Diagnostic Tools

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

    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)

  • Common Peripheral Vestibular Disorders Diagnostic Tools

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

    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

  • Common Peripheral Vestibular Disorders Diagnostic Tools

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

    ImagingAudio-

    Vestibular Tests

    Physical Exam.

    History

    C T : SSCD Sx. LVA Sx.

    M R : Menieres Disease R/O CP Angle lesions & Other DDx

  • Common Peripheral Vestibular Disorders Diagnostic Tools

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

    BPPVMenieres

    Disease

    SSCD Sx.Vestibular Neuritis

  • Common Peripheral Vestibular Disorders Diagnostic Tools

    Robert BrnyAustrian Anatomist

    1876 - 1936

  • Common Peripheral Vestibular Disorders Diagnostic Tools

    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, Menieres D., Surgery (Stapes), Bed rest

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

    History

    Physical Exam.

  • Common Peripheral Vestibular Disorders Diagnostic Tools

    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.

  • Common Peripheral Vestibular Disorders Diagnostic Tools

    Prosper MeniereFrench Physician

    1799 - 1862

  • Common Peripheral Vestibular Disorders Diagnostic Tools

    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

  • Common Peripheral Vestibular Disorders Diagnostic Tools

    M e n i e r e s D i s e a s e

    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

  • Common Peripheral Vestibular Disorders Diagnostic Tools

    M e n i e r e s D i s e a s e

    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

  • Common Peripheral Vestibular Disorders Diagnostic Tools

    M e n i e r e s D i s e a s e

    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

  • Common Peripheral Vestibular Disorders Diagnostic Tools

    Antonio ScarpaItalian Anatomist

    1752 - 1832

  • Common Peripheral Vestibular Disorders Diagnostic Tools

    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)

    Vibration induced nystagmus

    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

  • Common Peripheral Vestibular Disorders Diagnostic Tools

    Josef HyrtlAustrian Anatomist

    1810 - 1894

  • Common Peripheral Vestibular Disorders Diagnostic Tools

    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 !!!!! )

    Vibration induced nystagmus

    Sound / Pressure / Valsalva induced nystagmus

    Variations of symptoms

    between Patients

    History

    Physical Exam.

    Audio-Vestibular

    Tests

    Imaging

  • Common Peripheral Vestibular Disorders Diagnostic Tools

    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 .

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

    VEMP

    lower thresholds for response & increased amplitude of

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