Term
Short Lasting Episodes:
-How long does it last?
-Peripheral or central dysfunction?
-What are some of the potential disorders? |
|
Definition
-A few seconds to a few minutes
-Peripheral
-BPPV, perilymphatic fistula, or SSCD |
|
|
Term
Short Duration Precipitating Factors
-Getting out of bed, rolling over in bed, looking up – common for ___
-Rapidly sitting or standing – ___ ___
-Noises or rapid changes in atmospheric pressure-
___ ___ or _____________.
-Extension or rotation of neck – ___ insufficiency |
|
Definition
| BPPV; orthostatic hypotension; perilymphatic fistula; SSCD; vertebrobasilar |
|
|
Term
Intermediate Episodes:
-How long does it last?
-Peripheral or central dysfunction?
-What are some of the potential disorders? |
|
Definition
-20 minutes to several hours
-Can be central or peripheral
-Meniere's disease or migraine associated vertigo |
|
|
Term
Intermediate Duration Precipitating Factors
-High salt diets – worsen ___
-Perfumes, exercise, certain foods – __________
-Stressful situations –___ |
|
Definition
|
|
Term
Long Lasting Episodes:
-How long does it last?
-Peripheral or central dysfunction?
-What are some of the potential disorders? |
|
Definition
-More than 2-3 hours
-result of unilateral complete permanent injury to the peripheral system
-vestibular neuronitis, labyrinthitis, labyrinthine or neural trauma, cerebrovascular disease. |
|
|
Term
Long Duration Precipitating Factors
-Head trauma – traumatic injury to the vestibular system – ___ ___ ___
-___ ___ – purposeful destruction of the labyrinth or trauma to the ossicular chain, oval window or labyrinth
-Upper respiratory tract illness within 2-3 weeks of onset, or ear infection, or meningitis – ___ ___ |
|
Definition
| post concussive syndrome; Ear surgery; vestibular neuronitis |
|
|
Term
Continuous episodes (uncommon but serious):
-What causes them? |
|
Definition
| Medications, metabolic disease, and psychological disorders |
|
|
Term
| What are some appropriate questions regarding the diagnosis of BPPV? |
|
Definition
-How long does your vertigo last?
-Is there something that you do that causes your dizziness?
-Do you get dizzy just rolling over in bed? Or when bending over or looking up? |
|
|
Term
| What are some appropriate questions regarding the diagnosis of migraine associated vertigo (MAV)? |
|
Definition
-do perfumes, exercise, or certain foods cause your vertigo?
-Are you light sensitive during your dizzy spell? |
|
|
Term
| What are some appropriate questions regarding the diagnosis of anxiety induced vertigo? |
|
Definition
| do stressful situations cause or make your vertigo worse? |
|
|
Term
| What are some risk factors for vertigo? |
|
Definition
-Medications (25% of medications can cause dizziness)
-Neurologic disease- migraines, seizures, MS, stroke, psychiatric diseases -Previous otologic surgery -Family history of otologic and neurologic dysfunction |
|
|
Term
| What are the 4 eye movements that we assess? |
|
Definition
| Saccades, smooth pursuit tracking, gaze stability, and optokinetic nystagmus |
|
|
Term
| Ability to move the eyes in a rapid signal movement to fixate on a target of interest; fastest type of eye movements; speed depends on distance eye must travel to acquire target; can be reflexive or voluntary; targets presented need to require sudden rapid movement of eyes; targets presented within a +/- 30 degree range. |
|
Definition
|
|
Term
| Ability to track the movement of a target of interest maintaining the image on the fovea with smooth continuous eye movements. |
|
Definition
|
|
Term
| Ability to maintain gaze without the generation of other eye movements while looking straight ahead, left, right, up, and down. |
|
Definition
|
|
Term
| Development of reflexive eye movements in the form of jerk nystagmus during visualization of moving objects that fill 80-90% or greater of the visual field of view. |
|
Definition
|
|
Term
| List five types of eye movement which can be assessed as part of a bedside exam |
|
Definition
| Spontaneous nystagmus, saccades, smooth pursuit, convergence/divergence, gaze, and the Romberg test |
|
|
Term
How do you perform each of these bedside oculomotor tests?
-Spontaneous nystagmus
-Saccades
-Smooth pursuit
-Convergence/divergence
-Gaze
-Romberg test |
|
Definition
-Watch the patient for spontaneous nystagmus while taking case history
-Move eyes to finger as soon as it is raised. Try not to anticipate which finger or side
-Ask the patient to smoothly follow my finger as I move from side to side and up and down
-Ask the patient to follow your finger as you move your finger towards the patient and away from the patient
-Put your finger out 30 degrees to the side of the patient and have the patient look at your finger without moving their head. It should induce nystagmus.
-Have the patient stand on the a solid surface with eyes open and then eyes closed and then have them do the same thing but on a foam cushion |
|
|
Term
|
Definition
| Eyes closed, walk in place for 50 steps If patient deviates more than 30 degrees, abnormal result. Not a very reliable way to identify side of lesion. |
|
|
Term
| Describe the Dynamic Visual Acuity test |
|
Definition
| use Snellen chart and compare best corrected vision with head movement of about 2 Hz with best corrected vision. Loss of 3 lines indicated possible deficit. |
|
|
Term
Interpretation of Saccades:
-Velocity: ___ velocity of eye movement during the trajectory from the initial point of regard to the new eye location.
-___: % of distance eye moved in its first single movement relative to that of the target (<100% is undershoot; >100% is overshoot)
-___: time in ms from the initiation of the target movement to the initiation of eye movement
*Standard clinical test does not require different norms based on ___. |
|
Definition
| peak; Accuracy; Latency; age |
|
|
Term
Interpretation of Smooth Pursuit:
-Must use ___-sensitive norms: increases specificity of the test
-Velocity gain: indirectly a measure of how sinusoidal the eye movement was in comparison of peak eye velocity divided by peak target velocity. Gain should be __ if the eye tracked perfectly.
-___: percentage difference for velocity gain for right or left ear moving rightward or leftward.
-___ ___: measures how much the eye is lagging or leading the target |
|
Definition
| age; 1; Asymmetry; Phase angle |
|
|
Term
Optokinetic Nystagmus Analysis:
-Capture and follow a single target (nystagmus will have a large excursion for ___ component “look nystagmus)
-Gaze at center of target and try to ___ the targets as they go by (nystagmus will have low-amplitude slow component “stare” nystagmus)
-Velocity: velocity gain of eye movement response (peak velocity divided by ___ velocity)
-Gain: calculated for target movement to right and to left (should be symmetric- within ___% difference range) |
|
Definition
|
|
Term
Peripheral lesion:
-An acute lesion is usually only visible with ___ present
-Should be ___ fixed and must have a ___ component
-Must follow ___ law
-Must be enhanced with fixation ___ – Primary determiner of peripheral source
-Nystagmus ___ with head-shake test – If ongoing direction fixed, it can usually be enhanced with head-shake testing
-Linear ___ component |
|
Definition
| fixation; direction; horizontal; Alexander's; removed; enhanced; slow |
|
|
Term
| Nystagmus increases in intensity as the gaze is shifted toward the direction of the fast component |
|
Definition
|
|
Term
Central Lesion:
-Nystagmus seen with ___, does not diminish with time
-Can be direction fixed or ___
-Rarely in ___ gaze – Pure ___ or pure ___ can persist in primary gaze
-___ with fixation
-___ nystagmus post head-shake test
-Decreasing speed of ___ component |
|
Definition
| fixation; changing; primary; vertical; torsional; Enhanced; Vertical; slow |
|
|
Term
| What is the Dix-Hallpike used to diagnose? |
|
Definition
|
|
Term
| How do you perform the Dix-Hallpike? |
|
Definition
The patient starts sitting on a treatment table with his or her neck rotated 45 degrees to one side. This neck rotation places the ipsilateral posterior SCC in the sagittal plane, which will be the plane of the movement during this test. The clinician will guide and assist the patient into lying supine with neck now in 30 degrees of extension.
· The position change from sitting to supine should be performed relatively quickly, over the course of a couple of seconds. This position is maintained and the clinician monitors the patient’s symptoms and eye movements, looking for nystagmus. it is recommended that the patient be kept in the supine position for a time equal to the duration of the nystagmus observed. The patient is assisted to a seated position. The clinician again will monitor the patient for symptoms and nystagmus. The test is repeated with the neck rotated 45 degrees to the other side. |
|
|
Term
| What are 2 maneuvers that treat BPPV for the posterior canal? |
|
Definition
|
|
Term
| Explain the Semont and Epley maneuvers |
|
Definition
-Semont: Have the patient turn their head 45 degrees towards the unaffected side and then quickly lay them down on their side on the effected side. Have them lay there until the nystagmus subsides and then double that time. Then quickly sit them up without moving the head and lay them on the other side.
-Epley: Have the patient look 45 degrees towards the affected ear then lay the patient down in the supine position with their head extended 20-30 degrees. Lay them there for 30-60 seconds and then have them move their head to the other side and lay there for 30-60 seconds. Then have the patient roll onto that side with their face looking down at the table. Lay there for 30-60 seconds and then sit them up. |
|
|
Term
| What are 2 maneuvers to treat BPPV resulting from the horizontal canal? |
|
Definition
| BBQ Roll and Gufoni Maneuver |
|
|
Term
| How do you perform the BBQ roll and Gufoni Maneuver? |
|
Definition
BBQ Roll: Have the patient slow lay down on his/her back. Have the patient roll onto the affect side for 30 seconds then slowly roll onto your back and wait for another 30 seconds. Then roll onto the other side and wait for 30 seconds. Then instruct the patient to gently tuck their chin into their chest and roll onto there stomach and propping themself up on their elbows and wait for 30 seconds. Then gently tuck in the elbow to roll onto the side that you began with and wait for 30 seconds. Then sit up slowly keeping your head level.
Gufoni: Patient starts sitting up in the middle of the table. Quickly lay the patient down on the unaffected side for 2 minutes. Then turn the patient's head 45 degrees towards the ground and kept in this position for another 2 minutes. Then sit the patient up. |
|
|
Term
Pathophysiology of BPPV:
-Displaced ___ are present as mobile densities within the canal (usually posterior)
-After a head movement the mass of otoconia ___ within the SCC
-The movement displaces ___ fluid, deflecting the ___ of the involved canal and eliciting nystagmus and vertigo |
|
Definition
| otoconia; moves; endolymphatic; cupula |
|
|
Term
| The identification of canal involvement for BPPV is based on the ___ of the nystagmus observed when the patient is moved into the provoking position |
|
Definition
|
|
Term
| How do you instruct a patient for caloric testing? |
|
Definition
| “For this next test I’m going to put water/air into your ear for about 30 seconds and see how your eyes move. It might sound a little bit loud at first but do not be alarmed. You may start to feel dizzy - that is normal. Just sit back and try to relax.” Be sure to task the patient |
|
|
Term
Caloric Testing:
Irrigate with appropriate temperature and time based on stimulus type. Response reaches peak about ___ seconds after end of irrigation. When response begins to ___, provide fixation target. Allow fixation for __-__ seconds then remove. Continue recording until response subsides. |
|
Definition
|
|
Term
Calorics:
Can do either warm or cool first (VNG). Need to keep same ___ of temperature for both sides. Wait time between irrigations may be varied (strength of response, length of response, between __-__ minutes after response stopped) |
|
Definition
|
|
Term
| where caloric responses for one ear is significantly weaker than the other |
|
Definition
|
|
Term
| UW is greater than or equal to ___% |
|
Definition
|
|
Term
| When the total strength of the caloric responses is less than ___ degrees/sec, it can be defined as a bilateral weakness. This is usually an indicator of ___ AND ___ abnormality |
|
Definition
|
|
Term
| Compares the strengths between the right beating nystagmus (RW and LC conditions) and the left beating nystagmus (LW and RC conditions) |
|
Definition
| Directional Preponderance |
|
|
Term
-A DP greater than ___% is abnormal
-Significant directional preponderance is often associated with significant ___ weakness to one side |
|
Definition
|
|
Term
| When should you use the Rotary Chair? |
|
Definition
-If you can't perform calorics
-If you want to see what stage of compensation they are in (what does this mean?)
-When you want to get more info for pediatric patients
-If you want to know what the velocity storage mechanism is doing |
|
|
Term
| what disorder is best assessed using rotary chair? |
|
Definition
| Bilateral weakness. If we see a unilateral weakness on calorics but patient not describing symptoms, we assume they are compensated and this will provide more information |
|
|
Term
| What a disadvantage of Rotary Chair? |
|
Definition
|
|
Term
| What is the velocity storage mechanism? |
|
Definition
|
|
Term
| Healthy velocity storage causes the response to continue for __-__ seconds. |
|
Definition
|
|
Term
| Stimulation of the SCC causes nystagmus in the plane of that canal |
|
Definition
|
|
Term
| What kind of nystagmus would you expect for BPPV caused by the posterior canal? Horizontal canal? Anterior canal? |
|
Definition
Posterior: rightward torsional nystagmus/upbeating
Horizontal: horizontal nystagmus
Anterior: rightward torsional/downbeating (controversial) |
|
|
Term
| What frequencies are often tested during rotary chair testing? |
|
Definition
slow frequencies: .01, .02, .04, .08, .16 Hz
Fast frequencies: .32 and .64 Hz |
|
|
Term
-The slow frequencies during rotary chair are able to detect ___ vestibular deficits.
-The fast frequencies ___, ___, and ___. |
|
Definition
| peripheral; test phase, gain, and symmetry |
|
|
Term
| Speed or velocity of slow-phase eye movement compared to the velocity of the chair. |
|
Definition
|
|
Term
| timing; if I move 1 degree, has my eye moved 1 degree in the opposite direction. greatest clinical significance for documenting peripheral dysfunction; timing relationship between vestibular part of VOR and head motion |
|
Definition
|
|
Term
| difference between eyes. When chair changes from CW to CCW |
|
Definition
|
|
Term
| How do you position a patient during rotary chair testing? |
|
Definition
| Head tilted down approximately 30 degrees so that horizontal SCC parallel to the floor and perpendicular to axis of rotation. Secured in chair with some type of seatbelt. Feet, knees, head, and arms, and torso secured. Instructed to keep head stationary. DO NOT suggest nausea or claustrophobia. |
|
|
Term
Rotary Chair:
-all visual information needs to be eliminated = use ___ and have ___ ___ because test is influenced by alertness of patient. -___ lesions affect the velocity storage mechanism.
-Turn chair CW, CCW, CW, then CCW. Side we’re spinning ___ is ear that is being tested |
|
Definition
| blinders; lights off; Brainstem; toward |
|
|
Term
| When should you use rotary chair testing? |
|
Definition
-When you want more information about different
speeds of movement
-When VNG suggests unilateral compensated disorder (no spontaneous nystagmus) despite a unilateral weakness and ongoing complaints
-When caloric results are <10 deg/sec bilaterally, rotation test is used to define extent of bilateral weakness
-When caloric testing cannot be performed
-When results of the two ears cannot be compared reliably (mastoid bowl on one side)
-When baseline is required to follow natural progression of patient’s disease (Meniere’s Syndrome, vestibular schwannoma)
-For determination of effectiveness of treatment (chemical ablation of one or both vestibular systems) |
|
|
Term
Rotary Chair:
-___ phases are vestibular in origin
-___ phases are central in origin as the eyes are re-centered in an attempt to maintain a stable image as patient is rotated |
|
Definition
|
|
Term
| -In bilateral incomplete vestibular loss, gain is lowest/absent at ___ freq and may return in ___ freq. (correlation with self-report dizziness handicap) |
|
Definition
|
|
Term
| Patient stares at fixation light in dark enclosure for 10 seconds, then stares with fixation light off for 30 seconds – patient must be alerted when fixation is absent |
|
Definition
| Spontaneous nystagmus test |
|
|
Term
-Warm irrigations should cause endolymph to become ___ and ___. Causes an ___ response generating a nystagmus toward the irrigated ear
-Cool irrigations should cause endolymph to become ___ and ___. Causes an ___ response which generates a nystagmus away from the irrigated ear. |
|
Definition
| lighter; rise; excitatory; heavier; sink; inhibitory |
|
|
Term
| Rotary chair testing can be helpful in detecting ___ and ___ ___ vestibular disorders |
|
Definition
| bilateral; uncompensated unilateral |
|
|
Term
| How do you perform caloric testing? |
|
Definition
-Start alerting task
-Irrigate with appropriate temperature and time based on stimulus type
-Response reaches peak about 30 seconds after end of irrigation
-When response begins to decline, provide fixation target
-Allow fixation for 10 to 15 seconds then remove
-Continue recording until response subsides |
|
|
Term
UW with Calorics:
Positive number indicates weakness in ___; negative number indicates weakness in ___ |
|
Definition
|
|
Term
Directional Preponderance:
Value of 0% means responses are equal. ___ indicates right beating stronger, ___, left beating stronger |
|
Definition
|
|
Term
| Cutoffs for total caloric response below ___-___ degrees per second are considered to show a bilateral weakness (only used when no asymmetry) |
|
Definition
|
|
Term
| What are some common causes of unilateral weakness? |
|
Definition
Infection, Trauma, and Ischemia affecting labyrinthine blood
supply |
|
|
Term
| What is the most common cause of peripheral bilateral weakness? What is the most common central cause? |
|
Definition
| Vestibulotoxicity; Cerebellar degeneration and tumors |
|
|
Term
| What is the cause of a hyperactive caloric response (rare)? What about failure of suppression from fixation? |
|
Definition
| Central lesion; central lesion |
|
|
