Vestibujlar assessment

1. Assessing the
vertiginous
patient in ED
Jim Fleet

2. Vestibular assessment - Objectives
1. The differential diagnosis of
“dizziness”
2. Clinical anatomy and clinical
physiology of the vestibular apparatus
3. Diagnostic strategy
4. Clinical assessment techniques

3. History
• 62 year old male shop worker
• Brought into A&E via ambulance 06:00
– Complaining of “room spinning around
him”
• Walked downstairs after waking
normally and felt suddenly unwell
– Sweaty, clammy, nauseated
• Collapsed to ground, unsure if LOC

4. History
•
•
•
•
•
Vomited 3 to 4 times
Difficulty hearing
Mild frontal headache
Oscillopsia
Some rhinorrhea in preceding days
previously, otherwise well
• Nothing like this previously

5. History
• No ongoing medical conditions and no
regular medication
• Smokes 20-30/day since youth
• No alcohol

6. Examination
•
•
•
•
•
G.C.S 15/15
BP - 141/94; P - 88, reg; T – 35 0 C
Sats 99% air, BM 5.4
No meningism
Cardio-respiratory and abdominal
systems normal

7. Examination
•
•
•
•
•
Truncal instability with ongoing vertigo
Gait not assessed
Pupils equal and responsive
No ophthalmoplegia
Loss of hearing right ear

8. Examination
• Other cranial nerves normal
• Tone, power, sensation all normal
• Reflexes
– 2+ and symmetrical
– Plantars down-going

9. Nystagmus
• http://stroke.ahajournals.org/content/4
0/11/3504/suppl/DC1
• 1a

10. Investigations
• ECG – sinus rhythm, normal axis
• Blood – normal haematology and
biochemistry

11. Summary
• 62 year old smoker
• Collapse and acute vertigo
– Symptoms setting
• Vomiting
• Nystagmus and hearing loss
• Investigations normal

12. How to Proceed?
• Differential diagnosis?
• Additional information
– Further history?
– Further investigation?
– Further investigation?
• Inpatient or outpatient?

15. Dizziness
• Non-specific term used by patients
• Summation of symptoms and pathology
– Vertigo
– Disequilibrium
• Any pathology of balance homeostasis
– Pre-syncope
– Nonspecific “dizziness”
• Vestibular pathology important in the
dizzy patient
– 40% peripheral
– 10% central (higher in older age)

16. How common is it?
• Common!
– 3 rd most common medical symptom
reported in general medical clinics
– Most common complaint in over 75s
– 22-30% annual prevalence (Neuhauser, 2009)
(Kroenke, 1989)
(Sloane, 1989)

17. Aetiology
• Broad spectrum of
causes
• Surprisingly similar
in varying settings
–
–
–
–
A&E
Primary care
Medical clinics
Dizziness clinics

18. Anatomy

19. Inner ear anatomy

20. Inner ear anatomy

21. The Hair Cell

22. Central integration

23. Vestibulo- ocular reflex
Lateral rectus
Medial rectus
Oculomotor nucleus
Abducens nucleus
Vestibular nucleus
Neural firing rate
Head turning

24. Diagnostic strategy
• Stepwise approach
• First identify possible vestibular
pathology
– Does my dizzy/falling/unsteady/vertiginous
patient have vestibular deficit?
• Acute/intermittent vs chronic
– Based on history
• Peripheral vs central
– History and examination

25. Acute causes
• Peripheral
– Often common and self limiting
– Often outpatient management and follow
up
• Central
– Rare but more serious
– Often inpatient investigations

26. Differential diagnosis
Acute/intermittent
Chronic
Peripheral
Vestibular neuritis
BPPV
Meniere’s disease
Central
Stroke
Vertiginous migraine
Tumour/nerve
compression
Bilateral
vestibular
disorder
Cholesteatoma
Age related
changes?
Stroke
Tumour
Demyelination

27. Peripheral vs Central Disorder: Symptoms
PVD
Symptoms
CVD
Severe
Vertigo
Not always
Severe at onset
Nausea/Vomiting
Rare
Mild
Imbalance
Severe
Common
Hearing loss
Rare
Mild (except bilateral PVD)
Oscillopsia
Severe
Rare
Neurological symptoms
Common
Fast
Compensation
Slow

28. Identifying the vestibular patient - History
• What do you mean by dizzy?
– “…do you just feel lightheaded or do you see the
world spin around you as if you had just got off a
play-ground roundabout ?” (Evans, 1990)
• Notoriously unreliable E.g. movement
descriptions in syncope
(Newman-Toker, 2007)
– Timing
• ?Acute onset
• ?Recurrent
– Trigger
• ?Spontaneous
– Triage
• ?Red flags

29. Red flags in acute vertigo
(adapted from Barraclough, 2009)
• Any central neurological symptoms or signs
– General neurological
– HINTS testing
• New type of headache (esp. occipital)
– Suggests possible vascular event
• Acute deafness
– Suggests acute ischaemia/damage of the
labyrinth or brainstem
• Altered conscious
– Needs syncope risk stratification if T-LOC
– Encephalopathic process

30. Neurological examination – eyes
• Eye movements
– Assessment for nystagmus
• Is it up/down beating?
• Is it uni-directional?
• Skew
– Cover test
• VOR assessment - Head thrust test
• Dix-Hallpike to Epley manoeuvre if
considering BPPV

31. Head Thrust Test

32. Videos
•
•
•
•
Head thrust test –
Gaze evolved nystagmus
Cover test/skew deviation
Dix-Hallpike
1a +/- 1b
- bmj
- utah
- 3

33. HINTS testing
• Abnormal head trust test less helpful
• Can we improve bedside analysis
• HINTS study (Kattah, 2009)
– Head Impulse test
– Nystagmus – direction changing, vertical
– Test of Skew
• 100% sensitive and 96% specific
• Better than DW MRI up to 48 hours
• Junior neurology residents similar ability
2010)
(Chen,

34. Examination – ears and face
• Tympanic membranes
• New onset deafness
• Pupils
– ? Horners’
• Ataxia/cerebellar signs
• Sensory loss
• General neurological examination

35. Vertigo – what then?

36. Benign paroxysmal positional vertigo
• Free floating otoconia in canals
– Usually posterior
• Most common cause of vertigo
• Short lived intense rotatory vertigo related to
reproducible head position
• Vomiting unusual, hearing normal
• Rotatory upbeating, non-sustained
nystagmus (beware down beating)
– Dix-Hallpike 79% sensitivity and 75% specificity
(Halker, 2008)
• Epley manoeuvre rapidly fix problem
– 92% at 6 months and falls reduction
(Gananca, 2010)
(Richard, 2005)

37. Video – Epley manoeuvre

38. Summary
• 62 year old smoker
• Collapse and acute vertigo
– Symptoms setting
• Vomiting and ataxia
• Nystagmus and hearing loss

39. Other points - examination
• External ear normal
• Nystagmus
– Spontaneous bi-ocular leftwards horizontal
jerk nystagmus accentuated by left gaze,
suppressed by fixation
• Hearing
– Weber’s test to left
• Thrust test positive to right

40. MRI

41. Progress
• Remained ataxic
• Stayed for further inpatient
investigation
• Neurology and ENT review
– CVA?
– Acute labyrinth failure ? cause
• Sent to tertiary centre

42. Progress
• Images r/v
– ? Maturing frontal and cerebellar
contusions and evolving subdural
haematoma
• CT head
– R transverse petrous fracture involving
labyrinth and petrous potion of semicircular canals
• Gradual compensation
• For local follow up with ENT and falls
service

43. Summary
1. Vestibular anatomy/physiology
explains vertigo
2. Careful history can exclude mimics
3. Care examination can differential
peripheral and central causes

46. Mechanisms of Vertigo/dizziness
• Baloh & Honrubia, 2001
Type
Mechanism
Physiological
Sensory conflict due to unusual combination
of sensory inputs e.g. motion
Imbalance in tonic vestibular signals
Vertigo
Visual
Multi-sensory
Psychological
Disequilibrium/ataxia
Mismatch of visual and vestibular signals
e.g. Ocular and vestibular pathology
Impairment of 2 or more sensory inputs of
balance
Impairment of central integration of sensory
inputs
Loss of neurological function: proprioception,
motor, cerebellar

47. Vestibular pathology - is it important?
• Increasingly recognised
– Associated with reduced quality of life
– Symptoms often impairing
• 80% in vestibular dizziness
– Greatly increased risk of falls
• x12
(Agrawal, 2009)

48. Vestibular pathology - is it important?
• Asymptomatic prevalence exceptionally
common
• Also increased risk of falls
• 35.4% of US adults aged 40 years
• 84.8% in over 80s (Agrawal, 2009)
– Accumulation of damage with poor
compensation
– Depletion of vestibular hair cells and otoliths
– Dysfunction of the remaining hair cells
– Loss of vestibular ganglion cells

49. Relevance to elderly care?
• Age groups concerned
• Non-specific presentation
– Often referred to elderly care
• Multi-factorial
– Non speciality specific condition
– Patient preference
• Important sequelae
– Falls/fractures/function
• Treatable

50. Blood Supply

51. • http://www.asha.org/aud/articles/Centr
alVestib/