Clinical Assessment of Vertigo edited.pptx

Assessment used in vertigo patients to diagnose.

1. Clinical Assessment of Vertigo Presenter: Dr Stacy Arvinna Binti Jamarun Supervisor: Ass. Professor Dina Hashim

2. What is vertigo? It is not a disease but a symptom. It is a feeling in which the external world seems to revolve around the individual or in which the individual itself seems to revolve in space. Types Rotation : Rotatory vs Non rotatory Peripheral vs Central Imai, T., Takeda, N., Ikezono , T., Shigeno, K., Asai, M., Watanabe, Y., & Suzuki, M. (2017). Classification, diagnostic criteria and management of benign paroxysmal positional vertigo. Auris Nasus Larynx, 44(1), 1–6. doi:10.1016/j.anl.2016.03.013

3. Pathology of Vertigo Vestibular Peripheral (vestibular end organs) Intermediate (vestibular nerve) Central (CNS eg ; vestibular nuclei) Non Vestibular Ocular Other

4. Evaluation of Vertigo General test Nystagmus Oculomotor Test ENT Otoscopy Hearing assesment Neurootology test HINTS Di x Hallpike Maneuver and Supine Roll Test Fistula Test Neurology Test Test of Cerebellar Dysfunction Romberg Test Fukuda stepping test Tandem Gait Laboratory Test Caloric Test Electronystagmography Optokinetics Rotational Test Galvanic test Posturography

5. Clinical test

6. Nystagmus Involuntary rhytmical oscillatory movement of the eyes Triggered by inner ear stimulation Slow pursuit movement initially, fast rapid resetting phase Nystagmus is always named after the direction of the fast phase. Direction Rotatory / Tortional Horizontal Vertical

7. Types of Nystagmus in vertigo Peripheral Nystagmus generally horizontal Suppressed by Optic fixation Enhanced in darkness Central Nystagmus can be horizontal, rotatory or vertical; multidirectional Unable to be suppressed by optic fixation

8. What is Alexander’s law? It's a phenomenon where the slow-phase velocity of spontaneous nystagmus (caused by a vestibular lesion) is dependent on the direction of gaze.  Specifically, the nystagmus becomes more intense when the patient looks in the direction of the fast phase (the quick, corrective eye movement) and less intense when looking in the opposite direction. 

9. Spontaneous Nystagmus Occur while looking straight ahead, sides and focusing Not induced by any stimulus Waveforms Jerk/saw tooth vs pendular(no fast phase/beating direction) Convergence (move object in and out at visual axis)- absence in midbrain lesions but also common in >60 years old. Gaze evoked nystagmus Examiner's finger / pointed objects kept 30 cm away from patient's eyes in centre and moved in horizontal and vertical planes not exceeding 30° (to avoid physiological end-point nystagmus)

10. Oculomotor test Gaze-evoked nystagmus:  Observing eye movements when the patient looks in different directions.  Saccades:  Testing the ability to make quick, jerky eye movements to follow a target.  Smooth pursuit:  Assessing the ability to smoothly track a moving target.  Optokinetic nystagmus:  Evaluating eye movements in response to a moving visual field. 

11. Other Oculomotor testing Smooth pursuit test Track your finger/ light in the horizontal / vertical planes horizontal smooth pursuit is better than vertical and both will diminish with age Saccade test Track back and forth between two fingers about 20 cm apart without moving their head. Observe the eyes for either under- or over-correction and also conjugate movement. Abnormalities in smooth pursuit or saccade testing point to a central problem.

12. Head Shaking Nystagmus Test It is recommended that the clinician tilts the patient’s head ~ 30 degrees downward, and then oscillates the patient’s head horizontally (passively) 20-30 cycles at 1-2 Hz. The patient is instructed to keep eyes open, or should open his/her eyes before the end of 30 cycles if they had been closed. Elicitation of 3 or more beats of nystagmus suggests a vestibular imbalance with quick phase eye movements beating toward the more neurologically active side.

13. hints Consist of 3 components Head Impulse Test Nystagmus Test of Skew A positive HINTS exam has been reported to have a high sensitivity and specificity for the presence of a central cause of vertigo. U seful tool in detecting acute, time-sensitive, central causes of vertigo, including posterior circulation strokes like lateral medullary syndrome. 

14. Head Impulse test T est is done on patients who are currently  symptomatic . ( not symptomatic usually will have normal clinical findings) To perform the  head impulse test : Gently move the patient’s head side to side, making sure the neck muscles are relaxed. Then ask the patient to keep looking at your nose whilst you turn their head left and right. Turn the patient’s head 10-20° to each side rapidly and then back to the midpoint.

15. A  positive test  indicates there is a  disruption to the vestibulo -ocular reflex , so the  eyes move with the head , then  saccade rapidly back to the point of fixation  on the clinician’s nose (a ‘corrective saccade’). Patients will also have  difficulty fixating  on the clinician’s nose. If there is a  corrective saccade  (a positive head-impulse test) this is  reassuring  that the pathology is most likely a problem with the  vestibulocochlear nerve  on the ipsilateral side ( peripheral )

16. Test of skew Ask the patient to look at your nose and subsequently cover one of their eyes. Then, quickly move your hand to cover the patient’s other eye. During this process, observe the uncovered eye for any vertical and/or diagonal corrective movement. Repeat this manoeuvre on the other eye. Any  abnormal movement  observed here, often associated with  vertical   diplopia , is highly specific for a  central  cause of vertigo.

17. Hints intepretation

18. Fistula test Diagnostic procedure used to detect a perilymphatic fistula, an abnormal communication between the inner and middle ear, by observing eye movements (nystagmus) in response to pressure changes in the ear canal.   Producing pressure changes in the EAC which will be transmitted to the labyrinth. The stimulation of the labyrinth will cause nystagmus and vertigo. Applying pressure to the external ear canal (e.g., by pumping the tragus or using a pneumatic otoscope) and observing the patient's eye movements. 

19. Sites of labyrinthine fistula Horizontal semicircular canal Cholesteatoma destruction Fenestration operation Oval window - Post stapedectomy Round window membrane rupture

20. False positive; Hennebert's sign False positive fistula sign in absence of labyrinthine fistula Meniere's disease (fibrosis between stapes footplate and utricle) Hyper mobile stapes footplate (congenital syphilis ) In both these conditions, movement of stapes results in stimulation of Utricular macula False negative Negative fistula sign in presence of labyrinthine fistula Cholesteatoma granulation covering the labyrinthine fistula (prevent pressure change) Dead Labyrinth Total ear canal obstruction

21. Romberg test Neurological assessment used to evaluate balance, specifically assessing proprioception (the body's sense of position and movement) and identifying potential neurological issues by assessing the ability to maintain balance with eyes open and closed. 

22. Fukuda stepping test Patient asked to make 50 steps in one minute with eyes closed and hands out in front in a circle of 1 metre More than 30 degree deviation is taken as positive

23. Tandem gait Tandem gait, or heel-to-toe walking, involves walking in a straight line with the heel of one foot touching the toe of the other foot. It can be scored based on the number of side steps off a straight line, or by measuring the time it takes to complete a certain number of steps.  Useful marker of dysfunction in neurological conditions that extend beyond the vermis or vestibulocerebellar module Yoo D, Kang KC, Lee JH, Lee KY, Hwang IU. Diagnostic usefulness of 10-step tandem gait test for the patient with degenerative cervical myelopathy. Sci Rep. 2021 Aug 26;11(1):17212. doi : 10.1038/s41598-021-96725-6. PMID: 34446786; PMCID: PMC8390502. Cohen HS, Stitz J, Sangi-Haghpeykar H, Williams SP, Mulavara AP, Peters BT, Bloomberg JJ. Tandem walking as a quick screening test for vestibular disorders. Laryngoscope. 2018 Jul;128(7):1687-1691. doi : 10.1002/lary.27022. Epub 2017 Dec 11. PMID: 29226324; PMCID: PMC5995610.

24. Dix hall pike The Dix-Hallpike test is the most commonly used assessment for determining the involvement of the posterior semicircular canal, which is the most frequently affected canal. With the patient sitting up in bed the head is turned 45 degree to the side ( to maximally stimulate posterior semicircular canal ) P atient is brought into a supine position with the head just hanging over the edge of the bed ( 30° below ) P atien t's eyes observed for nystagmus for 1 minute ( Frenzel glasses eliminate visual fixation suppression of response)

25. The test must be performed quickly to ensure adequate displacement of the endolymp and otoconia, which helps to provoke the expected symptoms. A positive result, indicating canalithiasis of the posterior canal, occurs when the test induces vertigo and short-duration nystagmus. The direction of the nystagmus should align with the canal being tested. For the posterior canal, nystagmus will be up-beating and torsional in an ipsilateral direction. For example, if the  left posterior canal is affected  and the head is  turned to the left , the nystagmus will be up-beating and torsional to the left (ipsilateral). If the test is performed  on the unaffected side  (e.g. head  turned to the right  when the left side is affected), the nystagmus will still be up-beating but torsional to the right.

26. Supine roll test This test is to assess for horizontal canal BPPV. Patient is supine. Examiner flexes the cervical spine 20-30 degrees. Examiner quickly rotates the head to the right approximately 45 degrees. Hold for 30 seconds or until nystagmus and/or other symptoms have subsided Slowly return patient's head to midline. Next, quickly rotate patient's head to the left approximately 45 degrees.Hold for 30 seconds or until nystagmus and/or other symptoms have subsided. Slowly return patient's head to midline. Test is positive for nystagmus of other symptomatic complaints during the test. The patient may be positive on both sides. If this happens, the side that has more intense symptoms is considered the affected side.

27. The direction changing nystagmus is called "DCPN" for direction changing positional nystagmus. It may be always "beating" towards the floor ( geotrophic ), or ceiling ( ageotrophic ).

28. Cerebellar test Dysdiadochokinesia:  Difficulty performing rapid alternating movements.  Ataxia:  Loss of coordination and balance.   Intention tremor:  Tremor that worsens during voluntary movement.  Rebound phenomenon:  An exaggerated rebound of the limb when resistance is released Heel to shin test : to examine lower limb coordination Finger nose test/ Past Pointing

29. Past Pointing or dysmetria sign of cerebellar dysfunction where a person overshoots a target when attempting to point with their finger, indicating a problem with fine motor control and coordination.  The patient is asked to touch his nose with his finger and then to touch the examiner's forefinger at full extension. Then the examiner moves his finger to alternate positions. The patient repeats the process of touching his nose and then the examiner's finger as quickly as possible. Next the examiner maintains his forefinger at one location and the patient repeats the process, first with eyes open and then with them closed, as quickly as possible.

30. Laboratory test

31. Caloric test Induce nystagmus by thermal stimulation of the vestibular system Mechanism Convection current formation in endolymph due to temperature gradient -> ampullo -petal or ampullo -fugal flow due to warm or cold water -> activation of Vestibulo - Ocular Reflex -> vertigo and horizontal nystagmus Contraindications E.A.C. obstruction, Ear infection, T.M. perforation, Bradyarrythmias , Labyrinthine sedatives (for 24 hrs)

32. Fitzgerald - Hallpike Bithermal Caloric Test Procedure P atien t lies supine with 30° head elevation ( makes horizontal scc become vertical and more sensitive) and each ear is irrigated in turn for 40 sec with warm water at 44°C & then cold water at 30°C after a gap of 8 mins Duration of nystagmus is counted from start of irrigation to end point of nystagmus (Normal = 90- 140 sec) Direction of fast component (COWS) Cold -> Opposite ear Warm -> Same ear Depressed functions are seen with: Meniere's disease Acoustic neuroma Post labyrinthectomy Vestibular nerve section .

33. Cold Air Caloric Test Performed in perforated tympanic membrane as water syringing is contraindicated Air in coiled copper tube is cooled by pouring ethyl chloride in it Effluent cold air is blown into ear canal to produce vertigo &/ nystagmus

34. 2)electronystagmography U sed to evaluate people with vertigo and certain other disorders that affect hearing and vision. Detecting nystagmus (even which is not seen by naked eye) ; B oth Spontaneous and Induced nystagmus D epends on presence of Corneo -retinal potentials If nystagmus does not occur on stimulation, a problem may exist within the ear, nerves that supply the ear, or certain parts of the brain. This test may also be used to distinguish between lesions in various parts of the brain and nervous system.

35. Electrodes are placed at locations above and below the eye to record electrical activity. By measuring the changes in the electrical field within the eye, ENG can detect nystagmus (involuntary rapid eye movement) in response to various stimuli.

36. 3) optokinetics C ompensatory reflex that supports visual  image stabilization Used to diagnose central lesions (brainstem and cerebral hemisphere lesions) Normally, it produces nystagmus with slow component in the direction of moving stripes and fast component in opposite direction

37. 4)Rotational test Patient seated with head tilted 30 degree forward Rotated 10 turns in 20 seconds Stop the chair abruptly and observe the nystagmus (Normal 25-40 seconds) Performed in case of congenital abnormalities where ear canal has failed to develop (unable to perform caloric test) Disadvantage : Labyrinths cannot be tested individually

38. 5)Galvanic test transcranial stimulation by a direct current, which both, stimulates and inhibits vestibular afferents. The vestibular nuclei are polarized, which then activates the semicircular canals, otolith organs, and adjacent vestibular nerves. It modulates posture and balance, oculomotor responses, and spatial orientation Helps differentiating end organ lesion from vestibular nerve lesion. Feet together, eyes closed, arms out-stretched. Current of 1 mA passed to one ear - normally, patient sways towards side of anodal current. Pires APBÁ, Silva TR, Torres MS, Diniz ML, Tavares MC, Gonçalves DU. Galvanic vestibular stimulation and its applications: a systematic review. Braz J Otorhinolaryngol . 2022 Nov-Dec;88 Suppl 3( Suppl 3):S202-S211. doi : 10.1016/j.bjorl.2022.05.010. Epub 2022 Jul 5. PMID: 35915031; PMCID: PMC9760994.

39. 6) posturography Helps in evaluating vestibular function by measuring postural stability There are 2 types Static posturography  consists of assessing postural control while subjects maintain their stance in a relatively unperturbed state (usually quiet stance on a fixed support surface such as an instrumented platform, i.e. a force plate). Dynamic posturography  consists of assessing the subject's postural control in the presence of experimentally induced external perturbations. This can be done by means of a foam cushion, a special apparatus with a movable support surface, or by applying external perturbations directly to the body, for example by pushing/pulling the trunk, shoulders or pelvis. By performing a combination of static and dynamic posturography in different sensory conditions it is possible to quantify how much a subject's postural control system relies on visual, proprioceptive and peripheral vestibular information to maintain balance. Furman JMR, Baloh RW, Barin K, Hain TC, Herdman S, Horst RK, et al. "Assessment: posturography . Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology." Neurology 1993 Jun;43(6):1261‑4.

40. Thank you