Vestibular disorders

1. Vestibular Disorders
Ozarks Technical Community College
HIS 125

2. The Human Ear
The inner ear/labyrinth houses both the
organs of hearing and balance
Hearing=cochlea
Balance=semicircular canals and otolith
Balance is the ability to maintain the body’s
center of gravity over its base of support

3. A
n
a
t
o
m
y

4. Anatomy of the Vestibular
System

5. Anatomy
•Semicircular Canals
•Detect rotation in the different planes
•3 canals
•Superior, Horizontal, Posterior
•Otolith Organs: contain otoconia (“ear
rocks”) in a gelatinous membrane to
stimulate hair cells to detect linear
accelerations
•Utricle: horizontal plane (side-to-side)
•Saccule: vertical plane (up and down,
front to back)

6. The VOR
Vestibulo-Ocular Reflex
stabilizes images on the retina during head
movement by producing an eye movement in the
opposite direction of the head movement
This eye movement is called nystagmus
Preserves the image on the center of the visual
field
head moves right, eyes move left

7. Three Inputs to the Brain
Our brain integrates information from the
following systems to help us keep our
balance:
Vision
Vestibular
Proprioception (sensors in our feet)

8. Balance

9. Dizziness
For patients of all ages, the three most
common complaints to physicians are:
Headache
Back Pain
Dizziness
Dizziness is the #1 medical complaint in patients
over the age of 70

10. “Dizziness” is a vague term
Describe how you feel without using the
word “dizzy”
Swimmy feeling
Lightheaded
Heavy head
Off-balance
Dysequilibrium
VERTIGO

11. Vertigo
Sensation of spinning
Subjective vertigo=the patient feels like they are
spinning
Objective vertigo=the patient feels like the room
is spinning
Vertigo is most commonly associated with a true
vestibular disorder

12. A diagnostic conundrum…
LOTS of factors contribute to dizziness
Vision
Vestibular
Musculoskeletal/orthopedic
Neurological factors (MS, stroke)
Aging
Cardiovascular issues
Metabolic (diabetes, thyroid, dehydration)
Medications
Stress/anxiety

13. Most Common Vestibular
Disorders
Meniere’s disease
Benign paroxysmal positional vertigo (BPPV)
Vestibular neuritis
Vestibular labyrinthitis
Migraine
Or, if you are a college student…alcohol!
Alcohol is lighter than blood, so the hair cells float in the
endolymph. This causes the “bed spins” when you close
your eyes (take away vision) and lay down (feet off
ground=no proprioceptive cues)

14. Meniere’s Disease
Due to cochlear hydrops=overaccumulation
of endolymph in the cochlea
Usually characterized by 4 symptoms:
Periodic episodes of rotary vertigo or dizziness
(lasts hours to days)
Fluctuating, progressive, low-frequency hearing
loss (SNHL)
Tinnitus (often a “roar” or “buzz”)
A sensation of "fullness" or pressure in the ear

15. Common Audiogram in
Meniere’s Disease
In the early stages of
Meniere’s, the hearing
loss effects only the
low frequencies
As the disease
progresses, the
hearing loss will flatten
Usually results in poor
word recognition
scores
From: www.hearinglink.org

16. Meniere’s Disease
Cochlear Cross-Section
*Note the
displacement of
the vestibular
membrane due
to the
overabundance
of endolymph in
scala media
Hawkelibrary.com

17. Causes of Meniere’s Disease
Northern, J. Hearing Disorders (3
rd
ed)

18. Incidence
2/1000 persons
Most commonly unilateral (~75%)
Affects men and women equally
Most common in the patient’s 40s and 50s
Diagnosed based on case history,
audiogram, other specialized tests that look
specifically at vestibular function

19. Two Subvarieties of Meniere’s
Disease
Cochlear Meniere’s disease
No vertigo
Fluctuating and progressive SNHL
Aural fullness/pressure
May or may not have tinnitus
Vestibular Meniere’s disease
Spells of vertigo
No hearing loss
May have aural pressure

20. Meniere’s Treatment
Medication
Diuretic/Water pill=reduces fluid buildup in body
Vestibular suppressant
Meclizine, valium, dramamine
Steroids
Ototoxic medications
Meniere’s Diet
Restrict intake of salt, MSG, alcohol, chocolate, caffeine
Surgery
Endolymphatic shunt
Labyrinthectomy
VIII Nerve Section

21. BPPV
Benign Paroxysmal Positional Vertigo
Most common complaint: “I get dizzy when I roll
over in bed”
Due to loose otoconia floating in the semicircular
canals
Diagnosed with Dix-Hallpike Test
characterized by rotary nystagmus and vertigo which
lasts several seconds
Treatment
Canalith repositioning =putting loose otoconia back
where they belong
Epley manuever

22. Neuritis vs. Labyrinthitis
Usually viral inflammation of inner ear cavity
Vestibular Neuritis=inflammation of nerve
Sudden onset vertigo (hours to days), nausea,
and vomiting
Vestibular Labyrinthitis=inflammation of inner
ear/labyrinth
Same symptoms as neuritis AND otologic
symptoms
Hearing Loss
Tinnitus

23. Treatment for VN or VL
Patient will spontaneously recover after a
period of days to weeks
Medications to reduce dizziness and nausea
Antibiotics won’t help because this is not usually
a bacterial infection
BPPV is very common after a case of VN or
VL (Epley manuever)
For those patient’s that do not recover
spontaneously:
VESTIBULAR REHABILITATION

24. Vestibular Rehabilitation
May be performed by an audiologist
More commonly performed by a physical
therapist
Aids in compensation of the brain after a
vestibular insult, which makes the patient
feel better faster
Uses exercises that result in varying inputs
to the visual, vestibular and somatosensory
systems
Improves functional balance

25. Migraine-Associated Dizziness
Very common cause of dizziness
Approximately 35% of migraine patients have
some vestibular syndrome at one time or another
May not get a physical headache, but
instead the migraine manifests itself as
vestibular symptoms (vertigo, ear pressure,
tinnitus, nausea)
Commonly misdiagnosed as Meniere’s disease
Commonly accompanied by sound and light
sensitivity

26. Other Otologic Conditions that
Cause Dizziness
Superior Semicircular Canal Dehiscence
Perilymph Fistula
Vestibular schwannoma/acoustic neuroma
These conditions may result in:
Tullio Effect = sound-induced vertigo/nystagmus
Hennebert’s Phenomenon = pressure-induced
vertigo/nystagmus

27. How do we know if vertigo is
due to a vestibular weakness?
Case History
Onset, duration, ear symptoms, nausea
Audiologic and vestibular evaluation
Puretone and immittance audiometry
Video- or electro-nystagmography
Rotary chair testing
Computerized dynamic posturography
Vestibular-evoked myogenic potential (VEMP)
Electrocochleography (ECoG)

28. Videonystagmography (VNG)
Most common tool to assess vestibular function.
Consists of 3 subtests:
Oculomotor testing: the patient follows a visual
target with their eyes . Looking for nystagmus and
abnormal patterns.
Positional testing: checking for BPPV
Caloric testing: irrigate ears with water of calibrated
temperature, which stimulates the horizontal SCC
so we can see how well the vestibular system
works. The GOLD STANDARD for identifying the
affected ear in a vestibular disorder.

29. Rotary Chair Testing
Preferred test method
for children
Cannot provide ear
specific information

30. Computerized Dynamic
Posturography
Sensory Organization
Test
Varying inputs to the 3
systems: vision, vestibular,
proprioception
Motor Control Test
Measures reaction time to
disturbance of the platform
(pulling the rug out from
under them)
Assesses fall risk

31. VEMP (vestibular-evoked
myogenic potential)
Loud click sound in
test ear and we
measure resulting
muscle reflex in
neck
Abnormal VEMP in
patient’s with
Meniere’s, perilymph
fistula, SSCD

32. ECoG (electrocochleography)
Loud click in test
ear and we record
the electrical
potential from the
cochlea
Abnormal ECoG in
pt with Meniere’s,
perilymph fistula,
SSCD