Balance Disorders

Lindsay McInnis “our dear leader”Cagan Randall

Zach Petter

Case #1

C/C Dizziness for 2 wks post episodicInitial Questions:

HISTORY!!!!!!!!!!!!!!Central or Peripheral Lesion?

Acute / Chronic exacerbation?Side of the Lesion?

Ablative / Physiologic?Are they going to die w/o immediate help?

Answers could take a few visits?

Peripheral Lesions

Involvement of CN 8?Infection?Vasculature?Are the canals involved?Is the cochlea involved?Middle ear or outer ear?Rule out trauma?Autoimmunity?Ototoxicity?

Central LesionsBrainstem?Cerebellum?Cortex?Vascular?Systemic involvement (Inflammation)?Cortical imbalance?Pharmacology?Cardiac Conditions?

Consultation Crippling Dizziness lasting 2 weeks, unrelenting; never before experienced Dizziness would wake her up and last all day: “woozy” feeling all day Pt felts strange 3 days prior to episode Perception of eyes “snapping” to the right Vomiting QD during episosde Does not recall hearing loss or a fullness in the ears Sleep was the only escape from dizziness Any head movement created intense dizziness; perception of the world

spinning. No recent trauma including baro-trauma Never ingests high Na foods No past, medical, or social history. No coffee, tea, ETOH, Tobacco Meds: Synthroid, Acylovir, Amantadine No family hx

Consultation II Still confused a bit I ask about any familial illnesses. She tells me

about her daughters (3 yrs old) HFMD. (coxsackievirus single strand rna virus)

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Exam findings38 yr old female, real estate agent

5’4” 135 lb

B/P= 118/78 bilaterally

Carotid pulse= strong/symmetrical

Distal Pulses= strong/ symmetrical

Cardiac exam= no mumurs/thrills

Superficial Artery Auscultation= no bruits auscultated

Lung Fields= clear / resonant chest expansion= 1.5 inches

Otology exam= serous otitis media rt ear. Lt ear WNL no obstruction.

Fundascopic exam= WNL no intracranial press. Optic nerve in tact w/o any vascular changes.

Ortho

Soto Hall -

Jackson’s comp -

Valsalva -

Head thrust + to the left

Dix Hallpike + left posterior produce left tors nystagmus

VOR suppression produce dizziness

RAD= Straight neck; MRI head and c- spine= WNL

Labs…….

Optokinetics

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Thoughts? If bout reoccurs then Hi resolution MRI to image

the endolymphatic membrane to rule out Meniere’s disease.

Case #2

• Female patient, 32 years of age,

presents with a feeling of imbalance

and visual disturbance, onset 1week.

• Imbalance is worse in the dark, or in

situations where footing is uncertain.

• Dizziness and sometimes nausea

feeling.

• Objects appear blurry.

• Eyes feel jumpy.

History cont.

• Mild drinker- couple a night.

• Drug Hx- none

• Medication- Gentamicin (antibiotic) for strep throat 2

weeks ago. NSAIDs for mild HAs.

• Family Hx- Normal family with no real problems.

Exam

• 5’9” tall, 135lbs.• Vitals: WNL• Motor: WNL• Sensory: WNL• DTR: all 2+• Rombergs +, Mittlemyer +, Tandom gait +• One legged stand: cannot perform.

Exam cont.

• Visual tests: – Head thrust +– Horizontal nystagmus +– Verticle nystagmus +– Impaired coordination with

movements– No vertigo

• DDX???

Oscillopsia

• The visual symptoms, occur when the

head is moving.

• Mild blurring to rapid and periodic

jumping.

• Oscillopsia can also be used as a

quantitative test to document

Gentamicin toxicity.

Gentamicin

• Common used antibiotic medication.

• Gentamicin toxicity is the most common

single known cause of bilateral

vestibulopathy.

Bilateral Vestibulopathy

• Occurs when the balance portions of both inner ears are damaged.

• Symptoms typically include imbalance and visual disturbance.

• Imbalance worse at night and with uncertain footing.

• Vertigo is unusual.• All visual symptoms oscillopsia

Bilateral Vestibulopathy• Rotatory chair test with

optokinetic stimulus

superimposed upon its walls.

• The rotatory chair test is the gold

standard for diagnosing bilateral

vestibular loss.

60 year old woman presents to your office complaining of dizziness and blurred vision. She says it is not constant but happens when she gets out of bed and occasionally throughout the day. She feels like the room is spinning to the right for a brief time when she turns her head to the left. It causes her to feel nauseous and she has to close her eyes for a minute. If she stands up right away she cannot hold her balance and will fall back on to her bed.

20 year smoker20 year smokerSocial drinkerSocial drinkerNormal weight, but little activity Normal weight, but little activity since this problem 3 weeks agosince this problem 3 weeks ago

Clinical Findings

• All orthopedic tests were normal• Bloodwork, MRI and CT from a previous

doctor were WNL• Romberg’s test was + to R• Mittlemyer’s was + to R• Dick’s Hallpike was + to L

Differential Diagnosis

• Labyrinthitis • Vestibular neuronitis• Meniere’s Disease• Benign Paroxysmal positional vertigo• Perilymph fistula

Benign Paroxysmal positional vertigo (BPPV)

• Otoconia move from the utricle into the semicircular canal and weigh on the cupula.

• When there is pressure on the cupula it cannot tilt properly and it sends conflicting messages to the brain

Treatment

• Epley maneuver is performed to dislodge the otoconia

• Decrease salt intake• Exercise• Maintain a healthy weight• Adjustments

Slide 7,8,10,11 are slides created by the Carrick Institute by Dr. Brandon Brock