Vestibular Differential Diagnoses

What is to be expected in the subjective history for a patient with suspected BPPV?

“Room spinning”, specific position changes, episodes
brief in duration

What testing is important to rule out other conditions with a patient with suspected BPPV?

• Dix Hallpike or BBQ roll test (horizontal canal)

What are appropriate treatment measures for a patient with suspected BPPV?

Canal repositioning maneuver/Modified epley (posterior canal)

360 roll, appiani, Cassini (horizontal canal)

What is to be expected in the subjective history for a patient with suspected unilateral hypofunction/neuritis?

Initially with roomspinning (typically days). Then c/o imbalance and or lightheadedness (typically exacerbated with head movement)

What testing is important to rule out other conditions with a patient with suspected unilateral hypofunction/neuritis?

Acute - Spontaneous/gaze-holding nystagmus, HIT, DVA

Subacute - HIT, DVA

What are appropriate treatment measures for a patient with suspected unilateral hypofunction/neuritis?

• Adaptation (VOR), Habituation, progressive balance retraining

What percentage of patients with vestibular neuritis will develop BPPV within a short period?

10-15%

What is to be expected in the subjective history for a patient with suspected bilateral vestibular loss?

IMBALANCE, oscillopsia, ↓ visual focus with head movement, possible antibiotic/chemo tx or hx of autoimmune disorder

What testing is important to rule out other conditions with a patient with suspected Bilateral Vestibular Loss?

• Abnormal head thrust, DVA, eyes closed balance on foam

• ABC Scale

What are appropriate treatment measures for a patient with suspected Bilateral vestibular loss?

Substitution exercises, balance retraining, compensatory strategies (e.g. night lights), fall risk education. May still benefit from adaptation activities

What is to be expected in the subjective history for a patient with suspected cervical vertigo?

Usually NOT true roomspinning, Self spinning, lightheaded,
neck pain/trauma?

What testing is important to rule out other conditions with a patient with suspected Cervical Vertigo?

• Rule-out other potential causes

• Goniometrics, proprioception (JPE), Dix-Hallpike response,
  ligamentous integrity

What are appropriate treatment measures for a patient with suspected cervical vertigo?

Manual therapy, STABILIZATION!, proprioceptive ex’s,
POSTURE

What is to be expected in the subjective history for a patient with suspected meniere’s?

Roomspinning dizziness lasting minutes to hours, aural
fullness, tinnitus, hearing loss

What testing is important to rule out other conditions with a patient with suspected Meniere’s?

No gold standard
• May see abnormal positional testing (Dix-Hallpike, supine head turns, MSQ)
• Static/dynamic balance, worse over long periods with disease
• Dizziness Handicap Inventory/ABC Scale

What are appropriate treatment measures for a patient with suspected Meniere’s?

• Dietary modification (link), symptom/dietary journaling, refer, posture,
Habituation exercises
• Tx the “spin-offs”: Visual dependence, neck stiffness,
depression/anxiety

What is to be expected in the subjective history for a patient with suspected Vestibular Migraine?

Headache, dizziness may be present before/during/after HA

What testing is important to rule out other conditions with a patient with suspected Vestibular Migraine?

• Assess for visual/oculomotor sensitivity
• Balance/positional testing
• DGI/FGA, DHI/ABC-scale
• Assess for cervical contribution

What are appropriate treatment measures for a patient with suspected Vestibular Migraine?

Medical management
• Headache journaling, dietary modification (link), refer, cervical tx, balance treatment – including reducing visual dependence, habituation

What is to be expected in the subjective history for a patient with suspected 3PD?

Non-spinning vertigo (rocking, swaying, self-motion),
unsteadiness/imbalance, lightheaded/wooziness, mild dissociation (floating, spaced-out).
• May have visual and/or motion sensitivity. May have history of another vestibular condition which they’ve maladapted to. Also listen for psychological event near sx start

What testing is important to rule out other conditions with a patient with suspected 3PD?

• NO clinical tests specific to this condition
• May be symptomatic with clinical exam
• ABC Scale/DHI/MSQ may be helpful to track progress

What are appropriate treatment measures for a patient with suspected 3PD?

• Habituation exercises
• Education re: triggers and stress management
• Patients may also benefit from mental health counseling (CBT) and med mgm

What is to be expected in the subjective history for a patient with suspected acute stroke?

Acute onset sx’s, recent head/neck trauma?, concurrent
headache?

Possible Findings in patient with suspected acute stroke

• Oculomotor: Vertical spontaneous nystagmus, Normal Head Impulse Test, Internuclear ophthalmoplegia (with saccades), gaze palsy, direction CHANGING nystagmus with gaze holding, ocular misalignment
• General neuro: Facial palsy/droop, sensory loss, limb weakness or ataxia, hemiparesis

Interventions for patient with suspected acute stroke

IMMEDIATE/EMERGENT referral

Pathophysiology affected by acute central vestibular syndrome

Infarct of Posterior Inferior or Anterior Inferior Cerebellar aa. (AICA or PICA) impacting cerebellum and/or brainstem

Symptoms of acute central vestibular syndrome

Acute: Vertigo, emesis, truncal ataxia. Headache,
facial paralysis also possible

Presentation of acute central vestibular syndrome

• Spontaneous nystagmus (more likely vertical or
pure torsional, no fixation suppression)
• (+) Gaze-Holding Nystagmus (direction changing)
• (-) Head Impulse Test
• Other cerebellar or focal neuro signs

What is the HINTS Plus used for

Testing battery to help differentiate acute stroke
vs. peripheral vestibular dysfunction

What tests are included in the HINTS Plus exam

Head Impulse, Nystagmus, Test of Skew, Plus hearing

If head impulse test presents a positive test (unilateral saccade present toward affected side) this indicates

Peripheral impairment

If head impulse test presents a negative test (no saccade/normal) this indicates

central impairment

If a patient demonstrates horizontal nystagmus (beats away from affected side) this indicates

Peripheral impairment

If a patient demonstrates vertical or rotary nystagmus this indicates

central impairment

If the test of skew is negative (no skew) this indicates

Peripheral impairment

If the test of skew is positive (deviation present) this indicates

Central impairment

If hearing test is normal this indicates

Peripheral impairment

If the hearing test discovers new unilateral loss this indicates

central impairment

What type of nystagmus is peripheral?

Direction fixed

What type of nystagmus is central?

Vertical, direction changing, no fixation

If a patient describes vertigo symptoms is their condition peripheral or central?

Peripheral

If a patient describes dizziness/lightheadedness symptoms is their condition peripheral or central?

central

If patient reports hearing changes, nausea or vomitting acutely is this peripheral or central?

Peripheral

If patient reports headache, lateropulsion, visual motion sensitivity is this peripheral or central?

central

Characteristics of peripheral lesions

• Nystagmus is unidirectional with the fast phase toward the more
neuronally active ear
- E.g., hypofunction left ear → fast beat to right
• Nystagmus becomes more pronounced with gaze toward the side of the fast-beating component

Characteristics of central nystagmus

• May be unidirectional or bidirectional
• May be purely vertical or torsional
• Not inhibited by visual fixation
• Direction of the fast component may be directed toward the side of gaze.
(eg, left-beating in left gaze, right-beating in right gaze, up-beating in upgaze).
• Persistent down beating nystagmus suggests Chiari, or cerebellar lesion

What does down beating nystagmus indicate?

CNS.
I.e.) Arnold-Chiari's syndrome, spinocerebellar degeneration, stroke and MS

How to rule out non-vestibular conditions

Rule Out Neurocardiogenic
• Blood Pressure (OH)
- Response to Positional Changes
- Assess BP in supine or sitting and
then standing.

Drop of >20mmHg in systolic or >10mmHg diastolic
within 1 minute = POSITIVE

• Tilt Table Test
• Rule Out Other Factors
• Medication, Stress

What side effect do antidepressants have

dizziness

What side effect do calcium channel blockers have?

dizziness, lightheadedness, headache

What side effect do beta blockers have?

weakness, dizziness, fatigue

What side effect do ACE-inhibitors have?

dizziness as BP is lowered

What side effect do muscle relaxants have?

drowsiness/disequilibrium

What side effect do pain medications have?

confusion, drowsiness, nausea

What side effect do acid reflux medications have?

bleeding gums, irregular heart beat, dizziness, headache