bed side examination of the dizzy patient Herman Kingma, ORL-HNS department

1. bed side examination of the dizzy patient Herman Kingma, ORL-HNS department

2. history + bedside-examination + explanation • - history, examination and explanation require 20-30 minutes • - take the complaints of the patient seriously: • so, if you lack time ask patient to return for a special consultation

3. history • which complaints are related to vestibular deficits ? • patients often do not know which complaints are • associated with peripheral vestibular dysfunction • patients often think and are afraid that the complaints point • to a brain dysfunction • complaints are frequently a complex mixture of acute …. • and sustained symptoms !!!

4. history: my tip • when taking the history assume that there were and are • acute transient and sustained vestibular complaints • untill you find out that that is not the case

5. somatosensory foot sole pressure vision gravitoreceptors CNS interpretation learning adaptation compensation labyrinths hearing autonomic processes blood pressure heart beat frequency respiration rate circadian rhythm image stabilisation spatial orientation balance control

6. symptoms of vestibular dysfunction • acute loss or fluctuating peripheral vestibular function • transient: vertigo, nausea, falling / imbalance • remaining peripheral vestibular function loss • sustained: • - not feeling well, slight nausea • loss of balance at low speeds or complex situations • reduced dynamic visual acuity • reduced ability to discriminate between • self-motion and environmental motion • secondary: fear and fatigue

7. patient with severe bilateral vestibular hyporeflexia slow tandem walk fast tandem walk

8. cortex c mes cer cgl thal pons omn vn VOR: 8 msec OKR and Smooth pursuit: >75 msec

10. simulation of oscillopsia  reduced dynamic visual acuity in case of bilateral vestibular areflexia

11. acute loss or fluctuating peripheral vestibular function • transient: vertigo, nausea, falling / imbalance • remaining peripheral vestibular function loss • sustained: • - not feeling well, slight nausea • loss of balance at low speeds or complex situations • reduced dynamic visual acuity • reduced ability to discriminate between • self-motion and environmental motion • secondary: fear and fatigue

12. 5 major patterns Bronstein and Lempert ”Dizziness” • single episode of prolonged vertigo + sustained complaints • recurrent vertigo + sustained complaints • recurrent dizziness + sustained complaints • positional vertigo, less often sustained complaints • chronic dizziness, impaired visual acuity, unsteadiness

13. a vestibular function loss implies permanent impairment analogue to hearing and visual losses … and neuroplasticity differs per patient…!

14. bed-side examination

15. bed-side examination • balance • observe patient at entrance • Romberg eo/ec, tandem walk slow vs fast • oculomotor • gaze and fixation • convergation / amblyopia / cover test / skew deviation • pursuit and saccades • static vestibulo-ocular stability • spontaneous nystagmus* • positioning • Hallpike AD/AS * + barbecue AD/AS * • VOR • head shake 3D VOR + OCR* • head shake nystagmus test* • head impulse test (H/V) • additional • fixation suppression test • test for fistula and Tullio phenomenon * preferrably with • Frenzels glasses

16. without Frenzel’s glasses • observe patient’s gait / posture • Romberg + tandem • if abnormal: past pointing test • 3. gaze and fixation • 4. convergence, amblyopia, • cover test, skew deviation • pursuit • saccades • with Frenzel’s glasses • 6. spontaneous nystagmus • 7. Hallpike + HC-test • 8. 3d VOR + OCR • 9. head shake nystagmus test • without Frenzel’s glasses • 10. head impulse test (H/V) • 11. fixation suppression test • 12. observe patient’s gait / posture specific bed-side examination of the vestibular function

17. spontaneous eyes open nystagmus vertical, horizontal symmetric or pendular always central (acquired or congenital) 1st, 2nd or 3rd degree horizontal mostly peripheral sometimes central

19. impact of visual fixation upon nystagmus nystagmus increases by visual fixation always central (acquired or congenital) nystagmus decreases upon visual fixation always peripheral

20. PC canalolithiasis or cupulolithiasis: most common peripheral vestibular dysfunction right left right PC-canalolithiasis or cupulolithiasis Hallpike left PC-canalolithiasis or cupulolithiasis Hallpike left or right AC canalolithiasis or cupulolithiasis Hallpike sidewards or mid-Hallpike right HC-canalolithiasis sidewards or mid-Hallpike left HC-canalolithiasis sidewards or mid-Hallpike right HC-cupulolithiasis left HC-cupulolithiasis sidewards or mid-Hallpike

21. right left right PC-canalolithiasis Hallpike left PC-canalolithiasis Hallpike left or right AC canalolithiasis or cupulolithiasis Hallpike right left sidewards or Hallpike right HC-canalolithiasis geotropic sidewards or Hallpike left HC-canalolithiasis geotropic sidewards or Hallpike right HC-cupulolithiasis apo-geotropic left HC-cupulolithiasis apo-geotropic sidewards or Hallpike

22. right left right PC-canalolithiasis Hallpike left PC-canalolithiasis Hallpike left or right AC canalolithiasis or cupulolithiasis Hallpike sidewards or mid-Hallpike right HC-canalolithiasis exclude neurological origin of a down beat nystagmus sidewards or mid-Hallpike left HC-canalolithiasis sidewards or mid-Hallpike right HC-cupulolithiasis left HC-cupulolithiasis sidewards or mid-Hallpike

23. normal tests: if history points to deficit manage patient in line with the history (but no ablative therapies)

24. optimal patient management: reality • a vestibular deficit implies permanent function loss • stimulation of neuroplasticity and use of rehabilitation exercises in natural environment improve function: • time is valuable: act fast • frequently only the history points to a vestibular deficit • explaining the relation between the deficit and the complaints forms the keystone of the therapy, • allowing the patient to cope with his or her problems