bed side examination of the dizzy patientHerman Kingma, ORL-HNS department
- 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
history + bedside-examination + explanation
• 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 !!!
history
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
history: my tip
image stabilisation
balance control
spatial orientation
interpretationlearning
adaptationcompensation
CNS
labyrinths
visiongravitoreceptors
hearing
somatosensoryfoot sole pressure
circadian rhythmautonomic processes
blood pressure heart beat frequency respiration rate
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
symptoms of vestibular dysfunction
patient with severe bilateral vestibular hyporeflexia
slow tandem walk fast tandem walk
cmesthal
cortex
pons cer
vn
omn
cgl
VOR: 8 msec OKR and Smooth pursuit: >75 msec
simulation of oscillopsia reduced dynamic visual acuityin case of bilateral vestibular areflexia
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
• 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
5 major patternsBronstein and Lempert
”Dizziness”
a vestibular function loss implies
permanent impairment
analogue to hearing and visual losses
… and neuroplasticity differs per patient…!
bed-side examination
bed-side examination
balance• observe patient at entrance
Romberg eo/ec, tandem walk slow vs fastoculomotor• gaze and fixation• convergation / amblyopia / cover test / skew deviation• pursuit and saccadesstatic 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
without Frenzel’s glasses1. observe patient’s gait / posture2. Romberg + tandem
if abnormal: past pointing test3. gaze and fixation4. convergence, amblyopia,
cover test, skew deviation5. pursuit6. saccades
with Frenzel’s glasses6. spontaneous nystagmus7. Hallpike + HC-test8. 3d VOR + OCR9. head shake nystagmus test
without Frenzel’s glasses10. head impulse test (H/V)11. fixation suppression test12. observe patient’s gait / posture
specific bed-side examinationof the vestibular function
spontaneous eyes open nystagmus
vertical, horizontal symmetric or pendular
always central (acquired or congenital)
1st, 2nd or 3rd degree horizontal
mostly peripheral sometimes central
impact of visual fixation upon nystagmus
nystagmus increases by visual fixation
always central (acquired or congenital)
nystagmus decreases upon visual fixation
always peripheral
Hallpike
Hallpike
leftright
Hallpike
sidewardsor mid-Hallpike
right PC-canalolithiasis or cupulolithiasis
left PC-canalolithiasis or cupulolithiasis
left or right AC canalolithiasis or cupulolithiasis
right HC-canalolithiasis
sidewardsor mid-Hallpike
PC canalolithiasis or cupulolithiasis: most common peripheral vestibular dysfunction
Hallpike
Hallpike
sidewardsor Hallpike
left PC-canalolithiasis
left or right AC canalolithiasis or cupulolithiasis
right HC-canalolithiasis geotropic
left HC-canalolithiasis geotropic
right HC-cupulolithiasis apo-geotropic
left HC-cupulolithiasis apo-geotropic
sidewardsor Hallpike
sidewardsor Hallpike
sidewardsor Hallpike
right left
Hallpike
Hallpike
leftright
Hallpike
sidewardsor mid-Hallpike
right PC-canalolithiasis
left PC-canalolithiasis
left or right AC canalolithiasis or cupulolithiasis
right HC-canalolithiasis
left HC-canalolithiasis
right HC-cupulolithiasis
left HC-cupulolithiasis
sidewardsor mid-Hallpike
sidewardsor mid-Hallpike
sidewardsor mid-Hallpike
exclude neurological origin of a down beat nystagmus
normal tests: if history points to deficit
manage patientin line with the history
(but no ablative therapies)
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
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