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diagnosis
Han Young Hoon, M.D.
Department of Otorhinolaryngology, Head & Neck Surgery, MNUSC
Basic Anatomy & physiology
• The physiologic range of head movements in SCC : 0.1 to 15 Hz
: in this range SCC integrate acceleration signal into a velocity signal.
• Resting firing rate in each afferent of SCC and Otolith organs
:10~100 spikes/second
• Activity in the vestibular nerve is the major source of sensory input to
the vestibular nuclei, with almost 30,000 afferents projecting from each
labyrinth to the brainstem in humans
• The limits of stability are defined by a horizontal ellipse measuring
approximately 12.5 degrees from front to back.
• The lateral dimension of limits of stability depends on the subject’s
height relative to spacing between the feet. For a person 70 inches tall
with feet placed 4 inches apart, the lateral dimension of the “limits of
stability” ellipse is approximately 16 degrees from left to right.
Definitions of vestibular Sx.
( by International Classification of Vestibular Disorders)
• Vertigo - sensation of self (internal) or environmental (external)
movement when such movement is not occurring, for example,
spinning, rocking, swaying, tilting, bobbing, sliding, or bouncing.
• Dizziness - sensation of disturbed or impaired spatial orientation
without a sensation of self or environment movement
• Unsteadiness - sensation of being unstable-independent of position
without a directional preference.
Kerber KA, Meurer WJ, West BT, et al. Dizziness presentations in U.S.
emergency departments, 1995–2004. Acad Emerg Med. 2008;15(8):744–750
Vertigo
• Vertigo
: an illusion of spinning movement of subjective or objective
1. True Vertigo
• must be nystagmus with spinning sense in opened eyes
• vestibular system origin
• mostly is induced by ENT origin, pre-vestibular nuclei
region
2. False Vertigo
• rotatory sense of one’s head only in closed eyes
• not true vertigo, r/o psychological Dx.
Vertigo
• Vertigo
3. Central Vertigo
• vertigo due to a disease originating from the CNS
• Cause
: hemorrhage or ischemia to the cerebellum, vestibular
nuclei, and their connections within the brainstem
: CNS tumor, infection, trauma, multiple sclerosis
Most of Sx. is gradually developed acute Sx. rare
Differential Diagnosis of Vertigo
Peripheral lesion (vertigo) M/C, no CNS Sx.
Vestibular nuclei’s lesion Combined peripheral and CNS Sx.
Central lesion (vertigo) rare, no hearing Sx.
Unknown 18.9
42.3 (both) 13.3 21 13.6
or Unlocalized 5.5, 40%5
- Mann’s test
Figure 3: mCTSIB—Normal stability, eyes open (NSEO).
Figure 4: mCTSIB—Normal stability, eyes closed (NSEC).
Figure 5: mCTSIB—Perturbed stability, eyes open (PSEO).
Figure 6: mCTSIB—Perturbed stability, eyes closed (PSEC).
Figure7: Single leg stance golf swing take-away position.
Figure 8: Single leg stance golf swing follow-through position.
Neurotologic examination in dizzy Pts.
b. Deviation test (Lim coordination test)
- past pointing test
: 10 times with EO then more
10 times with EC : (+) > 10cm
: both lateralization peripheral
: widen or deviation central
- tandem walk test
: heel to toe walk on line
Neurotologic examination in dizzy Pts.
b. Deviation test
Central origin
BPPV
BPPV diagnosis in variable SCC
Diagnosis
Type
Maneuver Induced nystagmus
Dix-Hallpike Upbeating torsional
PSCC
Side-lying geographic Ny.
Schematic illustration of
Hallpike’s bithermal caloric test
Physical examination in dizziness Pts.
• General neurologic examination
• Audiologic test
: PTA,
BERA
Specific Laboratory test in dizziness Pts.
1. Electronystagmogram (ENG)
: Measure orbital movement electrically using charge difference between
retina and cornea to detect eye movement
: Compare Time and amplitude graph between Rt. & Lt.
: Electrodes are typically placed at each lateral canthus and above and below
at least one eye with a common electrode on the forehead.
: Available to correlate with
Oculomotor test (spontaneous N., Gazing stability, Smooth pursuit, Saccade )
Positional test (Dix Hall pike test, supine roll test)
Positioning test
Caloric test
Provocation test (Valsalva maneuver, Rotatory chair)
Specific Laboratory test in dizziness Pts.
2. Video-nystagmography (VNG) : Video gauided computerizing ENG
: Eye movements are recorded directly using infrared camera and digital
video image technology.
: for binocular recording. a reflected image of the eye is captured by cameras
mounted above, in front of each eye or adjacent to the lateral canthi
Example 1
• Gaze evoked nystagmus
Example 2
Normal Saccades results
Example 3-1
• Caloric Test
Example 3-2
• Bithermal Caloric Test result
Specific Laboratory test in dizziness Pts.
3-1. Rotatory chair
• The purpose of the test
: to expand the investigation of the peripheral vestibular system
by applying natural head movements and using 3 outcome parameters
to characterize the peripheral vestibular system together with its central
projections
(a) the timing relationship between eye movement and steady state
(sinusoidal protocol) or transient (a step test) head movement,
(b) the overall responsiveness of the system to the stimulus,
(c) the responsiveness when rotating to the right versus the left.
: In this manner, the test expands across frequency (beyond that of stimulation
by caloric irrigations) the investigation of the function of the peripheral
vestibular systems.
Specific Laboratory test in dizziness Pts.
3-2. Rotatory chair
: 0.01 ~ 0.64 Hz rotation cf) ordinary
environment 1~5Hz
: Advantage
1) test stimuli are similar to ordinary
times
2) less N/V, Sx. and more controllable
than caloric test
: But It’s hard to test fast stimuli > 1 Hz
and unilateral disease
Specific Laboratory test in dizziness Pts.
4-1. Vestibular-Evoked Myogenic Potential (VEMP)
• The purpose
: to provide information regarding VIII nerve and otolith organ function
: to potentially separate superior from inferior vestibular nerve and
likewise utricular from saccular involvement.
• Advantage
: it provides ear-specific information as like Caloric test .
• oVEMP - is measured at the inferior oblique muscle (directly under the eye) and
is reflection of the VOR
• cVEMP - is measured at the sternocleidomastoid muscle (SCM)
- is a reflection of the ipsilateral vestibule-collic reflex.
( measuring the pathway from the saccule, down the inferior vestibular
nerve to the brainstem, and then to motorneurons in the SCM, which
result in a relaxation of the contracted SCM muscle)
Specific Laboratory test in dizziness Pts.
4-2. Vestibular-Evoked Myogenic Potential (VEMP)