vestibular disordersphysical examination
Permission of patients to show their videos for educational purposes
“keep an eye on the eyes”
goals
1. determining peripheral vestibular deficit:- head impulse test
- Dix-Hallpike and lateral roll
- head shake test
- other tests
2. differentiate peripheral vs. central vestibular:- stability eyes and gaze
- eye position, -movements and range
- saccades
- other tests
- (Romberg, etc.)
RECOGNIZE FIRST, INTERPRETE LATER
PROBLEM CAN BE VERY SUBTLE
physical examination:
peripheral vestibular
goals
1. determining peripheral vestibular deficit:- head impulse test
- Dix-Hallpike and lateral roll
- head shake test
- other tests
2. differentiate peripheral vs. central vestibular:- stability eyes and gaze
- eye position, -movements and range
- saccades
- other tests
- (Romberg, etc.)
head impulse test (HIT)
normal HIT:
BE CAREFUL WITH NECK COMPLAINTS:
ROTATE INWARDS
head impulse test (HIT)
the vestibulo-ocular reflex (VOR):
head impulse test (HIT)
the vestibulo-ocular reflex (VOR):
VOR
MVN
VI
III
head impulse test (HIT)
the vestibulo-ocular reflex (VOR):
VOR
MVN
VI
III
head impulse test (HIT)
the vestibulo-ocular reflex (VOR):
VOR
MVN
VI
III
head impulse test (HIT)
the vestibulo-ocular reflex (VOR):
head impulse test (HIT)
the vestibulo-ocular reflex (VOR):
head impulse test (HIT)
give instructions to the patient: look at my nose
head impulse test (HIT)
HIT can be very clear sometimes:
head impulse test (HIT)
Testing vertical canals:
LARP
RALP
Head Impulse Test (HIT)
HIT Lateral canal after plugging:
Head Impulse Test (HIT)
HIT Posterior canal right after plugging:
Head Impulse Test (HIT)
HIT can “fool” the examiner:
Head Impulse Test (HIT)
HIT can “fool” the examiner:
Normal Overt saccades Covert saccades
Goals
1. Determining peripheral vestibular deficit:- Head impulse test
- Dix-Hallpike and lateral roll
- Head shake test
- Other tests
2. Differentiate peripheral vs. central vestibular:- Stability eyes and gaze
- Eye position, -movements and range
- Saccades
- Other tests
- (Romberg, etc.)
Goals
1. Determining peripheral vestibular deficit:- Head impulse test
- Dix-Hallpike and lateral roll
- Head shake test
- Other tests
2. Differentiate peripheral vs. central vestibular:- Stability eyes and gaze
- Eye position, -movements and range
- Saccades
- Other tests
- (Romberg, etc.)
BPPV
BPPV is systematically not recognized- Radiating rather than repositioning
Dizziness: >20% is BPPV- Always perform Dix-Hallpike: Often unexpected BPPV
- Combine with lateral roll (15%)
BPPV
Use Frenzel or Video goggles (fixation suppression ↓)
BPPV
Dix-Hallpike with BPPV AD:
BPPV
Dix-Hallpike with BPPV AD:
BPPV
Direction of the fast-phases of VOR:
BPPV
Direction of the fast-phases of VOR:
Not the expected eye movements? reconsider diagnosis
BPPV
Which canal?
BPPV
Reconsider diagnosis?
BPPV
Canalolithiasis Cupulolithiasis
Otoliths in long arm Otoliths near cupula / short arm
Longer latency Short latency
Exhaustible reaction Inexhaustible reaction
Often response to therapy Therapy more difficult
Supine position
BPPV
BPPV horizontal canals: 2 types of nystagmus possible
- Eyes to the ground (geotropic): Canalolithiasis
- Eyes away from ground (apogeotropic): Cupulolithiasis
Strongest nystagmus points to affected labyrinth
BPPV
BPPV horizontal canals: 2 types of nystagmus possible
- Eyes to the ground (geotropic): Canalolithiasis
- Eyes away from ground (apogeotropic): Cupulolithiasis
Strongest nystagmus points to affected labyrinth
BPPV
2 Questions:
- Geo- or apogeotropic?
- Which side is affected?
Lateral roll to the left
Lateral roll to the right
BPPV
Doubt about affected side lateral roll: Bown and lean
- Geotropic (Bow):
- Sitting patient bends head forewards 90º
- Nystagmus points to affected side
- Apogeotropic (Lean):
- Sitting patient bends head backwards 45º
- Nystagmus points to affected side
Goals
1. Determining peripheral vestibular deficit:- Head impulse test
- Dix-Hallpike and lateral roll
- Head shake test
- Other tests
2. Differentiate peripheral vs. central vestibular:- Stability eyes and gaze
- Eye position, -movements and range
- Saccades
- Other tests
- (Romberg, etc.)
Goals
1. Determining peripheral vestibular deficit:- Head impulse test
- Dix-Hallpike and lateral roll
- Head shake test
- Other tests
2. Differentiate peripheral vs. central vestibular:- Stability eyes and gaze
- Eye position, -movements and range
- Saccades
- Other tests
- (Romberg, etc.)
Head Shake Test
Head shake test: Charging velocity storage (3Hz)
Head Shake Test
Head shake test: Charging velocity storage (3Hz)
Head Shake Test
Head shake test: Charging velocity storage (3Hz)
VOR
MVN
VI
III
Head Shake Test
Head shake test: Charging velocity storage (3Hz)
VOR
MVN
VI
III
Velocity
storage
Head Shake Test
Head shake test: Charging velocity storage (3Hz)
VOR
MVN
VI
III
Velocity
storage
Head Shake Test
Head shake test: Charging velocity storage (3Hz)
VOR
MVN
VI
III
Velocity
storage
Velocity
storage
Head Shake Test
Head shake test: Charging velocity storage (3Hz)
VOR
MVN
VI
III
Velocity
storage
Velocity
storage
Head Shake Test
Head shake test: Charging velocity storage (3Hz)
VOR
MVN
VI
III
Velocity
storage
Velocity
storage
Head Shake Test
Head shake test: Charging velocity storage (3Hz)
Head Shake Test
Head shake test: Charging velocity storage (3Hz)
Head Shake Test
Head shake test: Recovery nystagmus
VOR
MVN
VI
III
Velocity
storage
Velocity
storage
Adaptation
Head Shake Test
Head shake test: Perverted nystagmus
VOR
MVN
VI
III
Velocity
storage
Velocity
storage
Head Shake Test
Head shake test: Perverted nystagmus
Head Shake Test
Head shake test: Perverted nystagmus
Other: Provocational testing
Provocational testing:
- Tragal compression (Hennebert)
- Valsalva / Coughing
- Barany-drum / Politzer balloon
Other: Provocational testing
Politzer balloon:
Other: Provocational testing
Politzer balloon:
Physical examination:
Differentiate peripheral vs. central
Peripheral vs. Central
Why so many tests?
Goals
1. Determining peripheral vestibular deficit:- Head impulse test
- Dix-Hallpike and lateral roll
- Head shake test
- Other tests
2. Differentiate peripheral vs. central vestibular:- Stability eyes and gaze
- Eye position, -movements and range
- Saccades
- Other tests
- (Romberg, etc.)
Goals
1. Determining peripheral vestibular deficit:- Head impulse test
- Dix-Hallpike and lateral roll
- Head shake test
- Other tests
2. Differentiate peripheral vs. central vestibular:- Stability eyes and gaze
- Eye position, -movements and range
- Saccades
- Other tests
- (Romberg, etc.)
Stability eyes and gaze
Stability eyes:
Stability eyes and gaze
Abnormality can be very subtle:
Stability eyes and gaze
Peripheral vestibular nystagmus: Alexander’s law
Stability eyes and gaze
Peripheral vestibular nystagmus: Alexander’s law
Peripheral
Nystagmus suppressed by fixation
Nystagmus with mixed components
Nystagmus according to Alexander’s law
No gaze evoked nystagmus
Stability eyes and gaze
2 types of nystagmus:
- Peripheral
- Central
Peripheral Central
Nystagmus suppressed by fixation No effect of fixation
Nystagmus with mixed components Purely vertical (e.g. downbeat) or horizontal
Nystagmus according to Alexander’s law Not according to Alexander’s law
No gaze evoked nystagmus Gaze evoked nystagmus
Central nystagmus increases with fixation:
Stability eyes and gaze
Without fixation
With fixation
Central nystagmus increases with fixation:
Stability eyes and gaze
Without fixation
With fixation
Stability eyes and gaze
Some types of nystagmus:
1. Vestibular (peripheral and central):
2. Gaze evoked:
3. ….Other, e.g.:
Stability eyes and gaze
Which nystagmus is not central?
A B
C D
Stability eyes and gaze
Testing gaze + sidepockets (!)
Stability eyes and gaze
Importance of sidepockets:
Stability eyes and gaze
Watch out for physiological end-point nystagmus:
Stability eyes and gaze
Some types of nystagmus:
1. Vestibular (peripheral and central):
2. Gaze evoked:
3. ….Other, e.g.:
Stability eyes and gaze
Some types of nystagmus:
1. Vestibular (peripheral and central):
2. Gaze evoked:
3. ….Other, e.g.:
Stability eyes and gaze
Gaze evoked nystagmus: Changes with direction of gaze
Stability eyes and gaze
All-in one: Alexander’s law - Sidepockets
Goals
1. Determining peripheral vestibular deficit:- Head impulse test
- Dix-Hallpike and lateral roll
- Head shake test
- Other tests
2. Differentiate peripheral vs. central vestibular:- Stability eyes and gaze
- Eye position, -movements and range
- Saccades
- Other tests
- (Romberg, etc.)
Goals
1. Determining peripheral vestibular deficit:- Head impulse test
- Dix-Hallpike and lateral roll
- Head shake test
- Other tests
2. Differentiate peripheral vs. central vestibular:- Stability eyes and gaze
- Eye position, -movements and range
- Saccades
- Other tests
- (Romberg, etc.)
Eye position, -movements, -range
Eye position:
NOT EACH EYE CONDITION IS DIRECTLY VISIBLE
Eye position, -movements, -range
Eye position: 2 types of abnormalities (hypo, hyper, eso, exo)
1. Tropia: misalignment always present
- Including cover- uncover test
2. Phoria: misalignment when synchronization is interrupted
- Cross-cover test
Eye position, -movements, -range
Eye position: Tropia (www.opthobook.com)
1. In primary position: e.g. Hirschberg’s test
Exotropia OS Esotropia OD
Hypertropia OS Hypotropia OS
Eye position, -movements, -range
Eye position: Tropia (www.opthobook.com)
2. With gaze: make a “box”
Exotropia OS Esotropia OD
Hypertropia OS Hypotropia OS
Eye position, -movements, -range
Subtle tropia: Cover-uncover test
Eye position, -movements, -range
Eye position: Tropia (www.ophthobook.com)
3. More subtle: Cover-uncover test
Exotropia OS
Eye position, -movements, -range
Eye position: Tropia (www.ophthobook.com)
3. More subtle: Cover-uncover test
Practice 1
Eye position, -movements, -range
Eye position: Tropia (www.ophthobook.com)
3. More subtle: Cover-uncover test
Practice 2
Eye position, -movements, -range
Eye position: Tropia (www.ophthobook.com)
3. More subtle: Cover-uncover test
Practice 3
Eye position, -movements, -range
When phoria: Cross-cover test
Eye position, -movements, -range
Eye position: Phoria (www.ophthobook.com)
Only evident when interrupting synchronization: Cross-cover
Exophoria
Eye position, -movements, -range
Eye position: Phoria (www.ophthobook.com)
Only evident when interrupting synchronization: Cross-cover
Practice
AND NOW MORE DIFFICULT…
Eye position, -movements, -range
Normal eye position:
Eye position, -movements, -range
Earth verticalNormal eye position:
Eye position, -movements, -range
Disorder utriculus pathway:
“New” vertical
Eye position, -movements, -range
Disorder utriculus pathway:
“New” vertical
Eye position, -movements, -range
Skew deviation and ocular tilt reaction:
Eye position, -movements, -range
Skew deviation and ocular tilt reaction:
Eye position, -movements, -range
Testing eye movements (smooth pursuit):
Eye position, -movements, -range
Testing eye movements (smooth pursuit):
MVN
VI
III
NPH
Cerebellum
Eye position, -movements, -range
Testing eye movements (smooth pursuit):
Eye position, -movements, -range
Testing eye movements (smooth pursuit):
Goals
1. Determining peripheral vestibular deficit:- Head impulse test
- Dix-Hallpike and lateral roll
- Head shake test
- Other tests
2. Differentiate peripheral vs. central vestibular:- Stability eyes and gaze
- Eye position, -movements and range
- Saccades
- Other tests
- (Romberg, etc.)
Goals
1. Determining peripheral vestibular deficit:- Head impulse test
- Dix-Hallpike and lateral roll
- Head shake test
- Other tests
2. Differentiate peripheral vs. central vestibular:- Stability eyes and gaze
- Eye position, -movements and range
- Saccades
- Other tests
- (Romberg, etc.)
Saccades
Testing saccades:
NPH
Cerebellum- Vermis
- Fastigial nucleus
VI
III riMLF
PPRF RIP Pons
Midbrain+
+
-
-
Motor Burst Omnipause
Saccades
Testing saccades: Close and wide
NPH
Saccades
Testing saccades: Close and wide
NPH
Saccades
Testing saccades:
NPH
Saccades
Testing saccades:
NPH
Saccades
Testing saccades:
NPH
Saccades
Testing saccades:
NPH
Hypermetria
Saccades
Testing saccades:
NPH
Saccades
Testing saccades:
NPH
Saccades
Testing saccades:
NPH
Saccades
Testing saccades:
NPH
Saccades
Testing saccades:
NPH
Saccades
Testing saccades:
NPH
Hypometria
Saccades
Testing saccades:
NPH
Saccades
Testing saccades:
NPH
Saccades
Testing saccades:
NPH
Saccades
Testing saccades:
NPH
Slowing
Other tests
Hyperventilation test:
NPH
Demyelinization nerve: Vestibular schwannoma, microvascular
Demyelinization central: MS
Canalopathy: FHM, SCA-6, EA-2, epilepsia
Other: Migraine, post-neuritis, fistula, craniocervical
Other tests
Hyperventilation test:
NPH
Demyelinization nerve: Vestibular schwannoma, microvascular
Demyelinization central: MS
Canalopathy: FHM, SCA-6, EA-2, epilepsia
Other: Migraine, post-neuritis, fistula, craniocervical
Other tests
Hyperventilation test:
NPH
Demyelinization nerve: Vestibular schwannoma, microvascular
Demyelinization central: MS
Canalopathy: FHM, SCA-6, EA-2, epilepsia
Other: Migraine, post-neuritis, fistula, craniocervical
Other tests
Hyperventilation test:
Positional testing: Eye movements not always BPPV!
NPH
Demyelinization nerve: Vestibular schwannoma, microvascular
Demyelinization central: MS
Canalopathy: FHM, SCA-6, EA-2, epilepsia
Other: Migraine, post-neuritis, fistula, craniocervical
Peripheral: Cupulolithiasis, SCDS, fistula, Meniere’s
Central: MS, cerebellair tumor/infarction/hematoma, ischemiabrainstem, migraine, whiplash/head trauma, alcohol
Other tests
Positional nystagmus cerebellar tumor:
NPH
Other tests
Testing fixation suppression:
NPH
Other tests
Testing fixation suppression:
NPH
Other tests
Testing fixation suppression:
NPH
Other tests
Testing fixation suppression:
NPH
The acute problem!
What to do?
Differential diagnosisTiming Trigger Diagnosis benign Diagnosis dangerous
Episodic Trigger BPPV
Orthostatic
CPPV/Tumor
Internal bleeding
Vascular stenosis
Vertebral artery
Spontaneous Meniere’s
Migraine
SCDS
Paroxysmia
Vasovagal
Panic
Arrhythmia/MI
TIA
Pulmonary embolus
Hypoglycemia
Acute Postexposure Perilymphatic fistula Skull base fracture
Vertebral dissection
Drugs (genta, AED)
Carbon monoxide, etc.
Spontaneous Neuritis
Labyrinthitis
CVA/Vertebral
Wernicke’s/encephalitis
..Other internal/neuro
Chronic Context e.g. Vestibular hypofunction
Spontaneous e.g. Cerebellar degeneration
Differential diagnosisTiming Trigger Diagnosis benign Diagnosis dangerous
Episodic Trigger BPPV
Orthostatic
CPPV/Tumor
Internal bleeding
Vascular stenosis
Vertebral artery
Spontaneous Meniere’s
Migraine
SCDS
Paroxysmia
Vasovagal
Panic
Arrhythmia/MI
TIA
Pulmonary embolus
Hypoglycemia
Acute Postexposure Perilymphatic fistula Skull base fracture
Vertebral dissection
Drugs (genta, AED)
Carbon monoxide, etc.
Spontaneous Neuritis
Labyrinthitis
CVA/Vertebral
Wernicke’s/encephalitis
..Other internal/neuro
Chronic Context e.g. Vestibular hypofunction
Spontaneous e.g. Cerebellar degeneration
Central or peripheral?: HINTS
HINTS:
- Head Impulse
- Nystagmus
- Test Skew deviation
NPH
+ +
Central or peripheral?: HINTS
HINTS:
- Head Impulse
- Nystagmus
- Test Skew deviation
Importance:
- Acute phase: HINTS more sensitive than MRI (88%)
NPH
+ +
Central or peripheral?: HINTS
HINTS: Head impulse test
NPH
Central or peripheral?: HINTS
HINTS: Nystagmus
NPH
Central or peripheral?: HINTS
HINTS: Testing Skew deviation
NPH
Central or peripheral?: HINTS
HINTS: Testing Skew deviation
NPH
CENTRAL OR PERIPHERAL?
Central or peripheral?: HINTS
HINTS: Peripheral nystagmus
NPH
Conclusions
Conclusions
1. Collect as much information as possible• Central tests
• Peripheral tests
2. Keep an eye on the eyes: often subtle abnormalities- Other neurological examination can be normal
3. Acute problem: HINTS
Questions
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