Vestib 1 Practical COMP

Question 1

If you are looking at an ABR for retrocochlear and conductive, how do you tell the difference?

Answer 1

You can not tell from just the graph, you must do bone conduction or reflexes. If they add bone to the graph and it falls into the gray range, then it would be a conductive hearing loss because of the air-bone gap.

Question 2

Tell me how latency and amplitude change with intensity (ABR) ?

Answer 2

Louder Intensity = higher amplitude & shorter latency
Smaller Intensity = shorter amplitude & longer latency

Question 3

The latency of wave 5 between ears should differ by no more than?

Answer 3

0.2 to 0.4 msec

Question 4

Why is latency important?

Answer 4

it is the most robust parameter in the clinical interpretation of the ABR

Question 5

Review what the test results look like for an uncompensated vestibular loss case

Question 6

The ABR is not sensitive …

Answer 6

to all central nervous system disorders, it is only sensitive from ear to brainstem

Question 7

which tests require you to task?

Question 8

what is tasking?

Answer 8

“tasking” refers to keeping the patient mentally occupied — usually by giving them something to think about or say — while their eye movements (nystagmus) are being measured.

Because if the patient starts paying attention to their dizziness, they might suppress their nystagmus (especially during tests like calorics). This makes the response weaker or inaccurate.

Question 9

true or false: water caloric irrigations have greater variability and are more prone to operator error than air caloric irrigations?

Answer 9

false

Question 10

list 2 reasons why you might perform ice water caloric irrigations

Answer 10

• may be used when traditional bi-thermal irrigations are very low or to help confirm diagnosis of bilateral loss
• may be useful for confirmation of successful abalative procedures such as gentamycin injections or vestibular nerve section
  may be useful when there is a strong pre-existing spontaneous nystagmus (reversing the bias in the system)
• may be useful to determine if there is any residual vestibular function in the system (even minimal) which - may help determine further course of treatment either surgically or rehab

Question 11

true or false: caloric reversal is the phenomena where oblique or vertical nystagmus is recorded with caloric irrigation

Answer 11

false - caloric perversion

Question 12

what is the caloric position? why do we place patients in the “caloric position?”

Answer 12

the caloric position (supine head elevated 30 degrees) brings the horizontal SCC into an orthogonal relationship with the gravity vector thereby ensuring maximum amount of stimulation during irrigation. perpendicular to the floor for max stimulation.

Question 13

what are the BSA recommended temperatues and irrigation time for AIR caloric irrigations. Warm air _____ degrees. Cold air ______ degrees. Irrigate for _____ seconds.

Answer 13

warm air = 50 degrees
cold air = 24 degrees
irrigate for = 60 sec.

Question 14

what are the BSA recommended temperatues and irrigation time for WATER caloric irrigations. Warm water _____ degrees. Cold water ______ degrees. Irrigate for _____ seconds.

Answer 14

warm air = 44 degrees
cold air = 30 degrees
irrigate for = 30 sec.

Question 15

what does COWS stand for? what does it mean?

Answer 15

COWS = Cold Opposite Warm Same

a cold irrigation will produce a nystagmus that beats in the opposite direction of the ear being stimulated and warm irrigation will produce a nystagmus that beats in the same direction of the ear being stimulated. this has to do with the direction of endolymph flow (ampullopetal=less density = excitatory flow) (ampullofugal = more dense = inhibitory flow). the stimulus doesnt transfer to the other side of the head. it only tells you direction of the nystagmus based upon endolymph movement toward or away from ampullla (occurs on same side as irrigation).

Question 16

what is the equation for unilateral weakness?

Answer 16

(RW+RC) - (LW+LC) ÷ (RW+RC+LW+LC) x 100

Question 17

what is the equation for directional preponderance?

Answer 17

(RW+LC) - (LW+RC) ÷ (RW+RC+LW+LC) x 100

Question 18

what are the vestibular nerve and canal connections?

Answer 18

SVN: lateral and anterior canals
IVN: posterior canals

Question 19

what is normal for unilateral weakness

Answer 19

below 20-25% is normal for unilateral weakness

Question 20

what is normal for directional preponderance?

Answer 20

below 30-35% is normal for directional preponderance

Question 21

what is abnormal for total eye speed?

Answer 21

anything less than 26

Question 22

whats alexanders phenomenon?

Answer 22

when the patients nystagmus increases when they look the same way of the beating & decreases or is eliminated when they look the opposite way. in order for it to be alexanders law they MUST have central gaze nystagmus

Question 23

what is the epley

Answer 23

most treatment for canalithiasis AC/PC BPPV

Question 24

what is gain? (vestib)

Answer 24

eye movement relative to something else

head impulse →eye movement relative to head movement

rotary → eye movement relative to chair movement

pursuits → eye movement relative to target moving in front

Question 25

tell me about the romberg

Answer 25

screens the body’s proprioception (somatosensory) system and the amount of disequalibrium caused by central vertigo, peripheral vertigo, and head trauma. the patient stands with their feet together and arms out to the side, we ask them to stand still for 10-15 seconds first with eyes open them again with their eyes closed. If you want to make it tandem they put one foot infront of the other.

Question 26

what does a positive romberg mean? (what will you see the patient do)

Answer 26

it means the patient swayed or fell with non-fluid motions. they will typically lean toward the side of the problem.

Question 27

what is the dix-hallpike

Answer 27

a test that assess for PC/AC BPPV

Question 28

what is the supine head roll

Answer 28

it is a positional test that assesses for HC BPPV

Question 29

what is the static positional nystagmus criteria ?criteria needed

Answer 29

Nystagmus that changes direction in any head position It is present in at least 3 head positions It is intermittent in all head positions (little here, little there) One or more positions that has a slow phase magnitude (velocity) >/=4-6 deg/s

Question 30

what is the semont

Answer 30

treatment for cupulolithiasis AC/PC BPPV

Question 31

what is the BBQ roll?

Answer 31

treatment for horizontal canal BPPV used for the geotropic/canalithiasis variant

Question 32

what is the gufoni

Answer 32

treatment for horizontal canal BPPV used for the ageotropic/cupulolithiasis variant

Question 33

what is the difference between canalithiasis and cupulothiasis symptoms

Answer 33

canalithiasis is a delayed onset and lasts for less than a minute cupulothiasis is an immediate onset and doesn’t fatigue

Question 34

if you are performing dix hallpike and see Delayed onset, upward & rightward torsional fast phases, & <1min response duration, what type of BPPV is it and what is the treatment?

Answer 34

canalithiasis, posterior SCC treatment = epley

Question 35

if you are performing dix hallpike and see Immediate onset, upward & rightward torsional fast phases, >1min response duration, what type of BPPV is it and what is the treatment?

Answer 35

cupulothiasis, posterior SCC treatment = semont

Question 36

if you are performing dix hallpike and see Delayed onset, downward & leftward torsional fast phases, <1min response duration, what type of BPPV is it and what is the treatment?

Answer 36

canalithiasis, anterior SCC treatment = epley

Question 37

if you are performing dix hallpike and see Immediate onset, downward & leftward torsional fast phases, >1min response duration, what type of BPPV is it and what is the treatment?

Answer 37

cupulothiasis, anterior SCC treatment = semont

Question 38

if you are performing the supine head roll and see Horizontal, geotropic fast phases (toward down ear), stronger w/ R ear down, may have delayed onset & will fatigue over time, what type of BPPV is it and what is the treatment?

Answer 38

canalithiasis, horizontal SCC treatment = BBQ roll

Question 39

if you are performing the supine head roll and see, Horizontal, ageotropic fast phases(beats away from ear down), stronger w/ L ear down, more immediate onset & longer response duration, what type of BPPV is it and what is the treatment?

Answer 39

cupulothiasis, horizontal SCC treatment = modified semont

Question 40

how do you interpret calorics

Question 41

what does the fukuda/stepping fukuda assess?

Answer 41

screens laryrinthine function via vestibulospinal reflexes

Question 42

how to you perform the fukuda/stepping fukuda?

Answer 42

tell the patient to hold their arms out straight in from of them and close their eyes, then ask them to march in place for 50 steps

Question 43

how do you interpret the fukuda/stepping fukuda results?

Answer 43

if the patient is normal they wont rotate more than 45 degrees. if the patient is abnoral they will rotate more than 45 degrees and this is considered a positive fukuda

Question 44

how to you perform the active/passive headshake test?

Answer 44

the patient has their eyes closed or is vision denied under goggles. shake their head back and forth and after 20 sec have them open their eyes and watch for nystagmus

Question 45

how do you interpret the results of the active/passive headshake?

Answer 45

if they are normal you will not see nystagmus, if they are abnormal nystagmus will be present after the headhshake or enhanced

Question 46

what is ocular tilt?

Question 47

how do you perform the dynamic visual acuity test?

Answer 47

the patient stands the proper distance from the eye chart (letters) and you ask them to read the lowest line they can. then stand behind them and move their head back and forth and ask them to read the lowest line possible while you move their head.

Question 48

how to interpret the results of the dynamic visual acuity test?

Answer 48

if there was no line change or a slight line change they are normal indicating their VOR is functioning properly. if they have a line change of 2 or greater they are abnormal, indicating oscillopsia

Question 49

what does dynamic visual acuity assess?

Answer 49

screens for oscillopsia (often caused by vestibular loss). looks at the VOR

Question 50

what do we look at during saccades

Answer 50

gain velocity acuracy

Question 51

what do we look at during smooth pursuits

Answer 51

gain symmetry

Question 52

What does the dix hallpike assess?

Answer 52

anterior and posterior canal BPPV abnormal = torsional nystagmus

Question 53

What are the treatments for BPPV?

Answer 53

habituation techniques & excersises particle repositioning maneuvers surgical intervention (rare)

Question 54

What is direction changing nystagmus?

Answer 54

key points is that it beats in one direction. Slows down and stops. Goes in the other direction. BUT it has to happen just in center gaze they cannot be moving positions and that happen or its something else

Question 55

What are the tests used for central findings?

Answer 55

oculomotor testing ENG/VNG having them fixate if they come in with center nystagmus

Question 56

What are the positional nystagmus criteria that make it pathological (abnormal) ?

Answer 56

it changes direction in any head position, or it is persistent in at least 3 head positions, or it is intermittent in all head positions, or it’s slow phase velocity exceeds 6 degree/sec in any head position

Question 57

What are saccades?

Answer 57

rapid shift in gaze, saccadic testing is the ability to track a fast moving target

Question 58

what is torsional/rotary nystagmus?

Answer 58

when the eyes rotate about the central axis of the globe (twist in circular motion). pure torsional is a sign of central problems but if we see it with positional testing it indicates a peripheral finding.

Question 59

nystagmus will beat?

Answer 59

away from the affected side

Question 60

how do you perform the halmalgi head thrust?

Answer 60

hold the patients head and instruct them to keep their eyes open during the test. then slowly move their head back and forth, then rapidly move the head to each side. after the rapid movement hold it there briefly to check for refixation saccades

Question 61

how do you interpret the results of the halmalgi head thrust?

Answer 61

if they are normal there will be no corrective saccades, if they are abnormal corrective saccades will be present. you will have refixation saccades in the direction of the damage

Question 62

what does the halmalgi head thrust assess?

Answer 62

screens SCC dysfunction in all canals & the detection of peripheral vesibulopathy

Question 63

what is caloric testing?

Answer 63

the most informative subtest of the VNG by being able to excite only 1 vestibular organ while the other one stays at rest

Question 64

what is directional preponderance?

Answer 64

comparing the slow phase velocity (SPV) of eye movements in the same direction, so using RW and LC to compare to LW and RC -typically seen with a preexisting spontaneous nystagmus

Question 65

video head impulse (vHIT) (halmagli made)

Answer 65

instrumented version of the bedside technique used to diagnose reduction in vestibular function -can detect SCC dysfunction in all canals and is useful for the detection of peripheral vestibulopathy

Question 66

advantages of vHIT

Answer 66

can be performed from 10 months to elderly, gives a real world measure, evaluates HF reactivity, gives canal specific information, high sensitivity to vestibulopathy, can help track VRT progress and is site specific

Question 67

two key aspects to remember when conducting vHIT

Answer 67

use quick acceleration and keep it unpredictable

Question 67

limitations of vHIT

Answer 67

only analyses HF deficits, some studies suggest insensitvity to dysfunction secondary to menieres disease, techniques can be challenging, will miss mild unilateral vestibular origins

Question 68

2 parameters for vHIT

Answer 68

gain and presence of refixation saccades

Question 69

common peripheral signs

Answer 69

sudden onset, intense severity, paroxysmal and intermittent pattern, worse with movement, will often show nausea, horizontal nystagmus, fatigue of signs, HL/tinnitus may occur

Question 70

common central signs

Answer 70

sudden or gradual onset, less intense severity, constant pattern, variability nausea, multi directional or vertical nystagmus, no fatigue of signs, typically no HL/tinnitus, CNS signs are typically present (such as headaches, changes in speech)

Question 71

with rotational testing, we are looking at ….

Answer 71

how the VOR functions in regard to movements of the individual -observing the function through head and eye velocity movement

Question 72

what are signs of insufficient VOR

Answer 72

nystagmus, oscillopsia, retinal slip

Question 73

what are the slow and fast phase of nystagmus driven by

Answer 73

slow phase is driven by the ears = peripheral vestibular fast phase is driven by the CNS = central

Question 74

when looking at a nystagmus video on a screen what do you need to remember

Answer 74

our left is the patients right the video is opposite