Equilibrium (balance) Disorders

Ahmed ElshebinyAhmed ElshebinyUniversity of MenoufyiaUniversity of Menoufyia

Case 1 : History

A 72-year-old, right-handed man was admitted to the hospital because of recurrent neurologic symptoms.

The patient had been well until 10 days earlier, when he briefly had numbness of the right side of

the mouth and tongue. That evening, he had slurred speech and a hyponasal

quality in his speech for 30 minutes, and vertical diplopia later developed but soon cleared.

The next morning, there was a brief recurrence of the vertical diplopia, followed by vertigo. Later that morning, transient diplopia again recurred

Past History Labile HTN Dyslipedemia apical lung resection 50 years earlier because

of tuberculosis.

Examination The temperature was 36.2°C, blood pressure 140/110 mm Hg. The patient appeared well. No bruits were heard around the neck, examination of the heart revealed no abnormalities. A neurologic examination revealed only slight

tottering to the right on tandem-gait testing And a questionable right Babinski reflex.

Hematological findings

Coagulation

Immaging Non contrast C.T C.T angio MRI Transcranial doppler Ultrasound neck vessels Echocardiography ECG

Discharge…… Treatment with heparin and warfarin was

begun. A few transient episodes of diplopia occurred, each lasting 30 to 60 seconds, and there was one bout of vertigo, with buzzing in the ears. The patient's condition improved, and he was discharged on the fourth hospital day with instructions to take dalteparin sodium and warfarin without aspirin.

Re-admission Three days after discharge, diffuse weakness

developed, along with dizziness and transient vertical diplopia. (The international normalized ratio, obtained at another hospital, was 1.7)

The blood pressure was 180/80 mm Hg. The temporal arteries were prominent, with strong

pulses and no nodularity or tenderness The left radial pulse was diminished, and the blood

pressure could not be measured in the left arm.

Temporal artery biopsy

what happened to the patient after the biopsy was ???performed and the diagnosis made

After the diagnosis was made, a course of methylprednisolone sodium succinate was begun.

On the first day, we thought his condition was improving, but it continued to worsen, and additional posterior-circulation infarcts developed.

He was eventually admitted to the intensive care unit, where a tracheotomy was performed. After further clinical deterioration and discussion with the patient's family, care was discontinued.

Autopsy

Balance Spatial orientation depends on input from :

(vestibular, visual, proprioceptive and cutaneous) Labyrinth righting reflexes. Optical righting reflexes (animals) vestibular impulses also reach the cerebral cortex. =

conscious perception of motion and supply part of the information necessary for orientation in space.

Balance disorders For patients over 75 years of age, dizziness is

the number one reason for visiting a physician,

dizziness is a significant risk factor for falls in elderly individuals.

Vertigo Illusion of movement of the body or

the environment May be associated with ( impulsion,

oscillopsia, nausea , vomiting, gait ataxia).

Differentiate vertigo from other symptoms

physiological or pathological Differentiate between peripheral and

central causes of vertigo

Nystagmus The characteristic jerky movement of the eye observed at the

start and end of a period of rotation. It is actually a reflex that maintains visual fixation on

stationary points while the body rotates, although it is not initiated by visual impulses and is present in blind individuals.

Nystagmus is frequently horizontal (ie, the eyes move in the horizontal plane), but it can also be vertical (when the head is tipped sidewise during rotation) or rotatory (when the head is tipped forward).

By convention, the direction of eye movement in nystagmus is identified by the direction of the quick component.

Ataxia Incoordination or clumsiness of movement

that is not the result of muscle weakness. Cerebellar disorders are associated with

hypotonia, however rigidity or spasticity may be present in certain diseases

Vestibular, Cerebellar and Sensory

Approach to a case of Vertigo History is crucial, Is it vertigo? If unclear , provocative

bedside tests Is it positional? Ask about tennitus, deafness or ear pressure Onset, recurrence, course, duration Cardiovascular risk factors? Ask about headaches and migraine Ask about previous viral infection Primary or reactive anxiety or depression Neurological symptoms, Neurological Examination , examine the neck , failure of

fixation suppression General Examination Follow up

Vertigo

Vertigo

physiologic pathologic

Peripheral CentralBenign positional

Menere

VN

Otosclerosis

Acute

Chronis

CPA tumor

Toxic vestibulopathy

Acoustic neuropathy

Peripheral or Central?Sign&SympPeripheralCentral

SeverityMarkedOften mild

NystagmusNever vertical or torsional

May be vertical

Visual fixationInhibits nystagmus and vertigo

No inhibition

Tennitus/deafnessOften presentUsually absent

Associated CNS abnormalities

NoneExtremely common).…(

Vestibular Examination VOR VSR

Caloric test Caloric stimulation can be used to test the

function of the vestibular labyrinth. convection currents in the endolymph COWS

Peripheral Vestibular disorders About three-fourths of vestibular disorders are

peripheral (inner ear and vestibular nerve). The most common peripheral vestibular

disorder is benign paroxysmal positional vertigo, followed by uncompensated Ménière disease, vestibular neuritis, labyrinthitis, perilymphatic fistula, and acoustic neuroma.

Benign Paroxysmal Positional Vertigo Severe episodes, nausea, vomiting Canalolithiasis? Mostly peripheral Most common cause of peripheral Positional vertigo may also be central, differentiate

by Dix-Halpike maneuver( Latency, Fatigability, habituation& reproducibility)

TTT: Vestibulosuppressants, repositioning maneuvers, vestibular rehab.

Ménière disease Repeated episodes( minutes to days) Intervals from weeks to years Tinnitus and Progressive SNHL (stepwise) As hearing loss increases , vertigo lessens Mostly sporadic, may be familial, may be anticipation Onset between 20-50 y More in men Endolymphatic hydrops? Caloric test and audiometry ttt-diuretics, may be with antihistamines, benzodiazepines,

anticholinergic and may be surgical

Acute Peripheral Vestibulopathy Spontaneous attack of vertigo of inapparent cause, without

deafness or CNS dysfunction Includes Acute Labyrinthitis and vestibular neuronitis of

unverified site and pathology Usually up to 2 weeks The patient lies on one side with the affected ear up Nystagmus away from affected ear is always present May be febrile May leave residual May recur Ttt- with antivertigals and or prednisolone 10-14 days

Toxic Vestibulopathies Alcohol Aminoglycosides Quinine and quinidine Cisplatinum

Otosclerosis Mostly conductive deafness May be associated with SNHL or vertigo Commonly familial Auditory symptoms begin before age of 30 Audiometry= usually mixed, mostly bilateral Should be difrenciated from Meniere’s TTT with sodium floride+ calcium

gloconate+ vit D or stapedictomy

CPA tumor Most common benign acoustic neuroma Arises from neurilemmal sheath of vestibular part of

acoustic n. in the internal auditory canal May be with neurofibromatosis Symptoms and signs MRI, brainstem auditory evoked potentials

Cerebellar and Central vestibular disorders

The most common central causes of dizziness and vertigo are cerebrovascular disorders, cerebellar disease, migraine, multiple sclerosis, tumors of the posterior fossa, neurodegenerative disorders, medications, and psychiatric disorders.

Central vertigo secondary to brainstem or cerebellar ischemia

usually lasts for 20 min to 24 h and is often associated with other brainstem characteristics, including diplopia, autonomic symptoms, nausea, dysarthria, dysphagia, or focal weakness.

Patients with cerebellar disease are frequently unable to ambulate during acute episodes of vertigo.

Patients with peripheral vertigo can usually ambulate during episodes and are consciously aware of their environment.

Causes of acute cerebellar ataxia Drugs Wernicke encephalopathy Vertebrobasilar ischemia or infarction Cerebellar hage Inflammatory disorders

Causes of chronic cerebellar ataxia MS Alcoholic cerebellar degeneration Phenytoin induced cerebellar degeneration Hypothyroidism Paraneoplastic cerebellar degeneration Heridetary spinocerebellar ataxias Friedreich ataxia Ataxia Telangiectasia Wilson Acquired hepatolenticular degeneration Crutzfeldt-jacob disease Posterior fossa tumors and malformations

Vestibular Rehabilitation Therapy

a specific form of physical therapy designed to habituate symptoms, and promote adaptation to and substitution for various aspects of deficits related to a wide variety of balance disorders .

References E-medicine specialities, Neurology E-medicine specialities, otolaryngeology Aminooff, et al , Clinical Neurology, 2009 Kumar and KlarK’s, Clinical Medicine , 2009 Ganong, Physiology, 2005 Harrison online textbook , 2008