Vestibular Disorders

Chad Lairamore, PT, PhD

Physical Therapy
University of Central Arkansas

Incidence

Dizziness

5.5% or 15 million people/year

One of most common complaints to
doctors with increasing age
Main reason to see MD for those 75 and
over
70% of those with initial complaints have
no resolution in 2 weeks
63% with persistent dizziness report
recurrent symptoms beyond 3 months

Problems in which of the following areas

would NOT cause vertigo and dizziness?

A. Peripheral vestibular system

B. Central vestibular system
C. Cerebellum
D. Inner ear
E. Lower extremity peripheral
nervous system

Anatomy of the ear

Outer Ear
Pinna
Tragus
External Auditory Canal (meatus)
Tympanic membrane

Function:
Collect & direct sound waves

Outer Ear Pathologies

Perforated eardrum
Causes: Explosions, trauma,
acute middle ear infections
Can be surgically corrected

Middle Ear
Components:
Auditory Ossicles: Malleus, Incus, Stapes
Tensor tympani & Stapedius muscles.
Eustachian tube
Function: Communicates sound waves via
vibration to inner ear
Pathologies: Middle ear infections
The middle ear is dry, Eustachian tube drains
anything out of the middle ear

Inner Ear
Bony & Membranous Labyrinth:
Utricle, Saccule, Semicircular canals,
cochlea
Round and oval windows
Areas where the tissue is thinner, can be
ruptured easily, which will cause symptoms.

Perilymph (surrounds semicircular

canal), Endolymph (fluid inside Utricle,
Saccule, semicurcular canals)

Function: Sensory info for

equilibrium and hearing

Inner Ear Pathologies

Benign Paroxysmal Positional Vertigo
(BPPV)
Labyrithitis
Menieres Disease
Perilymphatic Fistula (PLF)
Rupture of oval or round windows
causing leakage of perilymph into the
middle ear causing vertigo and
hearing loss.

Anatomy of Central Vestibular

System
Central Vestibular System
Areas within the brain that communicate with and
integrate vestibular information.
Brain stem
Controls vestibular reflexes

Vestibular cortex, Thalamus, Reticular Formation

Arousal
Awareness of the body
Discrimination between movement of environment vs. self

Cerebellum
Maintain vestibulo-ocular reflex (VOR)
Posture
Coordination

Central Vestibular System

Extensive connections between vestibular nuclei and
reticular formation, thalamus and cerebellum
Vestibular system contributes to arousal, conscious
awareness of body, ability to discriminate between
movement of self and environment.
What happens if a pt does not obtain an upright
position?
Think about reticular formation.
Orthostatic hypertension can happen.
Pts. Will be woozy getting up but is not always related to
orthostatic hypertension.

Central Vestibular Cont.

Cerebellar connections
Help maintain calibration of VestibuloOcular Reflex
Contribute to posture in static and dynamic
Influence coordination of limb movement
Vestibulo-Ocular Reflex (VOR)
Maintains stability of an image on the
fovea of the retina during rapid head
movements
Rapid movement of the eye opposite the
direction of head movement
video

Pathology
Central system
Brainstem infarction
o Symptoms: Transient clumsiness, Weakness, Loss
of vision, Diplopia, Drop attacks, Dysarthria

Cerebellar infarction
o AICA
May cause vertigo, also associated with hearing loss
Lesion here mimics a peripheral disorder

o PICA infarcts
Acute, severe vertigo, mimicking labyrinthine dz

o Vertebral artery infarct: typically only effects the

cerebellum (perfuse cerebellar issues like ataxia,
etc.)

TBI with labyrinthine or skull fracture

o Abnormal central processing resulting in vertigo

Pathology Central System

Vertebrobasilar insufficiency
Posterior circulation supplies blood to brainstem,
cerebellum and peripheral vestibular
apparatusvertebrobasilar insufficiency (VBI)
Drop attacks, transient blindness, dysarthria
Not as common.

Multiple Sclerosis (MS)

Demyelinating disease
Can affect CN VIII: causing identical symptoms as
unilateral peripheral vestibular hypofunction (MRI
required for dx)

Acoustic neuroma, meningioma, metastatic

tumor, or hematoma in the posterior fossa

Medical Treatment for Central

Disorders
Manage as those without
accompanying symptoms of
dysequilibrium
Surgical
Removal of tumors

PT to include:
Adaptation & fall prevention strategies

Anatomy of Peripheral Vestibular System

Peripheral Vestibular System

(located within the inner ear)

3 primary functions (Associated with

VOR)
Stabilization of visual images on the fovea of
the retina during head movement to allow
clear vision
Maintain postural stability, especially with
head movement
Provide info for spatial orientation

Anatomy Peripheral Vestibular

System
Each ear has:
3 Semicircular canals (SCC)
Anterior, posterior, horizontal
FYI: anterior is also called superior
Horizontal canal is also called lateral

2 otolith organs
Saccule
Utricle

Semicircular Canals
Each has a
contralateral
coplanar mate
Horizontal
SCC pair
Posterior and
contralateral
anterior SCC

Semicircular Canals
Endolymph
Fluid that moves freely within the
canals

Ampulla
Enlargement at one end of the
SCC

Semicircular Canals
Cupula: within ampulla
Gelatinous barrier
Contains sensory hair cells and projecting
cilia
Stereocilia (small) and Kinocilia (larger)

Movement of the cilia

Cause an excitation or inhibition in the hair cell
which in turn leads to a depolarization or
hyperpolarization of afferent vestibular nerves.
Dependant upon direction of motion
Sterocilia toward Kinocilia: excitation
Sterocilia away from Kinocilia: inhibition

Cupula is a
gelatinous organ

Semicircular Canals
Respond to motion in
own plane best
Coplanar pair: pushpull dynamic
Brain detects
movement by
comparing 2 SCC

Otolith Organs
Saccule & Utricle
Linear acceleration
Static head tilt

Otolyth
Sensory hair cells project into gelatinous
material
Otoconia (ear rocks)

Utricle excitation
Horizontal linear acceleration and/or static
head tilt

Saccular excitation
Vertical linear acceleration

Otoconia and underlying

hair cells

If a person turns their head to the

RIGHT. What vestibular organ was
primarily activated ?
A. saccule
B. utricles
C. anterior canal
D. posterior canal
E. horizontal
canal

Pathology
Unilateral Peripheral system
Benign Paroxysmal Positional Vertigo (BPPV)
Displacement of otoconia
50 70% of the cases are idiopathic
Under the age of fifty
trauma such as a fall, TBI, or whiplash injury

Over the age of fifty

Degeneration or dehydration of the gelatinous
membrane

Migrate into SCC

Free flowing in the endolympth - canalithiasis
or adhere to cupula cupulolithiasis

A 25 yr old is being treated for whiplash after

a car accident. She reports neck pain and
intermittent dizziness with head movements.
What is the best course of action?
A. Teach the patient to limit all neck
range of motion.
B. Refer her to a physician for a central
vestibular disorder
C. Treat her whiplash hoping that the
dizziness will subside on its own
D. Treat her whiplash and evaluate
her for a peripheral vestibular
disorder

Pathology
Unilateral Peripheral system
Vestibular neuronitis
Typically caused by a viral infection
If assoc. with hearing lossentire labyrinth
assumed to be involvedLabyrinthitis
Vertigo provoked by head movement, but not
necessarily head position
Acutely
Sudden severe vertigo, N&V, no hearing loss or
facial weakness
Typically resolves in ~ 1 week
Physician may prescribe anti-viral meds

Pathology
Unilateral Peripheral system
Ramsay Hunt syndrome (viral infection)
Form of labrynthitis
Herpes zoster (chicken pox) in external ear
VIII and VII CN affected, facial weakness, hearing
loss, vertigo
Tends to resolve on its own, can be treated with
antivirals.

Post-Traumatic Vertigo
Immediately following head trauma
Respond well to repositioning techniques
and vestibular exercise most notably for VOR

Pathology
Bilateral Peripheral systems
Drug Toxicity
Secondary effect
Aminoglycosidesconcentrated in endo and perilymph fluids,
exposing hair cells to high concentrations
Streptomycin & gentamycin most detrimental
Can affect the hair cells

Report progressive unsteadiness, especially with decreased visual

input
Bilateral loss of vestibular function, Fluctuating attacks of vertigo
(depends upon symmetry of hypofunction), tinnitus, fluctuating
hearing loss and ill-described aural sensations of fullness
Spontaneous recovery in hours to weeks when the drug is
discontinued

You are a PT student in acute care. You are treating

a 40 y/o male patient who has an endocarditis and
is taking Streptomycin. The patient complains of
losing his balance and hearing a high pitched
sound. If you want to impress your CI, you would
suggest:
A. A discussion with the MD regarding possible
Menieres disease
B. A discussion with the MD regarding
possible drug toxicity
C. Performing an evaluation for BPPV
D. Performing the clinical test of sensory interaction
and balance

Pathology
Bilateral Peripheral systems
Menieres Syndrome
Chronic disease
Most consistent finding: Increase in volume of endolymphatic
fluid and distention of canals
Affects women > men
Most cases idiopathic
Develops between ages 30-50
Progressive hearing loss and tinitus with frequency of attacks
Comes and goes, gets worse over time.
50% become bilateral
Hearing loss progresses to moderate degree and stabilizes
Medically managed by controlling fluid intake

Medical Management
Drug Type

Name

Indications

Antihistamine and
Anticholinergic

Meclizine; Antivert

Acute Vest. Neuritis

Labyrinthitis
Ramsay-Hunt

Phenothiazine

Phenergan

Acute Vest. Neuritis

Labyrinthitis
Ramsay-Hunt

Anti-inflammatory

Prednisone

Acute Vest. Neuritis

Labyrinthitis
Ramsay-Hunt

Antiviral

Acyclovir

Ramsay-Hunt

Dont have to memorize this chart.

Question: A person with symmetrical

bilateral vestibular dysfunction will
likely NOT experience?
A.Vertigo and nystagmus
This is usually a unilateral / central
problem
B. Tinnitus and fullness in the ears
C. Unsteadiness
D. Hearing loss

Nystagmus
Nystagmus
Due to imbalance in tonic firing rate of
vestibular neurons
Named for fast component of eye movement
Usually a central pathology.

Eye movement that typically occur:

Combined horizontal and rotational (torsional)
Single planarhorizontal or vertical
Direction changing

Discerning peripheral vs central

pathology based on nystagmus
Symptom or Sign

Peripheral

Central

Nystagmus direction

Mixed plane (horizontal

and torsional

Direction changing,
variable

Effect of fixation on
nystagmus

Decreases

Same or increases

Fatigability

Yes

No

Duration
(single episode)

Less than 1 minute

Symptoms may persist

Intensity of signs and

symptoms

Severe vertigo, marked

nystagmus, systemic
symptoms such as
nausea

Usually mild vertigo,

less intense nystagmus,
rare nausea

Balance

May be mild <50 years

of age
>50 may have (+)
Romberg

(+) Romberg, deviate

L/R during gait

Nystagmus video
Horizontal and rotational
nystagmus
Horizontal nystagmus
Vertical nystagmus
What is the difference between
the different types of
nystagmus?

Symptoms associated with central

vs peripheral pathology
Central Pathology

Peripheral Pathology

Ataxia often seen

Ataxia mild or not present

Abnormal smooth pursuits and

abnormal saccadic eye
movements

Smooth pursuits and saccades

usually normal. Positional testing
may produce nystagmus

Do not typically include hearing

loss

May include hearing loss, fullness

in ears, tinnitus

Acute vertigo is not usually

suppressed by visual fixation

Acute vertigo is usually more

intense, but can be suppressed
with visual fixation

Eyes oscillate at equal speeds

(pendular nystagmus)

Nystagmus exhibits slow and fast

phase (jerk nystagmus)

Pure persistent vertical

nystagmus regardless of
positional testing

Spontaneous horizontal
nystagmus

Youre taking the history of a 85 y/o female

who is active. She presents with: vertigo
with movement, nausea and vomiting, and
nystagmus with head movements. Which of
the following do you NOT expect to find
during your examination:

A. A positive Romberg
B. A fatiguing nystagmus
C. Ataxia
All others are Peripheral,
Nausea is mostly peripheral,
and rare in central

D. Normal smooth pursuits

Case Study 1
Your patient has complaints of intermittent severe
dizziness. The symptoms are aggravated by
rolling over in bed and getting up in the morning.
When observing the patient you notice a torsional
/ horizontal nystagmus with head movement that
subsides after 45 seconds
The patient states that focusing on an object
makes the dizziness better.

Is the lesion likely central or

peripheral?

1. Central
2. Peripheral

What is a likely diagnosis?

A. Vestibular neuronitis (no hearing

loss or facial weakness)
B. BPPV

Intermittent

C. Menieres Syndrome
D. Multiple sclerosis

Need to rule this out

If the patient has persistent

symptoms after multiple
treatments what should be
ruled out?
1. Gentamycin
toxicity
2. BPPV
3. Menieres
Syndrome
4. Multiple sclerosis

Case Study 2
Your patient is admitted with a diagnosis of
BPPV from a local physician. When
observing the patient you note an irregular
vertical nystagmus that is persistent.
The patient states that he is always a little
dizzy and is having difficulty focusing his
vision.

Is the physician diagnosis

correct?

1. Yes
2. No

Where is the lesion likely

located?

1. Posterior canal
2. Anterior canal
3. Central vestibular system
4. Peripheral vestibular system

Case Study 3
Your patient has complaints of intermittent
dizziness with a feeling of fullness and
ringing in both ears, also mild hearing loss.
The symptoms have persisted on and off
for multiple years (only lasting 1-2 hours).

What is the likely diagnosis?

1. Vestibular
neuronitis
2. BPPV
3. Menieres
Syndrome
4. Multiple sclerosis

Should a physician be
consulted?

1. Yes
2. No

Questions
Reading Assignment
OSullivan: Chapter 21