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Differential Diagnosis of Dizziness and Vestibular Screening

Differential Diagnosis of Dizziness and Vestibular Screening. How to screen the vestibular patient. Differential Diagnosis of Dizziness. What is dizziness? Very subjective symptom, often described as: Light headedness Loss of balance Dysequilibrium Vertigo. Differential Diagnosis.

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Differential Diagnosis of Dizziness and Vestibular Screening

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  1. Differential Diagnosis of Dizziness and Vestibular Screening How to screen the vestibular patient

  2. Differential Diagnosis of Dizziness • What is dizziness? • Very subjective symptom, often described as: • Light headedness • Loss of balance • Dysequilibrium • Vertigo

  3. Differential Diagnosis Common Complaints Considerations • Weakness, Fatigue, Light-Headedness • Tripping, Clumsy, Gait Abnormalities • Spinning/Vertigo*** • Low BP, O2 Sat • Potential cardiac issues • Decreased coordination, strength or ROM • Potential neurologic or neuromuscular involvement • Vestibular Dysfunction

  4. What is Vertigo? • “A sensation of motion in which the individual or the individual's surroundings seem to whirl dizzily” -Webster • Dysequilibrium often occurs when a conflict between balance senses are unresolved or if the vestibular system is not functioning correctly.

  5. Neuro Screens: Oculomotor Exam • Smooth Pursuits • Saccades • Vergence Testing • VOR Cancellation Test

  6. Oculomotor Exam: Smooth Pursuits • “Draw a large, imaginary rectangle” in front of your patient with your pen. • Instruct your patient to “follow the pen with your eyes only, don’t move your head” • Observe for smooth pursuits of the eyes. Watch for abnormal, saccadic movements or end-range nystagmus. • This can be repeatable if you perform this test several times. • Saccades may be more observable with increased target speed.

  7. Smooth Pursuits Video • Are the subject’s eyes moving smoothly or are there saccades?

  8. Oculomotor Screen: Saccades • Hold a target 12-18 inches next to your head. • Instruct your patient to look at the target, then look at your nose. • Try this in different directions including lateral and horizontal. • Observe for saccadic eye movements. Note the direction where you observe saccades. • Saccades are abnormal.

  9. Saccade video • Does this subject move her eyes directly from target to target?

  10. Oculomotor Screen: Vergence • Have your subject stare at your pen as you move it from 12” away to the subjects nose. Look t see if the subject can go cross-eyed. • Watch both eyes converge onto the pen. • Normally, the subject can converge up to 6cm away. Anything further away is abnormal.

  11. Convergence Video • Does this subject have the ability to converge within 6cm?

  12. Oculomotor Screen: VOR Cancellation Test • Have your patient clasp their hands in front of them. Instruct them to rotate their entire body side to side and ask the subject to look at their thumbs the entire time. • Watch the subject’s eyes as they look at their thumbs. • Eyes should be able to “cancel” the VOR and look at their thumbs the entire time. • Inability to cancel their VOR is abnormal.

  13. VOR Cancellation Video • Is this subject able to “cancel” his VOR?

  14. VOR Screening • Head Thrust Test • Dynamic Visual Acuity Test • Infrared/Frenzel Tests • Gaze Holding Nystagmus • Head Shake Test

  15. Be Advised…. • These screens are NOT diagnostic tests. They are screens to assist with our evaluation of the patient and formulation of treatment plans. • Not any single screen is definitive. Performing several screens will help to determine the potential problem and its severity. • Tests are repeatable.

  16. VOR Screen: Head Thrust Test • Hold your patient’s head firmly on both sides. • Instruct your patient to look at your nose while you turn their head from side to side. Advise the patient you will be moving their head slowly and also fairly quickly. • Tilt your patient’s head down 20-30 degrees. • Slowly more your patient’s head side to side, then follow with a quick thrust in one direction.

  17. VOR Screen: Head Thrust Test • Look for a “refixation” saccade or a delay to the side you are testing. The presence of a saccade is abnormal. • A positive head thrust test may be consistent with a vestibular hypofunction/weakness.

  18. Head Thrust Test Video • Is the patient able to look at the tester’s nose with a head thrust?

  19. Head Thrust Video #2 • What observations can be made with this test?

  20. VOR Screen: Dynamic Visual Acuity Test • This test requires good lighting, a Lighthouse eye chart and 10 feet of distance from the patient to the eye chart. • Ask the patient to read each letter from left to right. Stop the patient when they make their second error. • While standing behind your patient, hold their head firmly on both sides and quickly turn their head side to side at a speed of 2hz@ 45 degrees each for up to 10 seconds.

  21. VOR Screen: Dynamic Visual Acuity Test • Ask your patient to read the letters again while turning their head. Stop the patient when they make their second error. • The difference between the rows (in LogMar) should be < 0.3. Anything greater than that is abnormal. • An abnormal test may be consistent with a vestibular hypofunction/weakness. • This is a good way to quantify the severity of the problem.

  22. VOR Screen: IR/Frenzel Tests • IR and Frenzel goggles allow us to view the subject’s eye movements while eliminating the subject’s visual reference.

  23. VOR Screen: IR/Frenzel Tests • Gaze Holding Nystagmus • Head Shake Test • Special Tests

  24. IR Tests: Gaze Holding Nystagmus Video • Allows you to observe nystagmus in patients when it is not as apparent in room light.

  25. IR Tests: Head Shake Test • Head shake test can increase observable nystagmus and help clarify direction. • Positive test may be consistent with a vestibular hypofunction/weakness

  26. Head Shake Test • What is the direction of the nystagmus after the head shake test? • What does this mean?

  27. Head Shake Nystagmus Video • What is the direction of the nystagmus after the head shake test? • What does this mean?

  28. Special Test: Fukuda Test • Tests for vestibular involvement. • Have patient march in place with knees high, arms forward for up to 50 steps. • Observe the patient for safety, but also for rotation. • An observed rotation may be consistent with a vestibular dysfunction. (Fukuda, 1959)

  29. Group Exercise • Pick a partner and perform parts of the oculomotor exam. • Refer to the Group Exercise page.

  30. Common Clinical Diagnoses • Vestibular Hypofunction/Dysfunction • Concussion • Benign Paroxysmal Positional Vertigo (BPPV) • Most General Diagnosis is Dizziness and Giddiness ICD10 R42

  31. Vestibular Hypofunction • Diagnostic tests for this is Video Nystagmography (VNG) or Electronystagmography (ENG) which may quantify a patient’s overall weakness. • Patients present with severe onset of dizziness that lasts for days. May report oscillopsia once severity resolves. • Typical findings with vestibular screen may include: • Pos Head Thrust • Pos Head Shake Nystagmus • Spontaneous nystagmus with IR tests • Abnormal DVA (>3.0 Logmar)

  32. Concussion • Considered a mild TBI • Dizziness is common complaint with concussion (Zhou, 2015) • Up to 60 percent of these patients present with BPPV

  33. Questions?

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