ANATOMY OF THE PERIPHERAL AND CENTRAL VESTIBULAR NERVOUS

SYSTEM

VESTIBULAR ANATOMY
 Peripheral sensory apparatus
o Detects and relays information about head angular and linear velocity
to central processing system
o Orients head with respect to gravity
 Central processing system
o Processes information in conjunction with other sensory inputs for
position and movement of head in space
 Motor output system
o Generates compensatory eye movements and compensatory body ASCENDING PATHWAYS
movements during head and postural adjustments  Vestibular nerve  Vestibular cortex
 Vestibular nuclei  Oculomotor complex
FUNCTION OF THE VESTIBULAR SYSTEM  Medulla  Cerebellum
1. Provides information concerning gravity, rotation and acceleration
 Thalamus
2. Serves as a reference for the somatosensory and visual systems
3. Helps integrate arousal, conscious awareness of the body via connections with
vestibular cortex, thalamus, and reticular formation DESCENDING PATHWAYS
4. Allows for:  Provide motor output from the vestibular system to:
 Gaze and postural stability o Extraocular muscles (part of VOR)
 Sense of orientation o Spinal cord and skeletal muscles (generate antigravity postural
 Detection of linear and angular acceleration activity to cervical, trunk, and lower extremity muscles)
o Response to changing head position with respect to gravity (righting,
THE EAR equilibrium responses)

VESTIBULOSPINAL REFLEX
 Generates compensatory body movement to maintain head and postural stability.
Thereby preventing falls

CEREBELLUM
 Monitors vestibular performance
 Readjusts central vestibular processing of static and dynamic postural activity
 Modulates VOR
 Provides inhibitory drive of VOR

SYMPTOMS OF VESTIBULAR DISEASE

1. Vertigo 4. Disequilibrium
2. Dizziness 5. Oscillopia
THE INNER EAR 3. Lightheadedness 6. nystagmus

VERTIGO
 Feeling of being off balance/ spinning sensation
 No. 1 reason for consult among patients >75 years old
 Significant risk factor for falls in the elderly
 In children, it may affect normal childhood activities

DIZZINESS
 Sensation of whirling or feeling a tendency to fall
 Vague sensation of light-headedness

LIGHTHEADEDNESS
 Feeling that fainting is about to occur
 It is vague
 It is less localizing than vertigo
PERIPHERAL APPARATUS
 May be due to non-vestibular problem
 Membranous Labyrinth o Hypotension
o Semicircular canals (SSC) o Hypoglycemia
o Angular acceleration o Anxiety
o Ampulla contains sensory epithelium
DYSEQUILIBRIUM
 Otolith organs
 Sensation of being off balance
 Acute and chronic vestibular lesions will produce equilibrium
 Disequilibrium is associated with decreased somatosensation or weakness in the BENIGN PAROXYSMAL POSITIONAL VERTIGO
lower extremities  Peripheral cause
 Otoconia (calcium carbonate crystals) normally embedded in the utricle
OSCILLOPSIA  Crystals dislodged into the canals and may block normal fluid movement that the
 Visual illusion of oscillating movement of stationary objects canals used to sense head motion
 Subjective experience of motion of objects in the visual environment that are  Fluids not affected by gravity but crystals do and when they move, fluids move
known to be stationary and stimulates cupula to send false signals to the brain causing vertigo
 Can arise with lesions of peripheral or central vestibular systems, vestibular  Most common cause of peripheral vestibular disorder
hypofunction  Sign: nystagmus
 Indicative of diminished VOR gain  Diagnosis
o Motion of images in fovea o Dix-Hallpike test
o Diminished visual acuity o Roll tests
 50% recurrence rate after treatment
NYSTAGMUS
 Treatment protocol may differ each time
 Rapid alternating movement of eyes in response to continued rotation of the body
 Primary diagnostic indicator in identifying vestibular lesions DIX-HALL PIKE TEST
 Peripheral Vestibular Lesion
o Composed of both slow and fast component eye movements
 Physiologic nystagmus
o Vestibular, visual, extreme lateral gaze
 Pathologic nystagmus
o Spontaneous, positional, gaze evoked
 Labeled by the direction of the fast component

DIFFERENTIATION BETWEEN PERIPHERAL AND CENTRAL VERTIGO

Peripheral (Inner ear and vestibular nerve)

 Benign Paroxysmal Positional  Labyrinthitis

Vertigo  Perilymphatic Fistula ROLL TEST
 Meniere’s Disease  Acoustic Neuroma
 Vestibular neuritis

Central

 CVD  Posterior fossa tumor

 Cerebellar D/O  Neurodegenerative D/O
 Migraine  Medications
 Multiple Sclerosis  Psychiatric D/O

Peripheral Central
Nausea Severe Moderate
Imbalance Mild Severe
BPPV: CANALITHIASIS VS CUPOLOTHIASIS
Hearing loss Common Rare
Oscillopsia Mild Severe
CANALITHIASIS
Neurologic Symptoms Rare Common
 Loose crystals move freely in the fluid of the canal
Compensation Rapid Slow
 Symptom almost immediately stop when movement of the head ceases
 Treatment: Canalith Repositioning Maneuvers
Peripheral
 Ataxia mild
CUPOLOTHIASIS
 Smooth pursuit and saccades usually normal; positional testing ma reproduce
 Crystals hung up on the bundle of nerves that sense the fluid movement
nystagmus
 Vertigo persists even when the head is not in the offending position
 Sx of acute vertigo usually intense (more than central vestibular pathology)
 Treatment: Liberatory Maneuver followed by the Canalith Repositioning
 Nystagmus will incorporate slow and fast phases (jerk nystagmus)
Maneuvers

Central
 Ataxia often severe
 Abnormal smooth pursuit and abnormal saccadic eye movement tests
 Sx of acute vertigo not usually suppressed by visual fixation
 Pendular Nystagmus (Eyes oscillate at equal speeds)
CANALITH REPOSITIONING MANEUVER o Intratympanic injection with gentamicin or dexamethasone
o Air pressure pulse generator
o Surgery

INFECTION OF THE INNER EAR

 Vestibular Neuritis
o Viral (herpesviridae) infection of the vestibular nerve that causes
vertigo
 Labyrinthitis
o Infection, most commonly viral, of the labyrinth
o Causes vertigo and sensory type hearing loss or tinnitus
 In both cases, sudden movement of the head causes the vertigo
 However, it is not generally related to the side of the head which is down (as in
BPPV) but whether the patient is lying down or sitting up
 95% of vestibular neuritis is one-time experience
 Treatment is symptomatic although if herpes infection is suspected, an anti0viral
drug may be given
 Usually takes three weeks to recover from both Vestibular Neuritis and
Labyrinthitis
 Recovery may be due to a successful immune system or brain getting used to the
imbalance (Compensation)
LIBERATORY MANEUVER
PERILYMPHATIC FISTULA
 Abnormal connection (tear) in one or both of the small, thin membranes (the oval
window and the round window) that separate the air filled middle ear and the fluid
filled perilymphatic space of the inner ear
 Fluid leaks into the middle ear
 Due to the defect, changes in the pressure of the middle ear affects the inner ear
stimulating the balance or hearing structures within
 Symptoms: ear fullness, fluctuating or sensitive hearing, dizziness, and motion
intolerance
 Symptoms worse with changes in altitude (fast elevators, airplanes, and high
places) or increase in CSF pressure such as heavy lifting, bending over and
coughing or sneezing
 Most common cause is head trauma usually a direct blow to the head or whiplash
injury
 Other causes: Perforation of eardrum due to a strong nose blowing or sneezing,
or anything that may increase the ICP, scuba diving
 Rarely congenital and usually unilateral
 If traumatic in cause, restrict physical activity for 7-14 days, further tests done if
symptoms do not improve
 Perilymphatic space is connected to the CSF
 Perilymph fluid, which is high in sodium, is similar with CSF
MENIERE’S DISEASE
 Fistula causes perilymph in the inner ear escapes, due to the hydrostatic pressure
 Aka Idiopathic Endolymphatic Hydrops
of the CSF, and is replaced by CSF – lower levels of CSF in the brain and spinal
 Most cases are unilateral
cord – headache
 20-50 years old; M=F
 Treatment: surgery
 May be due to excessive production of fluid in the inner ear or inadequate
o Surgery usually takes about an hour with minimal pain
absorption
o After discharged, patients advised to stay at home for 3 days with
 Attacks may be induced by fatigue and stress limited activity
 Set of episodic symptoms including o Sedentary work may be done after three days and to avoid lifting of
o Vertigo more than 10 lbs as well as sporting activities for 1 month
o Hearing loss o Avoid contact sports, diving, weight lifting, and roller coasters until
 Intermittent occurring mainly at the time of the attacks of cleared by physician
vertigo
 Initially involves lower pitches but may involve all pitches ACOUSTIC NEUROMA
in chronic cases  Intracranial, extra-axial tumors that arise from Schwann cell sheath investing
 May become permanent either the vestibular or cochlear nerve
o Tinnitus  Most common symptom is unilateral hearing loss
o Sensation of fullness in the affected ear  In smaller lesion, there could be vertigo or balance problem
 Episodes last from 20 minutes up to 4 hours  In patients presenting with unilateral hearing loss, consider acoustic neuroma until
 Diagnostics: Audiometric exam, Electronystagmogram, Rotational or balance proven otherwise
platform testing, Electrocochleography  Definitive diagnosis is through Gadolinium – enhanced MRI
 Treatment  Treatment:
o Low salt diet and diuretics o Surgical excision
o Anti-vertigo medications o Arrest tumor growth through radiation therap
 o Careful serial observation
 Observation is recommended for the following
o Elderly patients
o Patients with small tumors, especially if hearing is good
o Patients with medical conditions that significantly increases the risk
for operation
o Patients who refuse treatment
o Patients with a tumor on the side of an only hearing ear or only seeing
eye
QUANTITATIVE VESTIBULAR TESTING
ELECTRONYSTAMOGRAPHY
 Diagnostic test to record involuntary movements of the eye caused by nystagmus
 Can also diagnose cause of tinnitus, vertigo, dizziness, or balance dysfunction
 ENG measurements are based on the presence of corneoretinal potentials
QUANTIFIED DYNAMIC ISUAL ACUITY
 Behavioral measure of vestibular function that quantifies one’s ability to see
clearly during predictable or unpredictable head movements
 Measuring visual acuity during head movements is one of the best functional tests
in patients with unilateral and bilateral vestibular hypofunction
 It can identify the side of vestibular dysfunction and measure individual
semicircular function
QUANTIFIED DYNAMIC VISUAL ACUITY
VESTIBULAR EVOKED MYOGENIC POTENTIAL TESTS
 Assess the saccule and its central projection (inferior vestibular nerve) to
evaluating the CN XI circuit
 Series of tones are presented to each ear individually, and the corresponding
evoked sternocleidomastoid responses are recorded during the patient’s neck
flexion
 Absence of response reflects damage to that side
 CANNOT be used in patients with conducting hearing loss
COMPUTER DYNAMIC POSTUROGRAPHY
 Test the vestibulospinal reflexes and assess balance maintenance
 Asses the major senses involved in balance: vestibular, vision and proprioception
 Gives insight to patient’s functional status, compensation and fall risk
 A force plate measures body sway under different visual and postural conditions
VESTIBULAR REHABILITATION
VESTIBULAR REHABILITATION
 Is a specific form of physical therapy designed to habituate symptoms and
promote adaptation to and substitution for various aspect of deficits related to a
wide variety of balance disorder
 It is effective both in peripheral and central vestibular disorders
 Protocol should be individualized
 Basis for success is through the use of existing neural mechanism for adaptation,
plasticity, and compensation
STRATEGIES IN VRT
 Habituation for positional or motion-provoked symptoms
 Adapting to improve the gain of the vestibuloocular or the vestibulospinal reflexes
 Substituting alternative senses to replace lost vestibular function by biasing use
away from the dysfunctional vestibular input
GOALS OF VRT
 Improve balance
 Minimize falls
 Decrease subjective sensations of dizziness
 Improve stability during locomotion
 Reduce over dependency on visual and somatosensory inputs
 Improve neuromuscular coordination
 Decrease anxiety and somatization due to vestibular disorientation
COMPONENTS OF VRT
1. Coordinated team of clinicians
2. Accurate diagnosis and assessment
o Quantifying the degree of damage to peripheral and central vestibular
pathways
o Evaluation of physiologic and neurologic compensation
o Detailed medical history and balance symptoms
o Evaluation of gait, ambulation, head movement, balance under
altered sensory cues under static and dynamic conditions
o Sensory evaluation to include visual and proprioceptive abilities
o Posturography to differentiate balance dysfunction due to vestibular
from proprioceptive loss by measuring shoulder and pelvis sway
o Evaluation of impact of symptoms to daily activities
 Dizziness Handicap Inventory
 Activities-Specific Balance Confidence Scale
3. Outcome measurement after VRT
o Computerized Dynamic Posturography (Vestibulospinal Reflex)
o Dynamic visual Acuity Test and Gaze Stabilization Test
(Vestibuloocular Reflex)
o VRT Benefit Questionnaire
o Dynamic Gait Index (Risk for Fall after VRT)
2016 EVIDENCE-BASED CPG FROM APTA
Strong Evidence
 VRT should be offered to patients with unilateral and bilateral vestibular
hypofunction who have vestibular deficit-associated impairments and functional
limitations
 Voluntary saccadic or smooth-pursuit eye movements should NOT be performed
in isolation (without head movement) for gaze stability in rehab
Moderate Evidence
 Specific exercise techniques aimed at identified impairments or functional
limitations may be offered
 Based on patients’ preference, supervised VRT may be provided
Expert Opinion
 Gaze stability exercise, as one part of home exercise program may be prescribed
a minimum of 3x/ a day
 Adequate supervised VRT that allow patients to comprehend the program’ goals
and understand how to independently manage themselves and progress can be
considered
FACTORS AFFECTING SUCCESS OF VRT
 Extent and location of damage to vestibular system
 Status of visual and proprioceptive system
 Physical strength
 Motor skills
 Integrity of Cerebellum
 General physical health
 Decision making and cognitive abilities
 Age
 Memory
 Presence of psychological and anxiety disorder