Deafness, vertigo, and

imbalance
By- Dr. Kajal (PT)
Introduction
 Disturbances of the eighth cranial nerve and its central
connections lead to various combinations of deafness,
vertigo, and imbalance.
 Cochlear division- supplies the cochlea and is concerned
with hearing.
 Vestibular division- supplies the semicircular canals, the
utricle, and saccule, and is concerned in postural and
equilibratory functions.
Physiology Of Hearing
Disorders of hearing
Conductive hearing loss
 Problem in the mechanical conduction of the soundwaves.
 May be a temporary problem.
 May also be a congenital defect in the ear.
 It may resolve with time, medication or surgical treatment.
 If it doesn’t resolve, hearing aids may be required.
Sensorineural hearing loss
 Damage of the hair cells in the cochlea.
 Can be congenital or it can be acquired later.
 It is not typically resolved with medical treatment, and
 Hearing aids are typically recommended for patients with this
type of hearing loss.
Mixed hearing loss
 This occurs when a patient has both conductive hearing loss
and sensorineural hearing loss.

 Treatment may include a combination of medical intervention

to resolve the conductive hearing loss and then hearing aids
for the remaining sensorineural hearing loss.
Auditory Neuropathy Spectrum Disorder
 Less common type of sensorineural hearing loss.

 Due to Auditory Neuropathy.

 While the amount of hearing loss varies in each case, patients

with this disorder perceive sound as distorted, which makes
speech difficult to understand, especially in noisy
environments.
Central Auditory Processing Disorder
 Normal hearing sensitivity but have difficulties processing.

 Treatment focuses on improving processing skills and

helping the patient develop strategies.
Causes Of Hearing Disorders
 Hereditary and congenital
 Infection
 Vascular causes
 Toxic effect of ototoxic drugs
 Trauma
 Neoplasia
 Metabolic
 Temporal bone abnormalities
 Autoimmune disorders
Assessment of Hearing
Tinnitus
 Tinnitus is a symptom in which the person hears noises in the ears or head in
the absence of any sound stimulus.
 It is a common complaint, which is only significant when its intensity overrides
the normal environmental sounds to reach consciousness.
 The subjective sensations can take many forms which include buzzing,
humming, hissing, roaring, clicking, or some similar description.
 It is usually constant, but some patients describe it as intermittent, pulsating, or
fluctuating.
 Associated with a conductive rather than a sensorineural hearing loss, it may
be lower in frequency.
Pure Conductive Hearing Loss
 Loss of sensitivity for sounds of all frequencies
 Speech discrimination is generally unimpaired
 They often complain of low-frequency tinnitus
 Generally speak at a reduced intensity level because they
can hear themselves well by bone conduction.
Sensorineural Hearing Loss
 Result of disorders between the cochlea and the brainstem.
 Speak with excessive loudness, and have better hearing for the lower
frequencies than for the high frequencies.
 Hear voices at normal intensity, due to intact low-frequency hearing,
but they do experience difficulty understanding what is being said to
them.
 Difficulty hearing against a noisy background.
 Tinnitus of a higher pitch than occurs in conductive hearing
impairments.
Tests for Hearing
 Rinne’s test

 Weber’s test
Tests of vestibular function
Nystagmus
 Vestibular lesion may cause a spontaneous nystagmus- with a slow
phase towards the side of the lesion and a saccade in the opposite
direction.

 Nystagmus due to labyrinthine origin is not affected by the direction of

voluntary gaze and is inhibited by fixation.

 In dysfunction of the semicircular canals or their peripheral neurons,

the nystagmus is always accompanied by vertigo
 If nystagmus persists for more than a few weeks, it is usually
due to an abnormality in the central vestibular pathways.

 With central lesions, subjective symptoms are less severe,

and nystagmus may be multidirectional, dissociated in the
two eyes, and unchanged by eye closure
Vestibulo-Ocular Reflex
 To do this, the VOR must generate rapid compensatory eye
movements in the direction opposite the head rotation.
Head Impulse Test
 The head impulse test is performed by having the patient first
fixate on a near target (e.g., the clinician’s nose).

 Patient is asked to keep their eyes focused on a target while their

head is manually rotated in an unpredictable direction using a
small-amplitude (5° to 15°), moderate-velocity & high-acceleration.

 Observe for saccade or nystagmus

Dix-Hallpike test
 For patients having benign paroxysmal positioning vertigo

 The patient is moved from a long-sitting position with the

head rotated 45° to one side, to a supine position with the
head extended 30° beyond horizontal, head still rotated 45°
Tests of stance and gait
 Romberg test, in which the patient is required to stand with
eyes closed, feet together, and arms to the side.

 Unterberger test, requires the patient with eyes closed to

stretch his hands out in front and to step up and down in the
same place, like a soldier marching on the spot.
Vertigo
 Vertigo may be defined as an awareness of disordered orientation of
the body in space.

 The derivation of the term implies a sense of rotation of the patient or

of his surroundings.

 Vertigo occurs with either physiological stimulation or pathological

dysfunction of any of the three stabilizing sensory systems: vestibular,
visual, and somatosensory.
 The external world may appear to move, often in a rotatory
manner, but other forms of movement, such as oscillation,
may be experienced.

 The body itself may be felt to be moving, either in rotation or

as a sensation of falling, or the movement may be referred to
within the body, e.g. within the head.
 The motor accompaniments- involuntary movements of the
whole body, such as falling, and disordered orientation
 In the eyes- nystagmus or rarely diplopia
 In the limbs- pass pointing
 Visceral disturbances- pallor, sweating, alterations in the
pulse rate and blood pressure, nausea, vomiting, and
diarrhoea
Peripheral Vestibular Disorders
Most Common
 Benign paroxysmal positioning vertigo,
 Vestibular neuritis, and
 Menière's disease
Benign Paroxysmal Positional Vertigo
 Also called benign positioning vertigo
 BPPV is a syndrome which can be the sequela of several inner ear
diseases, and often follows mild to moderate head injuries.
 In about 50 per cent of cases no cause can be found.
 Originally considered to be due to a lesion of the otolith organs
 Cupulolithiasis theory
 States that the cupula of the posterior canal becomes heavier than the
surrounding endolymph due to the degenerating utricular macula clot of
calcium carbonate which settles on it.
 Patient experience-
 Repeated brief episodes of vertigo, with nystagmus lasting less
than 30 seconds
 Usually precipitated by a positional change, such as turning in
bed, getting in and out of bed, extending the neck to look up, and
bending over and straightening up.
Menière's disease
 Menière's disease is an inner ear disorder characterized by
episodic symptoms of vertigo, hearing loss, tinnitus and aural
fullness, which often, but not always, occur together.
 The condition can be severely debilitating, with attacks
occurring without warning.
 The condition is thought to result from idiopathic distension of
the endolymphatic system and periodic ruptures of the
membranes separating endolymph from perilymph.
Vestibular Neuritis
 Acute rotational vertigo associated with spontaneous
nystagmus, postural imbalance, and nausea without any
auditory symptoms.

 The condition is usually self-limiting, with recovery from

symptoms taking place over a period of 1–6 weeks, although
rapid head movements may continue to cause mild
oscillopsia and impaired balance.
Central Vestibular Vertigo
Vestibular epilepsy
 Vestibular epilepsy is a cortical vertigo syndrome secondary to
focal discharge from either the temporal or parietal lobe, each of
which receive bilateral vestibular projections from the thalamus.
 Vestibular seizures are either simple or complex partial with
vertigo as the major component.
 Patients experience the sudden onset of dysequilibrium with
rotational or linear vertigo, usually accompanied by
contraversive body, head, and eye rotation
Vertebrobasilar insufficiency
 Vertebrobasilar ischaemia is commonly associated with vertigo,
as well as other symptoms of brainstem dysfunction.
 When the other features occur, ischaemia of the brainstem is
clear, but in patients with recurrent episodes of vertigo alone,
which are ascribed to vascular insufficiency, it is likely that these
are due to transient ischaemia of the vestibular labyrinth, since
the labyrinth is particularly susceptible because the labyrinthine
circulation is an end circulation with minimal collaterals
Basilar artery migraine
 Basilar artery migraine is a form of migraine most commonly
observed in adolescent girls.
 It is associated with the sudden onset of symptoms of brainstem
dysfunction which include vertigo, diplopia, dysarthria, drop attacks,
visual phenomena and, in some cases, loss of consciousness.
 This aura usually develops over a few minutes to an hour, and it
usually followed by a severe throbbing headache in the occipital
region, associated with vomiting
Benign paroxysmal vertigo
 This condition of childhood is characterized by attacks of acute
rotational vertigo, often causing the child to drop to the ground or
cry out while clutching for support.
 The episodes, which are usually accompanied by nystagmus and
postural imbalance, last up to 5 minutes, and usually occur in the
first 4 years of life and spontaneously resolve before 8 years.
 There is often a family history of migraine and many children
subsequently develop classic migraine.
Psychogenic vertigo
 Vertigo, a subjective symptom, occurs in a number of psychiatric disorders,
including anxiety, depression, and personality disorders, although rarely in
psychosis.
 In addition, vertigo as a symptom due to vestibular dysfunction can itself lead
to the development of psychiatric disorders, including anxiety, panic attacks,
and depression.
 This may, in turn, lead to the persistence of symptoms of persistent dizziness
and postural imbalance after central compensation or remission of a
peripheral vestibular disorder.
 This occurs particularly in individuals with an obsessive personality.