LR The Neurotologic Examination of The Dizzy Patient

THE NEUROTOLOGIC EXAMINATION OF
THE DIZZY PATIENT

Literature Reading
Supervisor : dr. Sally Mahdiani., M.Kes., Sp.THT-KL
Dept of Otorhinolaryngology – HNS

Hasan Sadikin General Hospital
Bandung
2016
Introduction
• Dizziness may refer to a light-headedness that
feels as if nearly passing out, near faint
dizziness
• Dizziness is a common symptom affecting 20%
to 30% of the general population in the United
States
• Among patients 75 years of age and older,
balance disorders are the most common
reason for visiting a physician
Voelker CJ. , Goebel JA. Clinical Evaluation of the Patient with Vertigo. In Bailey BJ. Head & Neck Surgery-Otolaryngology. 5th ed. Lippincot
2
Williams & Wilkins, Philadelphia. 2014. p.2673-2700
3
Roeser, Valente, Hosford-Dunn. Audiology : Diagnosis. Thieme Medical publishers, Inc., New York. 2000 3
The vestibular
labyrinth
Semicircular canals
The otolith organs
(SCCs) (horizontal,
(utricle and saccule)
superior and posterior)
detect high-velocity, to sense linear

angular head acceleration (including
movement gravity)
Williams & Wilkins, Philadelphia. 2014. p.2673-2700 4
THE NEUROTOLOGIC EXAMINATION
OF THE DIZZY PATIENT
5
Spontaneous nystagmus
Test Performance
• Static visual fixation
Outcome
• Nystagmus waveform, direction, effect of fixation
Interpretation of Clinical Finding

• Peripheral: Horizontal--rotary jerk nystagmus, suppresses with
visual fixation
• Central: direction changing, horizontal, vertical, torsional, or
pendular nystagmus, enhances with visual fixation
Gaze-evoked nystagmus
Test Performance
• < 30" eccentric gaze
Outcome
• Nystagmus waveform, direction

• Peripheral: Direction-fixed nystagmus, increases while gazing in the
direction of the fast phase (Alexander law)
• Brainstem or cerebellum: Direction-changing nystagmus, fast-phase
movement in the direction of gaze, or rebound nystagmus in neutral gaze
• CPA mass: Brun nystagmus (direction-changing nystagmus caused by a
combination of central GEN and vestibular nystagmus)
Saccades
Test Interpretation of
Outcome
Performance Clinical Finding
• Alternate • Accuracy, • Peripheral:
fixation on two conjugate normal.
stationary movement, Abnormalities
targets velocity, and indicate a
initiation central
etiology
Smooth pursuit
• Track visual target • Smooth versus • Normal in peripheral

jerking eye vestibular pathology.
movements Abnormalities (e.g.,
catch-up saccades)
indicate a central
etiology
Interpretation of
Test Performance Outcome
Clinical Finding
Fixation suppression
Test Performance
Rotate examination chair ± visual fixation
Outcome
Effect of fixation on rotation-induced nystagmus
Normal fixation suppression in peripheral pathology. Failure of

fixation suppression suggests central (floccular) dysfunction
Head Impulse Test (HIT)
Test Performance
• Rotational head thrusts while maintaining visual fixation
Outcome
• Refixation saccade
• Peripheral vestibular dysfunction: Refixation saccade

generated with rotational head thrusts toward the weak side
Head Heave Test (HHT)
Test
Performance Linear head heaves while maintaining visual
fixation
Outcome
Refixation saccade
Interpretation
of Clinical Otolith damage: Refixation saccade
Finding generated with linear head heaves toward
the damaged side
Postheadshake nystagmus
Test Performance
• Headshake
Outcome
• Nystagmus direction
• Asymmetric peripheral damage: nystagmus (in plane of

damaged canal with fast phase toward stronger ear).
• Central: cross-coupling of nystagmus
Dynamic Visual Acuity (OVA)
Outcome
• Visual acuity • Visual acuity • Peripheral
(static vs. head decline vestibular
movement) dysfunction:
Visual acuity
decline (>2
lines on Snellen
chart)
Positional testing
Test Performance
• Various static head positions
Outcome
• Nystagmus onset, direction, duration, effect of fixation

• Peripheral: Severe vertigo, transient, and usually direction fixed.
Removing visual fixation enhances nystagmus
• Central: Usually asymptomatic, persistent, direction changing, and
may be disconjugate. Removing visual fixation improves nystagmus
Positioning testing
Test
Performance Head movement to various head positions
(e.g., Dix-Hallpike)
Outcome
Nystagmus latency, direction, duration,
fatigability, reversal
Interpretation
of Clinical Central: Immediate (no latency), persists >1
Finding min, no reversal nystagmus, no fatigue,
direction changing, no vertigo
Limb coordination tests
Test Performance
• Limb coordination tests
Outcome
• Limb coordination. Arm drift with past pointing
• Peripheral (vestibulospinal): All limb coordination tests,

except past pointing, are normal Past pointing: excessive arm
drift toward side of peripheral lesion.
• Central: abnormalities in any of the tests
Gait
Interpretation of
Test Performance Outcome
Clinical Finding
• Tandem gait, • Gait • Peripheral:
Unterberger abnormalities. Abnormal tandem
(Fukuda) stepping Rotation with gait with eyes
test stepping closed, rotation to
side of lesion with
stepping test.
• Central: Gait
abnormalities
(e.g., ataxia,
shuffling, etc.)
Posture
Outcome
Peripheral:
Fall on
tandem and
Romberg Excessive
foam
tests sway and fall
Romberg
tests (eyes
dosed)
Mastoid vibration
Test • Vibration source on mastoid
Performance
Outcome • Nystagmus direction
Interpretation of • Nystagmus in the plane of the affected

Clinical Finding canal toward the stronger ear
Malleolar sign
• 256-Hz tuning fork on
Test Performance malleolus
Outcome • Conductive hyperacusis
• Patient hears tuning

Interpretation of fork vibration on side of
Clinical Finding superior canal
dehiscence
Pressure-evoked eye movements
Test Outcome Interpretation

Performance • Eye movement, of Clinical
• Tragal vertigo Finding
compression, • Perilymph fistula,
pneumatic otic syphilis, or
otoscopy, Valsalva semicircular canal
maneuvers dehiscence
Sound-evoked eye movements
Test Performance
Pure tones (~100 dB)
Outcome
Eye movement, vertigo
Perilymph fistula, otic syphilis, or semicircular canal dehiscence
Hyperventilation induced nystagmus
Test Performance
• Hyperventilate for 90 s
Outcome
• Nystagmus direction

• Peripheral: excitatory nystagmus toward affected ear
Highlights
• The three primary sensory inputs responsible
for balance originate from the vestibular,
visual, and somatosensory (proprioceptive)
pathways.
• A structured and thorough discovery of all
pertinent historical events is critical in the
evaluation of the dizzy patient.
25
• The head impulse test (HIT) is a bedside
technique used to detect unilateral or bilateral
vestibular hypofunction.
• Postheadshake nystagmus is considered a
pathologic sign of vestibular input asymmetry
in the plane of rotation.
26
• The dynamic visual acuity test (DVAT) has
been developed and studied for the purpose
of determining gaze stability during head
movements at higher frequency (greater than
2 Hz) and peak velocity (greater than 120
degrees/s).
27
2

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THE NEUROTOLOGIC EXAMINATION OF

THE DIZZY PATIENT

Supervisor : dr. Sally Mahdiani., M.Kes., Sp.THT-KL

Dept of Otorhinolaryngology – HNS

detect high-velocity, to sense linear

Interpretation of Clinical Finding

Interpretation of Clinical Finding

• Track visual target • Smooth versus • Normal in peripheral

Rotate examination chair ± visual fixation

Effect of fixation on rotation-induced nystagmus

Interpretation of Clinical Finding

Normal fixation suppression in peripheral pathology. Failure of

• Rotational head thrusts while maintaining visual fixation

Interpretation of Clinical Finding

• Peripheral vestibular dysfunction: Refixation saccade

Interpretation of Clinical Finding

• Asymmetric peripheral damage: nystagmus (in plane of

Interpretation of Clinical Finding

• Limb coordination tests

• Limb coordination. Arm drift with past pointing

Interpretation of Clinical Finding

• Peripheral (vestibulospinal): All limb coordination tests,

Outcome • Nystagmus direction

Interpretation of • Nystagmus in the plane of the affected

Outcome • Conductive hyperacusis

• Patient hears tuning

Test Outcome Interpretation

Pure tones (~100 dB)

Eye movement, vertigo

Interpretation of Clinical Finding

Perilymph fistula, otic syphilis, or semicircular canal dehiscence

Interpretation of Clinical Finding

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