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FIGURE 7–31. Case example: vestibular migraine; oVEMPs.
Psychiatric Aspects of Dizziness
There is an established relationship between dizziness and psychiatric disorders. Many patients with
chronic dizziness also experience anxiety, depression, and panic attacks; conversely, those with these
psychiatric conditions are at increased risk of developing dizziness. The relationship has a neurological
basis as the limbic, autonomic, and vestibular centers have significant interconnections (Rajagopalan
et al., 2017).
A patient’s psychiatric condition may be the sole reason for dizziness symptoms, while another
patient may experience a psychiatric response to a physical condition. Dizziness characteristics in
psychiatric conditions include:
n
Constant imbalance
n
Dizziness triggered by movement, visual stimulation, specific situations
n
Dizziness lasts minutes to days
n
Symptoms rarely improve without intervention (e.g., cognitive behavioral therapy,
pharmacological treatment, vestibular rehabilitation)
Persistent Postural-Perceptual Dizziness (PPPD)
PPPD is a chronic functional vestibular disorder, not a structural or psychiatric condition. Most often,
patients develop PPPD after an acute vestibular episode, such as vestibular neuritis. PPPD management includes education about the disorder, vestibular rehabilitation, cognitive behavioral therapy, and
pharmacological treatment. PPPD is diagnosed using specific criteria (Staab et al., 2017):
n
One or more symptoms of dizziness, unsteadiness, or nonspinning vertigo present on most
days for >3 months
Symptoms last hours but may wax and wane.
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Symptoms need not be present through the entire day.
n
Persistent symptoms occur without provocation but are exacerbated by:
Upright posture
Active/passive motion without regard to direction or position
Exposure to moving or complex visual environments
n
Precipitated by conditions that cause vertigo, unsteadiness, problems with balance, including
acute, episodic, or chronic vestibular syndromes, other neurological/medical issues, or
psychological distress
n
Symptoms cause significant distress or functional impairment.
n
Symptoms are not better accounted for by another disease or diagnosis.
Vestibular Rehabilitation
Most vestibular rehabilitation is completed by physical therapists or audiologists with specialized
training. There is a range of rehabilitation options available and will vary depending on the needs of
the patient. Candidates for vestibular rehabilitation include those with:
n
Acute vestibular impairment, including BPPV
n
Chronic dizziness/oscillopsia
n
Chronic imbalance/fall risk
n
Central vestibular impairments, including vestibular migraine and concussion
BPPV
BPPV is the most common peripheral vestibular disorder, most often involving the posterior SCC.
This can be easily identified with the Dix-Hallpike test. At this point, many clinicians will continue
through the Epley maneuver (Figure 7–32) to reposition the displaced otoconia into the vestibule. This
is sometimes called “canalith repositioning.” Patients may need to go through the maneuver several
times to alleviate symptoms, but 90% have symptom resolution in one to two treatments. Patients with
recurrent symptoms may learn to treat themselves at home.
n
For those with symptoms suggesting BPPV but who have negative Dix-Hallpike findings,
the clinician should complete supine roll/lateral head roll testing to evaluate the patient for
horizontal SCC BPPV. In positive cases, the patient will demonstrate nystagmus in both head
right and head left conditions. The position with the strongest nystagmus and dizziness is the
positive side.
n
Most patients demonstrate geotropic nystagmus, meaning that in the head right position,
nystagmus will beat toward the right ear and switch direction in the head left position. The
side with the larger nystagmus velocity is the involved ear. Ageotropic nystagmus may occur in
rare cases when otoconia adheres to the cupula. The side with the smaller nystagmus velocity is
the involved ear. For those with identified horizontal SCC BPPV, they can be treated using the
Lempert/barbecue roll maneuver or the Gufoni maneuver.
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FIGURE 7–32. Steps for performing right posterior semicircular canal canalith repositioning (Epley maneuver) for BPPV. Source: From Mayo Clinic Patient Education. Benign
Paroxysmal Positional Vertigo (BPPV) [MC6727]. Rochester, MN: Mayo Clinic, 2010,
p. 4; used with permission of Mayo Foundation for Medical Education and Research,
all rights reserved.
Vestibular Rehabilitation Therapy (VRT)
VRT is a significant component of dizziness rehabilitation and management. It has been well studied
in those with peripheral vestibulopathy. VRT is designed to assist in vestibular compensation and uses
treatment strategies focused on adaptation, habituation, and/or substitution. There are some known
limitations to vestibular compensation, but it is expected to occur within 4 to 12 weeks (Whitney &
Furman, 2021). There are three main components to VRT:
n
Adaptation: ability to make long-term changes in the neural response to head movement,
specifically focused on the functional VOR
n
Habituation: repeated exposure to an offending stimulus to gradually inhibit the patient’s
response to that stimulus
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n
Substitution: use of an intact sensory system to replace lost sensory system function; most
often done in cases of bilateral vestibular hypofunction
AUDIOLOGY NUGGET
Some patients may be at risk for prolonged/incomplete vestibular compensation
due to patient-specific characteristics.
n
Cerebellar disorders
n
Visual impairment
n
Head injury
n
Use of vestibular suppressants
n
Movement restrictions/limitations
n
Migraine
n
Anxiety/depression
365
The initial VRT evaluation will include:
n
Case history, questionnaires
n
Physical examination
Strength, range of motion, sensation
Oculomotor performance: gaze, smooth pursuit, saccades, vergence
Dix-Hallpike test
Post-headshake nystagmus
Head impulse test
Dynamic visual acuity test
Balance performance
n
Development of VRT program
Patients with vestibular deficits will begin with vestibular stimulation exercises called VORx1. To
complete this task, the patient will tape a card with a small letter printed on it to the wall. The patient
stands/sits about an arm’s-length away so that the letter is readable. From here, the patient rotates the
head side-to-side as quickly as possible while keeping the letter in focus for 1 to 2 minutes. This is
repeated approximately three times per day. If the patient loses focus, they are instructed to reduce
head speed, but to work on increasing the speed over time. Additional options make VORx1 more
challenging:
n
Perform this exercise while sitting.
n
Perform this exercise while standing; progress to tandem stance, gait.
n
Repeat this exercise moving the head up and down.
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n
Perform this exercise with a larger letter placed 8 to 10 feet away.
n
Perform this exercise with a letter placed on a patterned background.
Once VORx1 is mastered, many patients proceed to VORx2. For this task, the patient holds the
card. The head and card are moved side-to-side, but in opposite directions for 1 to 2 minutes. This
is repeated approximately three times per day. Again, the patient must keep the letter in focus. The
additional options above can also make VORx2 more challenging.
KNOWLEDGE CHECKPOINT
VRT is used to assist in vestibular system compensation. Monitoring progress is
important to document improvement and to know when modifications should
be made in the VRT program. Some examples of monitoring include:
n
Questionnaires
Dizziness Handicap Inventory (Jacobson & Newman, 1990)
Activities-Specific Balance Confidence Scale (Powell & Myers, 1994)
n
Balance measures (see Table 7–3)
Bedside measures: Romberg, tandem, single-leg stance
Posturography: foam (modified Clinical Test of Sensory Integration and
Balance — mCTSIB); computerized (sensory organization test — SOT)
Gait: gait speed, timed up-and-go (TUG), Dynamic Gait Index (DGI)
Central Vestibulopathy Considerations
VRT has been greatly successful in patients with central vestibulopathy but may take longer to reduce
symptoms. Appropriate vestibular system compensation relies on stable central function. In some cases,
there are fluctuations in performance, reducing the patient’s ability to appropriately compensate.
n
Common etiologies at risk for prolonged recovery include vestibular migraine, concussion,
and autonomic impairment. It is key that the underlying disorder is appropriately managed
as much as possible to facilitate compensation. For example, a patient with dizziness due
to vestibular migraine may not see symptom improvement/resolution until the underlying
migraine condition is managed or more stable.
Pediatric Rehabilitation Considerations
VRT is increasingly utilized for pediatric patients, especially those with concurrent sensorineural hearing
loss, sensory integration disorders, and concussion. There is little understanding of the prevalence of
congenital vestibulopathy; however, at least 14% of those with significant hearing loss demonstrate
concurrent vestibular impairment (Martens et al., 2022) and may be at risk for significantly delayed
gross motor skill development (Dhondt et al., 2022).
n
Pediatric evaluations begin with similar bedside evaluations as noted above and rehabilitation
planning focuses on the same underlying principles of adaptation, habituation, and
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substitution. Modifications, such as using toys or games, are needed to ensure that activities
are engaging and age appropriate.
Aging and Rehabilitation Considerations
Dizziness and imbalance are more likely with age; 33% of those over 70 years and >50% of those over
80 years of age report difficulties (Jonsson et al., 2004). The most common type of dizziness in older
adults is (1) presyncope (i.e., state of lightheadedness, muscle weakness, blurred vision, and feeling
faint), followed by (2) medication side effects and (3) vestibular pathology (Meldrum & Hall, 2021).
n
BPPV is nearly seven times more common in those >60 years of age than in younger adults
(von Brevern et al., 2007). Patients over 60 years of age also demonstrate more severe
imbalance and prolonged recovery when compared to younger patients (Scheltinga et al.,
2016).
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CHAPTER 7 Vestibular Assessment and Differential Diagnosis
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Practice Questions
Use the passage below to answer Questions 1–4.
The patient is a 55-year-old male reporting sudden onset of left ear hearing loss, tinnitus, and
vertigo 2 weeks ago. He reports that he experienced rotational vertigo for a few hours, which
gradually reduced to a consistent feeling of unsteadiness. The patient reports no change in
hearing and tinnitus in his left ear. VNG testing demonstrates 7°/second right-beating nystagmus in gaze center and gaze right with vision denied. Remaining oculomotor testing is within
normal limits. Dix-Hallpike testing is negative bilaterally. Static positional testing demonstrates
7° second geotropic nystagmus in head right and head left positions. Caloric responses are
as follows: right warm = right beating, 15°/second; right cool = left beating, 12°/second; left
warm = left beating, 4°/second; left warm = right beating, 3°/second. Fixation suppression is
appropriate.
1. What disorder do you suspect with this clinical presentation?
Vestibular neuritis
a.
b. Superior semicircular canal dehiscence syndrome
371
c. Benign paroxysmal positional vertigo
d. Labyrinthitis
Explanation: While vestibular neuritis, benign paroxysmal positional vertigo, and labyrinthitis present
with acute onset vertigo, only labyrinthitis presents with concurrent unilateral hearing loss. Therefore,
d is the correct answer.
2. What is the canal paresis for the above case?
a. 59%
b. 6%
c. 100%
d. 74%
Explanation: Use Jongkees’s formula to calculate the canal paresis. Total eye speed is 27°/second for
the right ear and 7°/second for the left ear. Canal paresis is calculated as: [(27 – 7)/(27 + 7)]. Therefore,
canal paresis is (a) 59%.
3. What degree of nystagmus is noted in gaze testing?
a. First degree
b. Second degree
c. Third degree
d. Fourth degree
Explanation: Significant gaze-evoked nystagmus is noted in gaze center and gaze right. Since nystagmus is noted in two conditions, it is considered (b) second-degree nystagmus.
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