Back To Chiropractic CE Seminars

Neurology: The Dizzy Patient ~ Advanced ~ 6 Hours

Welcome to Back To Chiropractic Online CE exams:

This course counts toward your California Board of Chiropractic Examiners CE. (also accepted in other states, check our website or with your Chiropractic State Board)

The California Board requires that you complete all of your CE hours BEFORE

the end of your Birthday month. We recommend that you send your chiropractic

license renewal form and fee in early to avoid any issues.

COPYRIGHT WARNING

The copyright law of the United States (Title 17, United States Code) governs the making of photocopies or other

reproductions of copyrighted material. Under certain conditions specified in the law, libraries and archives are authorized

to furnish a photocopy or other reproduction. One of these specified conditions is that the photocopy or reproduction is not

to be "used for any purpose other than private study, scholarship, or research." If a user makes a request for, or later uses,

a photocopy or reproduction for purposes in excess of "fair use," that user may be liable for copyright infringement. This

site reserves the right to refuse to accept a copying order if, in its judgment, fulfillment of the order would involve violation

of the copyright law.

Exam Process: Read all instructions before starting!

1. You must register/pay first. If you haven't, please return to: backtochiropractic.net

2. Open a new window or a new internet tab & drag it so it's side-by-side next to this page.

3. On the new window or new tab you just opened, go to: backtochiropractic.net website.

4. Go directly to the Online section. DON'T register again.

5. Click on the Exam for the course you want to take. No passwords needed.

6. Follow the Exam instructions.

7. Upon passing exam (70%), you’ll be able to immediately download your certificate,

and it’ll also be emailed to you. If you don’t pass, you must repeat the exam.

Please retain the certificate for 5 years. DON’T send it to the state board.

If you get audited and lose your records, I’ll have a copy.

I’m always a phone call away... 707.972.0047 or email: marcusstrutzdc@gmail.com

Marcus Strutz, DC

Back To Chiropractic CE Seminars

33000 North Highway 1

Ft Bragg CA 95437

ADVANCED LECTURE ON THE

EVALUATION AND

MANAGEMENT OF THE DIZZY

PATIENTBy:Larry E. Masula, D.C., DACNB, FAVRB, FAFICCDipolmate American Chiropractic Neurology Board, Fellow American Vestibular Rehabilitation Board, Fellow Academy of Forensic and Industrial Chiropractic Consultants

mazu1021@gmail.com

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 3

Larry E. Masula, DC, DACNB, FABVR, FAFICC

Carrick Institute for Advanced Neurological Studies: Frederick C.Carrick, PhD, Cambridge University.

Diplomate American Chiropractic Neurology Board

Fellow American Board of Vestibular Rehabilitation

Fellow Academy of Forensic and Industrial Chiropractic Consultants

Evaluation and Management of Dizziness and Balance Disorders, NeilT. Shepard , PhD, director of the Dizziness and Balance DisordersProgram at the Mayo Clinic, Rochester, Minnesota, and professor ofaudiology in the Mayo Clinical School of Medicine. Joel A. Goebel,M.D., FACS. Director, Dizziness and Balance Center WashingtonUniversity School of Medicine, St. Louis, MO

American Institute of Continuing Medical Education, Certified in 101Vestibular Rehabilitation, 201 Ocular Motor Testing, 202 Gaze,Headshake and Positional Testing. Richard E. Gans, PhD., ExecutiveDirector American Institute of Balance

2/1/2020Larry E. Masula, D.C, DACNB.FABVR, FAFICC 4

Objectives

▪ General overview of the clinical anatomy and physiology

of the vestibular system and posterior fossa (cavity) will

be discussed with emphasis on diagnostics and

chiropractic management.

Larry E. Masula, D.C. DACNB, FABVR, FAFICC 2/1/2020 5

Recommended Reading▪ Clinical Neurophysiology of the Vestibular System, Edition 2,

Robert W. Baloh, Vicente Honrubia. Chapters 1-3

▪ Principles of Neural Science, 4th Edition, Eric R. Kandel, James H. Schwartz, Thomas M. Jessel, McGraw-Hill. Chapter 42: The Cerebellum

▪ Technique of the Neurological Examination, 4th Edition, DeMeyer, W. McGraw-Hill. Chapter 8: Examination of Cerebellar Dysfunction

▪ Neurological Differential Diagnosis, 2nd Edition, John Patten, Springer 1996. Chapter 12: The Extrapyramidal System and the Cerebellum

▪ The Neurology of Eye Movements, 3rd edition, Leigh & Zee

▪ The Brain That Changes Itself, Norman Doidge, M.D.

▪ Vestibular Rehabilitation, 4th Edition, Susan J. Herdman, Richard A. Clendaniel

Larry E. Masula, D.C. DACNB, FABVR, FAFICC 2/1/2020 6

IRISIS 1889

Larry E. Masula, D.C, DACNB, FABVR FAFICC 7

Almond Blossoms 1890

2/1/2020Larry E. Masula, D.C, DACNB, FABVR FAFICC

8

At Eternity’s Gate 1890

2/1/2020Larry E. Masula, D.C, DACNB, FABVR, FAFICC

9

The Church at Auvers 1890

2/1/2020Larry E. Masula, D.C, DACNB, FABVR, FAFICC

10

Prisoners Exercising 1890

2/1/2020Larry E. Masula, D.C, DACNB, FABVR, FAFICC

11

2/1/2020Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 12

Can You Find a Common Theme

Among These 5 Paintings

Can You Find a Common Theme

Among These 5 Paintings▪ 1. Yes, they have been painted by the same artist

▪ 2. Yes, they are all roughly painted within one year

▪ 3. Yes, the artist may well have had a disturbance of

spatial orientation (vertigo). Why? Much of the paintings

are leaning to the left.

▪ 4. If so, on which side is the artist’s problem?

▪ 5. What are the possible causes?

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 13

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 14

Answer: The left vestibular system was most

likely affected and may have failed.

Explanation: Due to the length of time, based on the painting

dates, (over a year) it was no longer an acute problem. We will

discuss the various problems which affect our sense of spatial

awareness. We will also discuss why in this case; the left

vestibular apparatus was no longer being inhibited by the right and

why the left vestibular system appeared overly active.

2/1/2020Larry E. Masula, D.C.DACNB, FABVR, FAFICC 15

Who is the

Artist?

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 16

On the Verge of Insanity

Vincent cut off his left ear on December 23, 1888 after being

upset with a fellow painter. It was the first of several serious

breakdowns that plagued him until his tragic suicide a year

and a half later. We don’t know precisely what his illness

was, but it had a huge impact on his life.

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 17

2/1/2020Larry E. Masula, D.C, DACNB, FABVR, FAFICC. 18

January 28, 1889

Van Gogh’s - Letter to his brother Theo from

Arles, France

“I well knew that one could break one’s arms and legs

before, and that then afterwards that could get better

but I didn’t know that one could break one’s brain and

that afterwards that got better too.”

Because▪ Patient Care and Safety are Preeminent

▪ Develop Improved Diagnostic Skills

▪ There is a Great Need for Skilled Practioners

▪ (9.47%) 31 million Americans experience Lower back

pain at any given time. www.acatoday.org/backpain

▪ (21.1%) 69 million US adults aged 40 years and older had

vestibular dysfunction. Disorders of Balance and

Vestibular Function in US Adults. Data From the National

Health and Nutrition Examination Survey, 2001-2004

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 19

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 20

WHAT IS DIZZINESS AND

VERTIGO?

Historical Background

Prosper Meniere (1861) – first to recognize the association

of vertigo with hearing loss and to localize the symptoms to

the inner ear.

Robert Barany (1906)

▪ First clinical description of BPPV in 1921.

▪ Introduced Caloric testing – most widely used test of the

vestibulo-ocular reflex (VOR)

▪ Nobel Prize for mechanism of caloric stimulation

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 21

Vertigo and Dizziness are considered:

▪ Either an unpleasant Disturbance of Spatial Orientation

▪ The Illusory perception of body movement (spinning,

wobbling, or tilting) and/or of the surroundings

Larry E. Masula, D.C, DACNB, FABVR, FAFICC2/1/2020 22

Dizziness / Vertigo

▪ Dizziness refers to various abnormal sensations relating

to perception of the body’s relationship to space.

▪ Dizziness – may represent a variety of symptoms which

may include spinning, or movement of the environment,

light-headedness, or presyncope, or imbalance while

walking

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 23

Centers for Disease Control and Prevention

▪ Falls Are Serious and Costly

▪ One out of five falls causes a serious injury such as broken bones or a head injury.1,2

▪ Each year, 2.5 million older people are treated in emergencydepartments (visits) for fall injuries.3

▪ Over 700,000 patients a year (1/3) are hospitalized because of a fall injury, most often because of a head injury or hip fracture.3

▪ Each year at least 250,000 older people are hospitalized for hip fractures.5 More than 95% of hip fractures are caused by falling,6 usually by falling sideways.7

▪ Falls are the most common cause of traumatic brain injuries (TBI).8

▪ Adjusted for inflation, the direct medical costs for fall injuries are $34 billion annually.9Hospital costs account for two-thirds of the total.

Larry E. Masula, D.CDACNB, FABVR, FAFICC. 06/15/2019 24

The Burden Dizziness and Vertigo

Impose on the CommunityDizziness is the third most common major medical symptomreported in general medical clinics1 and accounts for about 3%–5% of visits across care settings.2 In the United States, thistranslates to 10 million ambulatory visits per year because ofdizziness,3 with roughly 25% of these visits to emergencydepartments.2 Many patients have transient or episodic symptomsthat last seconds, minutes or hours, but some have prolongeddizziness that persists continuously for days to weeks.4

▪ 1. Kroenke K, Mangelsdorff AD. Common symptoms in ambulatory care: incidence, evaluation, therapy, and outcome. Am J Med 1989;86:262–6 [PubMed] [Google Scholar]

▪ 2. Newman-Toker DE, Hsieh YH, Camargo CA, Jr, et al. Spectrum of dizziness visits to US emergency departments: cross-sectional analysis from a nationally representative sample. Mayo Clin Proc2008;83:765–75 [PMC free article] [PubMed] [Google Scholar]

▪ 3. Kruschinski C, Hummers-Pradier E, Newman-Toker D, et al. Diagnosing dizziness in the emergency and primary care settings [letter]. Mayo Clin Proc 2008;83:1297–8 [PubMed] [Google Scholar]

▪ 4. Neuhauser HK, von Brevern M, Radtke A, et al. Epidemiology of vestibular vertigo: a neurotologic survey of the general population. Neurology 2005;65:898–904 [PubMed] [Google Scholar]

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 25

Ischemic Posterior Circulation Stroke:

Posterior circulation strokes (Posterior Fossa) patients

exhibit many neurological symptoms including vertigo. They

represent approximately 20% of all ischemic strokes.

In contrast to the anterior circulation, several differences in

presenting symptoms, clinical evaluation, diagnostic testing,

and management strategy exist presenting a challenge to

the treating physician.

▪ Ischemic Posterior Circulation Stroke: A Review of Anatomy,

Clinical Presentations, Diagnosis, and Current Management

Amre Nouh,1 Jessica Remke,2 and Sean Ruland1,*

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 26

Normal Anatomy & Physiology

▪ The peripheral vestibular system consists of:

3 semicircular canals

Otolithic apparatus (utricle and saccule) and

The vestibular, 8th cranial, nerve

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 27

Anatomy of Tympanic Cavity

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 28

Important Structures include: Int. Auditory meatus, Cochlea, SCC’s, Cn7, Cn 8, Eustachiantube anteriorly, Mastoid air cells post.

Anatomy of Tympanic Cavity

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 29

The inner ear has two parts: the bony labyrinth and the membranous

labyrinth. The membranous labyrinth is contained within the bony

labyrinth, and within the membranous labyrinth is a K+ rich fluid called

endolymph. Between the outer wall of the membranous labyrinth and the

wall of the bony labyrinth is the location of perilymph.

Bony Labyrinth

The bony labyrinth (also

osseous labyrinth or otic

capsule) is the

rigid, bony outer wall of the

inner ear in the temporal

bone. It consists of three

parts: the vestibule,

semicircular canals, and

cochlea. These are cavities

hollowed out of the substance

of the bone and lined by

periosteum.

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 30

Membranous Labyrinth

▪ The membranous labyrinth is a collection of fluid filled

tubes and chambers within the bony labyrinth which

contain the receptors for the senses of equilibrium and

hearing.

2/1/2020Larry E. Masula, D.C. 31

Cochlea “unraveled”

2/1/2020Larry E. Masula, D.C. 32

The middle ear functions as an amplifier. Sound enters the ear within the external auditory

meatus (EAC) - sound energy moves the tympanic membrane (ear drum) which transfers

this energy to the bony ossicles in the middle ear cavity. They in turn transfer compressed

sound energy to the Oval window of the cochlea via the stapes bone. Frequency from the

TM to the Oval window (force) increases. Mechanism one - TM is 17x larger than oval

window. Mechanism two - Ossicles transfer one unit of energy by factor of 1.3. Therefore,

17 x 1.3 = sound amplified ~ 22x Pathologically, Ossicular sclerosis = dampened sound.

2/1/2020Larry E. Masula, D.C., DACNB, FABVR,FAFICC 33

ANATOMY

Let’s Dive into the Anatomy

Middle Ear - Dimensions

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 34

Dimensions of middle ear

a) 1/3 of the middle ear is above TM -“Epitympanic Recess”

b) Tympanic cavity proper (waist)

c) The Head of the Malleolus and Incus lie in the Epitympanic Recess

d) H = 15mm, AP = 15mm, Width-ETR = 6mmW, TC = 2mmW, Inf. Floor

= 4mmW

2/1/2020Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 35

The roof is small, and the floor is long.The tympanic Membrane is 9-10 mm thick and titled at 55° downward and forward

toward the floor, which together predispose foreign objects to lodge at bottom. Clinical

Note: Ear Lavage is best directed toward the roof for foreign body removal.

The Lateral Wall is made up o 2 parts. A membranous part and a bony part (Epitympanic

Recess). The TM consists of 3 layers. External-skin – derived from ectoderm. Internal –

mucosa of middle ear – derived from endoderm. Middle – fibrous layer is from

Mesoderm.

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 36

Examination: of the tympanic membrane with an otoscope reveals various structures which

include: Pars flaccida which is quite perforable due to infection, Handle of malleus and Umbro,

Pars tensa – stiffer because it sits in a bony sulcus. Cone of Light which transmits downward

and forward because of the 55° angle to the floor

Lateral Wall – (Tympanic Wall)

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 37

Nerve Supply to Tympanic Membrane

The Auriculotemporal nerve (branch of mandibular div. of Cn5) exits the Foramen Ovale and suppliesthe pars tensa and the EAC . It also innervates the teeth which is the reason why teeth pain maycause referred otalgia. CN. VII, X innervate the pars flaccida. Clinical Note: when stimulated or waxirritates the TM, the patient can develop reflex bradycardia, cardiac arrest or a cough. CN. IXinnervates (medial) inner TM surface, parts of the external ear and the posterior 2/3 of the tongue

supplying touch, pain, and temperature.

Nerve Supply to Tympanic Membrane

▪ Clinical Gem: The glossopharyngeal nervesupplies the posterior 2/3 of the tongue andtonsillar region. I recently had a patient, Jim,who presented with vertigo, minimal ear andpharyngeal pain. He had developed tonsillarcancer. Cancer of either structure can refersymptoms via the glossopharyngeal nerve tothe middle ear.

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 38

2/1/2020, Larry E. Masula, D.C., DACNB, FABVR, FAFICC 39

These few nerve fibers within the middle ear are

important in the differential of Stroke vs. Vestibular

Pathology. Why is this important? Because later on

we will learn that the Facial nerves Geniculate

Ganglion can contain a latent Herpes Zoster virus.

Sometimes this virus can be activated. It enters the

7th fiber that travels through the middle ear to the

skin of the tympanic membrane. In this case the

patient will develop severe ear pain and/or hemi-

facial paralysis like Bells Palsy or Stroke. During

otoscopy there may be hemorrhagic blisters on the

anterior 2/3 of the tongue, the TM or within the

middle ear. “Ramsey Hunt Syndrome”

Note: Varicella Zoster (Herpes)– can affect CN.7 and create Hemi-facial

paralysis often seen with stroke facies, Tympanic hemorrhagic blisters and

may cause hearing loss and vertigo

(Ramsey Hunt Syndrome)

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 40

Medial Wall aka (Labyrinthine Wall)

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 41

Medial Wall (labyrinthine wall)▪ Most prominent feature is a circular

inward bulge = Promontory, (Base of

Cochlea), Tympanic Plexus of nerves.

▪ Foot Plate of Stapes attaches to Oval

Window. Movement of Stapes: Annular

lig. holds stapes to Oval window.

Posterior part of annular lig, is shorter

and thicker causing the stapes to tap

the oval window like a door hinge and

not a piston. Stepes is innervated by Cn.

7.

▪ Hook in the superior anterior wall – NOT

SHOWN (processes cochleiformis) for

the tendon of tensor tympani which

bends the tendon to move it laterally to

attach to the handle of malleus. During

contraction the tensor tympani pulls the

malleolus and the TM medially creating

tension to dampen sound. It is

innervated by a branch of the

mandibular division of the trigeminal

nerve.

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 42

Medial Wall (Labyrinthine Wall)

▪ One of the most important structuresis a longitudinal bulge (bony “Facial”canal) along the superior aspect ofthe Medial wall.

▪ It originates from the Facial Nucleusin the Pons and moves anteriorly andmedially to enter the internal acousticmeatus. It exits and travels across thetop of the Vestibule terminating in theGeniculate Ganglion which sits behindthe superior anterior surface of themedial wall. Its first branch is theGreater Petrosal nerve before itenters through the boney (facial)canal in the petrous part of thetemporal bone where it extendsbackwards to the posterior wall andwithin the posterior wall the facialcanal and nerve turn downward.

▪ It is not exposed within the middle earcavity.

▪ The superior bulge (upper left) iscreated by the Horizontal Semicircularcanal.

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 43

Posterior Wall (Mastoid Wall) Special window in superior medial aspect

of posterior wall- “Aditus to antrum” -

opening into the mastoid antrum.

Facial Canal descends within the

posterior wall.

The bony “Pyramidal Eminence” - is

hollow and contains the stapedius muscle

with an exiting tendon which attaches to

the neck of the stapes. Importance:

dampen stapes movement and sound.

Innervated by a branch of the Facial

nerve.

The Chorda Tympani nerve (CN.7) and

the Posterior tympanic artery (not shown)

also enter the posterior wall. The chorda

tympani traverses through the middle ear

to exit through the anterior wall.

Not Shown- the short process of the

Incus attaches to the posterior wall at the

Fossa Incudis.

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 44

Posterior Wall (Mastoid Wall)

The Facial nerve descends andwill eventually emerge throughthe styloid mastoid foramengiving off the posterior auricularbranch which supplies thestylohyoid and posterior belly ofthe digastric muscles, theoccipital region and auricularmuscles. Its terminal branchesmove forward in the face to thetemporal, zygomatic, buccal,marginal mandibular andcervical muscles.

2/1/2020, Larry E. Masula, D.C, DACNB, FABVR, FAFICC. 45

Anterior Wall (Carotid Wall)2 Special Structures

1. Upper canal is a bony canal. Houses

the Tensor Tympani muscle which takes

3 origins from the bony canal, w/ the

superior cartilage of the eustachian tube,

and from the undersurface of the greater

wing of sphenoid (skull). It then enters

the canal and then converts to a tendon

which turns and moves laterally and

attaches to the handle of malleus. Upon

contraction it pulls the handle of the

malleus inward to pull the TM and the

ossicular chain tense. Purpose: contracts

to dampen loud sounds. Innervation:

mandibular division (motor) of CN5.

2. Eustachian Tube (petrotympanic tube)

connects the tympanic cavity w/ lateral

wall of pharynx.

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 46

Anterior Wall (Carotid Wall)

▪ Which artery sits

anteriorly?

▪ Int. Carotid. Covered by a

sympathetic plexus from

the superior cervical

ganglion. Sympathetic

fibers enter the middle ear

as Superior and Inferior

fibers.

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 47

Anterior Wall (Carotid Wall) Summary

▪ How many features in the

Anterior Wall?

1. Canal for Tensor Tympani

2. Opening of Eustachian

Tube

3. Lesser Petrosal Nerve

4. Sympathetic Fibers

5. Chorda Tympani Nerve

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 48

Anterior Wall (Carotid Wall)

Jugular Fossa sits directly beneath the floorof middle ear. Contains the internal jugularvein, CN’s 9, 10, & 11.

CN.9 gives off a branch which enters thefloor (not shown) bringing parasympatheticand sensory fibers to the tympanic plexuscollectively supplying all walls of the middleear including the eustachian tube andmastoid.

A branch from the tympanic plexus (lesserpetrosal nerve) exits the anterior wall andascends through the foramen Ovale anddescends back downward carryingparasympathetic pre-ganglionic fibers fromthe tympanic plexus to the parotid gland.

Chorda Tympani nerve CN.7, traverses themiddle ear and exits the anterior wall viaPetrotympanic fissure and through which theanterior tympanic artery enters to supply themiddle ear.

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 49

Chorda Tympani - Middle Ear

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 50

Chorda Tympani – Branch of Facial N.

What is the relationship of theChorda Tympani (facial n.)contents of the middle ear?

It passes completely throughthe middle ear between theneck of the Malleus and theIncus and is covered withmucosa. It supplies theanterior 2/3 of the tongue withtaste receptors. Infections,strokes, and middle-earoperations may be damagingcausing dysgeusia (distortedtaste).cial

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 51

Eustachian tube ▪ Clinically Important:

The initial 1/3 is bony and the last 2/3 is

fibrocartilage. Angles 30º downward and 35º

anteromedially to open in the nasopharynx.

Attached to the end of the tube are the

Salpingopharyngeus, Tensor Veli Palitini

muscles, and the Levator Palatini muscles

(CN.10) Function: to elevate the soft palate

and open the end of the tube to equalize

pressure within the middle ear.

Reason why PICA strokes, can generate

unilateral swallowing impairment or having

food get stuck in the throat.

Test: have the patient say AAH repeatedly

and observe for a soft or complete impairment

of palatal elevation. The unaffected side will

elevate, and the palate may deviate in thatdirection

2/1/2020Larry E. Masula , D.C., DACNB, FABVR, FAFICC 52

Inferior Wall (Jugular Wall)

▪ The floor is made by the

petrous part of the temporal

bone with one important

cuniculus.

▪ Sympathetic fibers which

start from the Inferior

Salivatory nucleus travel

with other fibers of the 9th

nerve to enter the floor of

the middle ear cavity and

extend to the Promontory

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 53

Roof

▪ The roof is called the Tegmentum Tympani. The roof is very thin. Clinically it is important because middle ear infections may extend upward especially in children due to an overlying Petrous -Squamous suture which may not be ossified producing a subdural abscess, meningitis and a temporal lobe abscess or infection. Fractures likely resulting in CSF leak.

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 54

Clinical Review

▪ If the horizontal SCC is affected from a middle earinfection, it will result in Vertigo.

▪ If the facial canal is damaged it will result in facial palsy.If it is damaged proximal to the nerve to the stapedius,it results in paralysis of the stapedius giving rise tohyperacusis.

▪ Middle ear infections may extend posteriorly creatinglife-threatening mastoiditis. If the infection exits theroof (Tegmentum Tympani) it can produce anextradural abscess, meningitis, or a Temporal lobeabscess.

▪ If it extends backward through the Mastoid, it candamage the Sigmoid Sinus resulting inthrombophlebitis, and further backward enter thecerebellum or brainstem.

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 55

CSF Leak from Middle Ear

Fracture of the middle cranial fossa, typically damages the

roof of the middle ear (Tegmentum Tympani which is a thin

bone). This may also disrupt the ossicular chain, rupture the

tympanic membrane and may damage the roof of the

external acoustic meatus. Blood and CSF leak into the

middle ear cavity and through the ruptured TM.

▪ This is called “Otorrhea”

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 56

Contents of Middle Ear summary

▪ Air

▪ Ossicles (Malleus, Incus,

Stapes) all attached via

synovial joints

▪ Muscles (Stapedius, Tensor

Tympani Tendon)

▪ Nerves

▪ Vessels (Anterior tympanic

artery, Posterior tympanic

artery)

▪ All structures lined by

mucosa

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 57

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 58

Understanding Vestibular

Neurophysiology

Understanding Neurons – the Big

Picture

▪ Stimulation of receptors results in activation of the 1st

order afferent (sensory) neuron

▪ Activation of the 2nd order afferent neurons is

dependent on the FOF of its pre-synaptic neuronal

pool (1st order neurons).

▪ Activation of the thalamus and all cortical structures

is dependent upon the FOF of ALL pre-synaptic

neuronal pools of the somatosensory system).

▪ As a result, receptor injury will result in impaired

cortical representation. (Head Maps)

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 59

Central Integrative State (Health) of a Neuron and

Cellular Immediate Early Gene Response –

There is a constant influx of neuronal membrane potential differences due to:

1. Spatial Summation (multimodal) on the receptor

2. Temporal Summation (high frequency unimodal) on the receptor

3. pH

4. Glucose

5. Oxygen tissue saturation

6. Temperature changes

7. Summation of all presynaptic (+) and (-) input which includes all cortical and segmental integration

8. In summary: stability or fragility of a neuron is based on the FOF of its presynaptic pools or receptor potentials

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 60

What Do We Do?

“Alterations in the neuron occur at the synapse,strengthening and increasing, or weakening anddecreasing, the number of connections between theneurons.” (Michael Merzenich, considered the world’s leadingresearcher on brain plasticity)

Our rehabilitative purpose is therefore to:

1. Strengthen and enhance synaptic activity

2. Improve motor function

3. Improve brain activity via cortical

re-organization

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 61

Cellular Survival is dependent upon

FuelGlucose

O2

Activation

2/1/2020Larry E. Masula, D.C., DACNB, FAVRB, FAFICC 62

Summary: Cellular Survival is Altered by

▪ FOF of all presynaptic input (Activation)

▪ Identify and manage Dysglycemia, Hypoglycemia,

Metabolic Syndrome, Insulin resistance. (Fuel - glucose)

▪ Identify and manage anemia (Fuel – O2)

▪ Adequate protein and fat intake

▪ Inflammatory conditions

▪ Infections

▪ Autoimmunity

Larry E. Masula, D.C., DACNB,FABVR, FAFICC 2/1/2020 63

Anatomy and Physiology of the

Vestibular System

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 64

Vestibular Function:

an Overview

▪ Expressed simply, the role of the vestibular sensory

organs is to transduce the forces associated with head

acceleration and gravity into a biologic signal.

▪ The control centers in the brain use this signal to develop

a subjective awareness of head position in relation to the

environment and to produce motor reflexes for

equilibrium.

Larry E. Masula, D.C., DACNB, FABVR, FAFiCC 2/1/2020 65

Vestibular Function: Overview

continued

▪ The force associated with head acceleration generates a

signal in the labyrinth that is proportional to head

acceleration, 1:1 ratio.

▪ The overall objective of the CNS is to compute head

position by performing the equivalent of a mathematical

integration of the labyrinthine and otolithic input signals.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 66

Larry E. Masula, D.C., DACNB, FABVR, FAFCC 2/1/2020 67

Vestibular Nerve Physiology

▪ The vestibular system monitors the forces associated with

Angular and Linear accelerations of the head by means of

5 organs located within the labyrinthine cavity of the

temporal bones on each side of the skull.

▪ The Cristae Ampularis sensory organ of the 3

semicircular canals senses angular acceleration of the

head

▪ The Otolithic Organs (saccule and utricle) sensory organ

the Maculae senses linear acceleration.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 68

The Semi-Circular Canals

The semicircular canals provide sensory input about head

velocity, which enables the VOR to generate an eye

movement that matches the velocity of the head movement.

The desired result is that the eye remains still in space

during head motion, enabling clear vision. Neural firing in the

vestibular nerve is proportional to head velocity over the

range of frequencies in which the head commonly moves

(0.5 to 7 Hz).

2/1/2020Larry E. Masula, D.C, DACNB, FABVR, FAFICC. 69

the Semi-circular canals

The fluid filled SCC is filled

with K+ rich Endolymph which

has a viscosity slightly

greater than H2O.

The sensory epithelium of the

cristae is covered by the

gelatinous cupula.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 70

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 71

Cristae Ampularis - enlarged

Lateral Line System

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 72

A similar system is found in fish in which water passing over the tiny pores

within the lateral line of the fish move the cupula resulting in depolarization of

the nerve inducing a motor output and digestion

Semicircular Canals

▪ The cupula has the same density as the endolymph

▪ Semicircular canals do not respond to gravity in

static head positions however, there is tonic firing of

approximately 100 spikes/sec.

▪ The canals lie roughly in the same planes as the

extraocular muscles

▪ Each canal excites a pair of muscles and inhibits a

pair of muscles in its same plane. Its partner excites

the muscles it inhibits, and vice-versa

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 73

Eye Muscles

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 74

The plane in which the eyes

deviate are the result of

vestibular activation by the

canals stimulated

▪ Once vestibular signals leave the vestibular nuclei - they

divide into vertical, horizontal, and torsional components

of a motor command.

▪ Lesion of the central vestibular pathways can cause a

pure vertical, pure torsional, or pure horizontal nystagmus

of the eyes

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 75

Canal Related Eye Movements

E.g. If I rotate my head horizontally to the right activating theright horizontal canal, I activate the right medial vestibularnucleus, which activates the right oculomotor nucleus andthe left abducens nucleus activating the right medial rectusand the left lateral rectus. Right horizontal canal activationbiases conjugate eye movements to the contralateral side, inthis case to the left.

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 76

Activation of the Sensory Hair Cells

▪ Angular movement of the head causes endolymph flow in

one of the semicircular canals to deflect the cupula

▪ Deflection of the stereocilia toward the kinocilium results

in depolarization, or increased firing rate

▪ Deflection of the stereocilia away from the kinocilium

results in hyperpolarization, or a decreased firing rate

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 77

Semi-Circular Canals

The semicircular canals provide sensory input about

head velocity, which enables the (VOR) vestibular

ocular reflex to generate an eye movement that

matches the velocity of the head movement. The

desired result is that the eye remains still in space

during head motion, enabling clear vision. Normal

neural firing of the vestibular nerve is proportional tohead velocity over the range of frequencies in which the

head commonly moves (0.5 to 7 Hz).

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 78

Semi-Circular Canals

The coplanar pairing of the canals is associated with

a push-pull change in the quantity of semicircular canals

output. When angular head motion occurs, the endolymph of

the coplanar pair of canals is displaced in opposite

directions. This results in a neural firing increase in one

vestibular nerve and a hyperpolarization (decrease) on the

opposite side.

For the lateral canals, displacement of the cupula towards

the ampulla (ampullopetal flow) becomes excitatory,

whereas vertical canal displacement of the cupula away

from the ampulla (ampullofugal flow) is excitatory.

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 79

Semi-Circular Canals

Clinically, this push-pull mechanism is an important point

which explains why patients with Unilateral Peripheral

Vestibular loss avoid head motion towards the side of their

lesion.

More will be said about this when we discuss how the

central nervous system compensates for overload.

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 80

OTOLITHIC ORGANS: Utricle and Saccule

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 81

Otolithic SystemEven with the head at rest, the calcareous material, becauseof its mass, exerts a force upon the otolithic receptor equalto the product of its mass and acceleration due to thegravitational pull of the earth, which at sea level is 9.80m/sec².

The Fg (force) acting upon the underlying sensory cellschanges with different degrees of head tilt.

The otolithic system is sensitive to gravity and linearacceleration. Because of their orientation in the head, theutricle is sensitive to a change in horizontal movement, andthe saccule gives information about vertical acceleration(such as when in an elevator). Remember Utricle is lateralforward and backward – the Saccule is Sit and Stand.Exception: both are subject to A/P acceleration

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 82

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 83

Otolith Function

The brain therefore has difficulty determining tilt vs translation without

accessory input from the canals

Otolithic System

▪ Remnant of the lateral eyed animals

▪ Turned on by near vision

▪ Primes the legs

▪ Turned off by long axis distraction of the cervical spine

▪ Fires into midline Cb specifically the Nodulus

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 84

The Otolithic SystemAn otolith also called statoconium or

otoconium, is a structure in the

saccule or utricle of the inner ear,

specifically in the vestibular labyrinth

of vertebrates

Each macula consists of a sensory

membrane containing the receptor

cells that supports a “heavy load,”

the otoliths.

The otolith is composed of

calcareous (calcium carbonate)

material embedded in a gelatinous

matrix. This is important because

osteoporosis patients frequently are

subject to otolithic degeneration

resulting in BPPV.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 85

Vestibular Nerve Physiology

Each vestibular neuron fires

tonically at a resting rate of

approximately 90-100 spikes

per second.

Upon activation these

peripheral vestibular afferents

have two main targets: the

vestibular nuclear complex

and the cerebellum

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 86

Vestibular Nuclei Complex

4 Major Nuclei1. Superior Vestibular Nucleus

VOR relay center

2. Medial Vestibular Nucleus VOR relay center

VSR relay center

3. Lateral Vestibular Nucleus VSR relay center (major-

ipsilateral LVST). Mainly LE extensor muscles for stability. Input is mostly from the Otoliths

4. Inferior Vestibular Nucleus Connected to all other nuclei

Larry E. Masula, D.C. DACNB , FABVR, FAFICC 2/1/2020 87

Vestibular Nuclear Complex

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 88

The 4 vestibular nuclei are: Super Vestibular Nucleus, Medial Vestibular Nucleus,

Lateral (Dieter’s) Vestibular Nucleus, and the Inferior (caudal) Vestibular Nucleus.

Vestibular Nucleus Function

The vestibular nucleus is a multi functional nucleus with two

very important functions.

1. it tells you where your head is relative to gravity and

where gravity is relative to your head.

2. it establishes appropriate postural reflexes i.e., the

vestibular ocular reflex (VOR) and the vestibular spinal

reflexes (VSR).

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 89

Vestibular Nuclei Projections

The vestibular nuclei receiveprojections from the cortex,the cerebellum, subcorticalvisual centers, and the spinalcord. Vestibular circuitry istherefore embedded withinlarger networks involved in theintegration of vestibular,visual, and proprioceptiveinformation. This provides anongoing global control of eyeand body orientation in thedynamic context of voluntarymovement and externalperturbations.

2/1/2020Larry E. Masula, D.C, DACNB, FABVR, FAFiCC 90

Vestibular Nuclei Commissure

▪ Commissures link thevestibular nuclei from eitherside of the brainstemthrough mutually inhibitoryconnections

▪ This allows for informationto be shared across thebrainstem (push-pull)

▪ Which means that duringactive head rotation to theright, the right vestibularapparatus is excited andvia the commissure and theleft side becomes inhibited

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 91

VOR (vestibular ocular reflex)

VOR gives us the ability tomove our head and maintainvisual (foveal) fixation on atarget without developing anyretinal slip or blurring of vision.

The VOR has a directpathway and an indirectpathway which we will talkabout that at another time.The main ascending tracksare from the superior andmedial vestibular nuclei to theextraocular muscles travelingthrough the mediallongitudinal fasciculus to driveoculomotor activity

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 92

VSR

The VSR has to do withmaintaining balance and thisis just one part of our balancesystems. The distributivespinal reflexes are importantwhen you becomedestabilized while walking ona sandy beach, wet slipperypavement, on ice or standingon a foam surface.

Vestibular spinal reflexes arehard wired reflexes that keepus upright against gravity byallowing us to create anappropriate motor commandto avoid a fall .

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 93

The medial vestibular spinal nucleus

and tract The media vestibulospinal trackinterfaces with the ventral horn ofthe spinal cord to create motoractivation for cervical spinestabilization. it is therefore usefulin the rehabilitation of patientswith ligament laxity secondary toa traumatic cervical sprain andstrain.

I personally have had numerouspatients over the years who havecome into the office followingphysical therapy or chiropracticwhich the patient terminatedbecause they couldn't handle thecervical exercises or mobilization.

These same patients have doneexceptionally well by putting themin a rotational chair and rotatingthem while the head is stabilized,performing ocular motor therapy,implementing the SenMoCorhead laser target maze, utilizingtrigeminal stimulation, EMS andTENS stimulation

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 94

The medial vestibular spinal

nucleus and tract As a chiropractor we often here of patients who repeatedly

bang their head against the roof of the car when getting in

and out of the vehicle. This is often secondary to poor head

and neck maps in the brain. Improved head/neck maps may

be obtained through vestibular rehabilitation. This can all be

done without further traumatizing an unstable region.

Stimulation in this manner is aligned at creating better

cortical representation of their head and neck by generating

better “Head/Neck Maps”

2/1/2020Larry E. Masula, D.C., DACNB,FABVR, FAFICC 95

Lateral Vestibulospinal Nucleus

and TractThe LVST also innervates the anterior horn to create motor

activation. It extends further down the spine than the medial

vestibular spinal tract to innervate the extensors of the trunk

and legs.

It is pretty much ipsilateral but there is some bilaterality to it

but, for the most part it is strictly ipsilateral and important for

postural responses and standing upright.

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 96

The Caudal Vestibular Nucleus and

TractThese guys innervate the dorsal columns (sensory) region of

the spinal cord for the purpose of receiving an effort copy of

the motor commands thus gating all incoming information

that says the same thing and only allowing that information

which is leftover (the errors) to ascend

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 97

CLASSIFICATION of

VESTIBULAR REFLEXES▪ Old thinking. Cristae is a kinetic receptor and maculae

are static receptors

▪ Both receptor organs produce motor reflexes that cannot

be totally differentiated

▪ It is therefore appropriate to differentiate the reflexes by

categories based on their functional role

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 98

CLASSIFICATION of

VESTIBULAR REFLEXES▪ Vestibulo-Ocular Reflex, The VOR acts to maintain stable vision

during head motion. This means that the eyes precisely counter-rotate to compensate for the head and keep the eye stable in space.

▪ Angular VOR, The angular VOR is primarily responsible for gazestabilization

▪ Linear VOR, The linear VOR, is mediated by the otoliths,compensates for translation and acceleration in a linear direction(which is basically the same thing). The linear VOR is most importantin situations where near targets are being viewed and the head isbeing moved at relatively high frequencies.

▪ Vestibulospinal Reflex, The purpose of the VSR is to stabilize the body.

▪ Vestibulocollic Reflex, this is not an ocular reflex but a neck reflex. The vestibulocollic reflex (VCR) acts on the neck musculature to stabilize the head. The reflex head movement produced counters the movement sensed by the otolithic or semicircular canal organs.

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 99

Vestibular Reflexes summary

1. Maintain posture.

2. Evokes extensor musculature activity (tone) above T6

and below T6 to compensate for gravitational forces.

3. Produce “kinetic” contractions of muscles for

maintenance of equilibrium and ocular stability during

movement. Includes reflexes arising from BOTH the

canals during angular acceleration and the otoliths

during linear acceleration.

4. Help maintain muscular tone: a role of both maculae

and cristae

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 100

Reflexes: continued

Labyrinthine contribution to skeletal-muscular tone is

demonstrated following unilateral labyrinthectomy studies in

cats which results in:

Tone is decreased in the ipsilateral extensors

Tone is increased in the extensor muscles of the

contralateral extremities due to loss of inhibition

Meaning that, a unilateral vestibular deficit (UVD) patient

will present with ipsilateral extensor muscle hypotonia

and contralateral hypertonia of the extensors.

WOULD THIS AFFECT HOW YOU MANAGE YOUR

CERVICAL SPINE PATIENTS?

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 101

Does my dizzy patient have a

stroke?Craniocervical pain

Narrative reviews have suggested that craniocervical pain mayaccompany dizziness in patients with stroke in the posterior fossabecause of the stroke itself (mass effect or direct involvement of pain-sensitive structures) or its underlying cause (e.g., dissection or aneurysmof the vertebral artery).22

Two studies addressed this issue. Headache or neck pain was present in a minority of patients presenting with acute vestibular syndrome (38%, n = 9/24;9 and 29%, n = 29/1016). A statistically significant association with central causes (38% v. 12%, p < 0.05) was found in the larger study.

6. Kattah JC, Talkad AV, Wang DZ, et al. HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke 2009;40:3504–10 [PMC free article] [PubMed] [Google Scholar]

9. Norrving B, Magnusson M, Holtas S. Isolated acute vertigo in the elderly: Vestibular or vascular disease? Acta Neurol Scand 1995;91:43–8 [PubMed] [Google Scholar]

22. Edlow JA, Newman-Toker DE, Savitz SI. Diagnosis and initial management of cerebellar infarction. Lancet Neurol 2008;7:951–64 [PubMed] [Google Scholar]

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 102

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 103

DIFFERENTIAL DIAGNOSIS

Differential Diagnosis Should Include:

▪ A good diagnosis is not like a batting average where

you play the percentages. You might strike out! A

thorough examination is essential. You need to know

whether you are looking at:

A One level lesion

Multifocal / multiple lesions

A Central Lesion

A Peripheral Lesion

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 104

Peripheral causes of vertigo

▪ 1. Benign paroxysmal positional vertigo▪ 2. Vestibular neuronitis▪ 3. Recurrent vestibulopathy▪ 4. Meniere’s disease▪ 5. Head trauma (labyrinthine concussion)▪ 6. Otosclerosis▪ 7. Herpes zoster oticus▪ 8. Cholesteatoma▪ 9. Perilymph fistula▪ 10. Aminoglycoside (antibiotics) ototoxicity

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 105

Central causes of vertigo

▪ Vascular: vertebrobasilar ,TIA, cerebellar or brain stem stroke

▪ Cerebellopontine angle tumors: acoustic neuroma, meningioma, cholesteatoma, metastatic tumor

▪ Demyelinating disease: MS, postinfectious demyelination

▪ Cranial neuropathy: focal involvement of VIII nerve or in association with systemic disorders

▪ Intrinsic brainstem lesions: tumor, arteriovenous malformations

▪ Seizure disorders (rare)

▪ Spinocerebellar degeneration

▪ Hypertensive medications

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 106

Most Frequent Vertigo Syndromes Diagnosed in a

Dedicated Neurological Dizziness Unit(N=4790) Vertigo and Dizziness by Brandt, Dietrich, and Strupp-2005

▪ BPPV 18.3%

▪ Phobic Postural Vertigo 15.9%

▪ Central Vestibular Vertigo 13.5%

▪ Vestibular Migraine 9.6%

▪ Vestibular Neuritis 7.9%

▪ Meniere’s Disease 7.8%

▪ Vestibular Paroxysmia 2.9%

▪ Perilymph Fistula 0.4%

▪ Unknown 4.2%

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 107

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 108

You must be a lot like Sherlock Holmes

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 109

Nothing Replaces a Good Bedside Neurological Examination

▪ History and physical examination provide the most important information

▪ Often, patients have difficulty describing the exact symptom experienced

▪ The first step is to define the symptom

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 110

A case history specific to balance

may include the following:▪ Collection of results from other health professionals

▪ Fall risk data

▪ Medical history including blood pressure and other vitals history of dizziness ,balance problems or falls Medication use alternative medicines presence of other comorbidities

▪ Nature of dizziness and or imbalance symptoms including the following : Aggravating factors Alleviating factors Accompanying symptoms (e.g., Hearing loss, tinnitus aural fullness Duration (seconds , minutes , hours , days ) Frequency initial onset (How did it begin (gradual / sudden)

▪ Pattern (time of day , , activity symptomatic )

▪ Quality and character ( spinning , imbalance , disorientation )

▪ Patient questionnaire on dizziness

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 111

Physical Examination▪ A general medical examination is important. Physical

examination is very important in patients complaining of

Vertigo because it can be the earliest symptoms of a

neurodegenerative disorder

▪ Postural hypotension measurement

▪ Orthostatic hypotension – probably the most common

▪ Identifying an irregular cardiac rhythm may help

▪ Other measures to consider include a visual assessment

and a musculoskeletal inspection (significant for arthritis

and peripheral neuropathy)

▪ Vertigo can also be an important symptoms of stroke,

tumor, demyelination, or other pathologies of the nervous

system

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 112

2/1/2020, Larry E. Masula, D.C., DACNB, FABVR, FAFICC 113

Frenzel Goggles are a diagnostic tool used

in ophthalmology, otolaryngology and audiovestibular medicine for the

medical evaluation of involuntary eye movement (nystagmus). They are

named after Frenzel, a German physician. The purpose of

the goggles is to disable the patient's ability to visually fixate on an

object while at the same time allowing the examiner to adequately

visualize the eye. This is done by using high-powered

(+20 diopters) magnifying glasses with an illumination system. With

such a high-powered lens, it is unlikely that the patient can adequately

focus and visually fixate on an object to suppress nystagmus.

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 114

Videonystagmography (VNG) is a technology for testing inner

ear and central motor functions. It involves the use of infrared

goggles to trace eye movements during visual stimulation and

positional changes.

Computerized Dynamic Posturography

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 115

Computerized Dynamic Posturography

(CDP) is well documented in the clinical and

scientific literature as an objective method of

differentiating sensory, motor, and central

adaptive functional impairments of balance.

AireX Pad®

The Airex® Balance Pad is a

reasonably priced product

which has a smooth surface,

making it ideal for barefoot

balance testing and training.

Due to the yielding foam, the

body is constantly challenged

to maintain balance. This pad

is also great for balance,

mobility, standing stability and

motor-skill training.

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 116

BESS Test with Airex Balance Pad

2/1/2020Larry E. Masula, D.C , DACNB, FABVR, FAFICC. 117

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 118

While this test is

frequently used for

mTBI evaluation it is a

very useful tool for

vestibular evaluation

by means of a

Romberg test, Tandem

Romberg and Unipedal

stance. These tests

are performed with

eyes open and closed

both on a compliant

and then again on a

non-compliant surface.

This form is

downloadable from the

Internet and serves as

a great patient handout.

Bedside Diagnostic Gems

mnemonic

▪ V – Vascular

▪ I _ Infectious

▪ N – Neoplastic, Neurological

▪ D – Degenerative

▪ I – Inflammatory

▪ C – Connective tissue/muscle

▪ A – Autoimmune

▪ T – Trauma

▪ E – Endocrine/environmental

▪ S - Soft tissue

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 119

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 120

VASCULAR

VINDICATES

VASCULAR: Cardiovascular Disease and

Cerebrovascular Disease

▪ Many vascular disorders may generate dizziness or lightheadedness. Therefore, Everything should be Considered Vascular Until Proven Otherwise Arrhythmias

Tachycardia

Bradycardia

Ischemic cardiomyopathy

Vasovagal syncope

Carotid sinus hypersensitivity

Conduction blocks w/ elongation of the PR interval

Brain ischemia

Etc.

06/21/2019Larry E. Masula, D.C. DACNB, FAVRB, FAFICC. 121

Clinical Aspects of Brainstem

DisordersCommon symptoms found in the majority of brainstem

lesions include diplopia, dysarthria, VERTIGO nausea and

vomiting.

These lesions are typically vascular in nature but can be as

result of other disorders such as MS and pontine gliomas

etc.

2/1/2020Larry E. Masula, D.C, DACNB, FABVR, FAFICC. 122

Clinical Case. Your patient presents with the

following: What is the diagnosis?

▪ Vertigo, nausea and vomiting

▪ Ipsilateral facial pain and temperature loss

▪ Ipsilateral Horner’s

▪ Ipsilateral Ataxia and dysmetria

▪ Weakness of palate, pharynx and larynx

▪ Dysphagia, hoarseness, diminished gag reflex

▪ Contralateral pain and temperature loss

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 123

2 Types Medullary Vascular Lesions

There are typically only 2 kinds ofmedullary ischemic attacks,

▪ Dorsal lateral

▪ The paramedian and basil arelumped together.

▪ Dorsal lateral infarction causesdamage typically referred to as aWallenberg syndrome. Typically,you will have:

▪ Ipsilateral Horner’s syndrome,loss of pain and temperature overthe face on the same side of thelesion. There can be cerebellarfindings on the ipsilateral sidecausing ataxia.

▪ Contralateral loss of pain andtemperature with..

▪ You can get severe nausea,vomiting, vertigo, and nystagmusdue to vestibular influence.Hiccups may be common do tolesion in the 9th and 10th nerveswith difficulty swallowing.

2/1/2020Larry E. Masula, D.C., DACNB, FAVRB, FAFICC 124

Wallenberg Syndrome

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 125

Lateral Medullary Syndromeaka: Wallenberg Syndrome (posterior inferior Cb artery)

Larry E. Masula, D.C. DACNB., FABVR, FAFICC 2/1/2020 126

Regional territories

Lateral Medullary Syndrome

“Wallenberg Syndrome”

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 127

Note the cranial nerve locations and their trajectories which become affected

Larry E. Masula, D.C, DACNB, FABVR, FAFICC. 2/1/2020 128

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 129

Labyrinthine Artery - Vascular Supply

It is important at this point to also review the clinically important Labyrinthine artery.

45% from AICA

▪ 24% superior cerebellar artery

▪ 16% basilar

▪ Two divisions: anterior vestibular artery

common cochlear artery

▪ Vascular pathologies can give pulsatile tinnitus or deafness

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 130

Vestibular Migraine

I include vestibular migraines because of its seeminglyneurovascular nature even though it is not necessarily anischemic lesion. It is important to know due to the clinicalpresentation of headaches and dizziness.

Vestibular Migraine is associated with dizziness and vertigoas a common aura in migraineurs. It is estimated that about30% of migraineurs will be affected with this form of aura.

You could get dizzy and have balance problems without havinga migraine at all. Other times, the vertigo symptoms happenbefore, during, or after the headache. Sometimes, you mighthave migraines for years before the vertigo symptoms begin.

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 131

2/1/2020Larry E. Masula, D.C.DACNB, FABVR, FAFICC 132

Acute Vasculature

Vestibular Syndrome

Ocular Motor Assessment

1st step is to observe normal ocular movements and search

for any Nystagmus of the eyes, with a fast movement in one

direction and a slow movement in the other.”

Nystagmus can be classified as spontaneous, gaze-evoked,

or positional. The direction of nystagmus – conventionally

described by the direction of the fast phase, which is the

direction it appears to be “beating” toward. Fast phase

component may be horizontal, vertical, rotatory, or any

combination of these.

2/1/2020Larry E. Masula, D.C.DACNB, FABVR, FAFICC, 133

Acute Vestibular Syndrome

H.I.N.T.S. to I.N.F.A.R.C.T.

“H.I.N.T.S.” Battery

1. Head Impulse Test

2. Nystagmus

3. Test of Skew

▪ STROKE FINDINGS:

“I.N.F.A.R.C.T.”

▪ Head Impulse test -Normal

▪ Fast-phase Alternating

nystagmus

▪ Re-fixation on Alternating

Cover Uncover Test

▪ Any ONE of these points to

a Stroke

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 134

2/1/2020Larry E. Masula, D.C. DACNB, FABVR, FAFICC 135

Nystagmus Testing

▪ Performed in

Primary Gaze

Lateral Gaze

Vertical Gaze

▪ In a normal volunteer: there is No nystagmus inprimary gaze. During lateral gaze some nystagmusmay be normal. Learn to suppress this with fixationby placing a piece of paper between their head andthe wall and ask them to look at the wall as if thepaper was not present. Otherwise, you might seenystagmus which would not be there without the

sheet of paper.

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 136

Nystagmus

https://youtu.be/1q-VTKPweuk?t=105

Patient with vestibular neuritis. Note: here it is again, when

he looks to the left see that the nystagmus increases. It is

left beating and there is a rotatory component towards the

left and it increases when he looks to the left and you can

see the torsional component.

When he looks to the right it lessens but the fast component

is still towards the left.

Unidirectional nystagmus, does not change direction and

this exam is reassuring.

2/1/2020Larry E. Masula, D.C, DACNB, FABVR, FAFICC. 137

Nystagmus

https://youtu.be/1q-VTKPweuk?t=157

Compare to this lady who when she looks to the right, she

has small horizontal nystagmus with the fast component to

the right. Then, when she moves more central and to the

left, you can see that the nystagmus beats towards the left.

So, she has direction beating nystagmus or bidirectional

nystagmus which is worrisome.

Note: nystagmus is named for the direction of the fast

phase

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 138

Test of Skew

(Vertical)

Cover / Uncover test

https://youtu.be/1q-VTKPweuk?t=201

Examiner takes their hand and covers the eye and then

quickly covers the other eye to observe if there is any

vertical movement of the eye when it is uncovered.

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 139

Test of Skew

https://youtu.be/1q-VTKPweuk?t=214

Observe that when the hand is taken away from the right

eye, the eye will go medially and upward and when the

examiners hand is taken away from the left eye it goes

medially and downward.

This abnormal skew deviation is worrisome

2/1/2020Larry E. Masula, D.C., DACNB, FAVRB, FAFICC 140

Head Thrust Test

A unilateral or bilateral vestibulopathy can be identified using theHead-Thrust test. The head thrust test is a test of vestibularfunction that is performed as part of the bedside examination. Thismaneuver tests the vestibulo-ocular reflex (VOR).

The patient sits in front of the examiner and the examiner holds thepatient's head steady in the midline. The patient is instructed tomaintain gaze on the nose of the examiner. The examiner thenquickly turns the patient's head about 10–15 degrees to one sideand observes the ability of the patient to keep the eyes locked onthe examiner's nose. If the patient's eyes stay locked on theexaminer's nose (i.e., no corrective saccade) (A), then theperipheral vestibular system is assumed to be intact. Thus in apatient with acute dizziness, the absence of a corrective saccadesuggests a CNS localization. If, however, the patient's eyes movewith the head (B) and then the patient makes a voluntary eyemovement back to the examiner's nose (i.e., corrective saccade),then this suggests a lesion of the peripheral vestibular system andnot the CNS.

2/1/2020Larry E. Masula, D.C, DACNB, FABVR, FAFICC. 141

Bedside Head Thrust Test

2/1/2020Larry E. Masula, D.C. 142

Head Impulse Test

https://youtu.be/1q-VTKPweuk?t=295

Hold onto the patients skull while the patient fixates on

examiners nose (or camera). Move head (maybe 20

degrees), slowly to the right, then BRISKLY to midline. What

you are looking for are catch-up Saccades of the eyes

In this video her eyes remain fixed on the camera =

NORMAL or Abnormal?

2/1/2020, Larry E. Masula, D.C., DACNB, FABVR, FAFIICC 143

Head Impulse Test

▪ https://youtu.be/1q-VTKPweuk?t=324

Abnormal

Notice that this man presents with nystagmus when he looks

to the left and when his head is turned to the right. Do you

see that there is a larger movement of the eyes from the

right back to the midline? That is an abnormal HIT which is

reassuring which shows that he has a peripheral nerve

problem and probably does not have a brain problem.

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 144

Head Impulse Test

https://youtu.be/1q-VTKPweuk?t=389

This lady has a rock-solid head impulse test. She is

WORRISOME because she has acute vertigo and

nystagmus and we cannot find a nerve problem. She

probably has a BRAIN problem.

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 145

2/1/2020Larry E. Masula, D.C.DACNB, FABVR, FAFICC 146

2/1/2020Larry E. Masula, D.C.DACNB, FABVR, FAFICC 147

2/1/2020Larry E. Masula, D.C.DACNB, FABVR, FAFICC 148

08/15/2019Larry E. Masula, D.C., DACNB, FABVR, FAFICC 149

INFECTIOUS

VINDICATES

Infectious Disorders

Otitis ExternaPathophysiology

Typically begins with otitisexterna in elderly diabetics.

Infection spreads to surroundingtissues and adjacent temporo-occipital bones, almost alwayssecondary P. aerugiosa.

Commonly affects the facial nerve in the fallopian canal or at the stylomastoid foramen and can spread across the dura to produce purulent meningitis.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 06/22/2019 150

INFECTIOUS DISORDERS:

Malignant Otitis ExternaDiagnosis – CT scan of the temporal bone may reveal:

1. External canal mass

2. Clouding of the mastoid air cells

3. Sequestra of the bony canal

4. Erosion at the base of the skull

5. Soft tissue masses within the parapharynx and

nasopharynx

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 151

INFECTIOUS DISORDERS:

Otitis MediaPathophysiology

The middle ear is involved with most viral URI’s. The nasal,paranasal, and pharyngeal mucositis spreads to involve theEustachian tube and middle ear mucosa, since the mucosa ofthe pharyngeal end of the Eustachian tube is continuous withmucociliary system of the middle ear. If the eustachian tubebecomes inflamed it swells and closes. If the tube is closed /blocked, then the middle ear and mastoid system becomedisconnected with the air in the nasopharynx and atmosphericsystem. This results in the air within the middle ear and mastoidbeing absorbed by the mucosa and a negative pressuredevelops. The negative pressure causes the TM to becomesucked inward and secondly the microcirculation within thetympanic cavity is encouraged to release fluid and mucusresulting in an inability for the TM to generate sound energycausing conductive deafness. Secondary bacterial infectionmay develop leading to otitis media.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 152

INFECTIOUS DISORDERS:▪ Otitis Media (Inflammation of the middle ear)

Is a common cause of conductive hearing loss, particularly in

children. 2 Forms

A- Suppurative Otitis (infected)

B- Serous Otitis (non-infected)

Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 2/1/2020 153

INFECTIOUS DISORDERS:

Otitis MediaDiagnosis

Most common organisms:

Streptococcus Pneumonia

Hemophilus Influenza

Translucency of TM is lost. The TM may be retracted and

the middle ear- atelectic. Impaired mobility may be observed

during pneumatic otoscopy.

Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 2/1/2020 154

INFECTIOUS DISORDERS:

Chronic OtomastoiditisPathophysiology

From an untreated / unresponsive acute Otomastoiditis.

Characterized by thickened mucosa with obliteration of the

mastoid air cell lumen, perivascular fibrosis, and osteitis.

Polypoid granulomas may fill the mastoid antrum, the middle

ear, and extrude through a tympanic perforation.

Cholesteatoma (keratinized squamous epithelium) can

invade the middle ear destroying the ossicles and labyrinth

and pneumatized temporal bone cells. Producing conductive

hearing loss and vertigo.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 155

INFECTIOUS DISORDERS:

Cholesteatoma

Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 2/1/2020 156

INFECTIOUS DISORDERS:

Mastoiditis

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 157

Intracranial Extension of Ear Infections

Background-from either acute otitis media or mastoiditis and

bone destruction. Febrile patient w/ continued ear pain,

mastoid pain, headache despite antibiotic treatment.

▪ Route of Spread may spread backward-

▪ 1. Direct extension

2. Hematogenous

3. Thrombophlebitis

Resulting in:

Meningitis

Epidural Abscess

Sigmoid Sinus Thrombophlebitis

Brain AbscessLarry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 158

INFECTIOUS DISORDERS:

Viral Vestibular NeuritisPathophysiology-part of a systemic viral illness, i.e. measles, mumps and mono, HERPES SIMPLEX II

A unilateral vestibular deficit (UVD), arising from a viral causein most patients, results in either sudden deafness or acuteprolonged vertigo with nystagmus rapidly beating (fastphase) toward the side of the lesion. This also results in aYaw rotation toward the side of the lesion and a Roll tilt in thesame direction. Acute symptoms usually abate within 3-5days, but the patient may be left with the equivalent of avestibular neuropathy.

▪ Diagnosis-

1. Caloric responses are decreased and/or absent on the side of the lesion. Ultra-high hearing loss. VNG abnormalities

2. Must be differentiated from other forms of labyrinthitis

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 159

INFECTIOUS DISORDERS

Labyrinthitis

▪ A viral or bacterial infection of the fluid within the inner ear.

▪ Within one-week sufferers are usually able to situp and after two weeks will begin to compensatefor the dizziness/vertigo. Acute episodesusually end after one to two months. Althoughpermanent vestibular damage may remain insome cases, most people recover fully fromviral labyrinthitis.

▪ Labyrinthitis will classically affect hearing as wellas balance which are also symptoms of an AICAstroke

2/1/2020Larry E. Masula, D.C., DACNB, FABVR,FAFICC 160

Differential Diagnosis of Acute Peripheral Vestibulopathy

History Examination Laboratory

Viral Neurolabyrinthitis

Developing over hours, resolving over days, prior flu-like illness

Normal except for signs of acute unilateral vestibular loss

ENG: caloric hypo excitabilityAudio: may show ultrahigh frequency loss

Bacterial Labyrinthitis Abrupt onset, hearing loss, prior ear infections

Signs of otitis mediaor meningitis

ENG: absent caloric Audio: sensorineural loss. CSF: Pleocytosis

Labyrinthine Ischemia Abrupt onset w/ neurologic symptoms, prior vascular disease

Signs of brainstem or cerebellar infarction

ENG: absent caloric Audio: sensorineural lossImaging: Brain infarction

Perilymph Fistula Abrupt onset w/ head trauma, barotrauma, or sudden strain lifting, coughing, sneezing

Positive fistula test, may be chronic otitis w/ TM perforation

ENG: caloric hypo excitabilityAudio: usually sensorineural lossImaging: CT may show erosion from cholesteatoma

Larry E. Masula, D.C. 2/1/2020 161

Endolymphatic Hydrops(Meniere’s Syndrome)

Pathophysiology

1. An increase in the volume ofendolymph distending theendolymphatic system

2. The labyrinth dilates until thesaccular wall makes contactwith the stapes footplate andthe cochlear Scala

3. Hearing loss and vertigo arecaused by ruptures in themembranes separatingendolymph from perilymphcausing a sudden increase inpotassium which inhibitslabyrinth receptors

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 162

Meniere’s cont.

Bacterial and viral. Majority unknown

1. Family history 50% of cases

2. Considered to be rare based on AMA epidemiological

studies, perhaps as low as 1% of vertiginous patients

... Meniere's disease is an inner ear disease that typically

affects one ear. This disease can cause a fullness, pressure

or pain in the ear, severe cases of dizziness or vertigo,

hearing loss and a ringing or roaring noise, also known as

tinnitus.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 163

Perilymph Fistula’s

A perilymph fistula (PLF) mayalso cause vertigo, It is anabnormal connection (a tearor defect) in one or both of thesmall, thin membranes (theoval window or the roundwindow) that separate the air-filled middle ear and the fluidfilled perilymphatic space ofthe inner ear. This smallopening allows perilymph(Na+ rich fluid) to leak into themiddle ear. - See more at:http://vestibular.org/perilymphfistula#sthash.bcdq3m49.dpuf

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 164

Perilymph Fistula’s

Leaks through the round and oval windows can occurfollowing; severe nose blowing, strenuous exercise,barotrauma, and surgical trauma.

The symptoms of perilymph fistula may includedizziness, vertigo, imbalance, nausea, and vomiting.Usually however, patients report an unsteadiness whichincreases with activities that elevate CSF pressure andwhich is relieved by rest. Some people experienceringing or fullness in the ears, and many notice ahearing loss. Most people with fistula’s find that theyget worse with changes in altitude (fast elevators,airplanes, and travel over mountain passes.

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 165

Perilymph Fistula Test

▪ The development of nystagmus in response to the

application of pressure on the external auditory canal

constitutes a positive result for the perilymph fistula test

and suggests the presence of a fistula between the air-

filled middle ear and the fluid-filled inner ear.

▪ Hosuk Chu, M.D., and Won-Ho Chung, M.D. N Engl J Med 2012; 366:e8

January 26, 2012 DOI: 10.1056/NEJMicm1010568

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 166

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 167

NEOPLASTIC -

NEUROLOGICAL

VINDICATE

Internal Acoustic Meatus for Facial Nerve

and Vestibular Nerves

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 168

Acoustic neuromas are usually located in the angle between the cerebellum and the

pons, in the back of the skull (posterior fossa) applying pressure in and around the

internal acoustic meatus and may impair both Cn.7,8. Common symptoms are one-

sided hearing loss, tinnitus, vertigo/dizziness and facial paralysis

NEOPLASM: Cerebellopontine Angle

TumorsLesions in the area of

cerebellopontine angle cause

signs and symptoms secondary

to compression of nearby cranial

nerves, including CN V, VII, VIII.

I.E., involvement of CN V from a

cerebellopontine mass lesion

often results in loss of the

ipsilateral corneal reflex.

Patients with larger tumors can

develop Bruns nystagmus due to

compression of the cerebellar

flocculi.Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 169

NEOPLASM: CPA Tumors

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020, 170

2/1/2020Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 171

Br J Neurosurg. 2008 Jun;22(3):441-3. doi:

10.1080/02688690801911614.

Cerebellopontine angle epidermoid tumor

presenting with bilateral gaze nystagmus.

Han IB1, Huh R, Chung SS, Kim OJ.

Abstract

Vestibular symptoms have been rarely described in

cerebellopontine angle epidermoid tumors. We report a

case of CPA epidermoid tumor presenting with subacute

onset of vestibular symptoms such as vertigo, gait ataxia,

and nystagmus masquerading as acute vestibular neuritis

or central vertigo. The vestibular symptoms disappeared

after excision of the tumor.

PMID: 18568737 [PubMed - indexed for MEDLINE]

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 172

Cerebellopontine angle epidermoid tumor

2/1/2020Larry E. Masula, D.C. 173

Clin Exp Otorhinolaryngol. 2012 Dec; 5(4): 234–236.

Published online 2011 Sep 15. doi: 10.3342/ceo.2012.5.4.234

PMCID: PMC3506776

A Posterior Petrous Meningioma with Recurrent

VertigoSeong Jun Choi, MD,1 Jong Bin Lee, MD,1 Joon-Ho Bae, MD,1 Jung-Hee Yoon, MD,1 Ho-Jin

Lee, MD,1 Chan-Ho Kim, MD,1 Keehyun Park, MD,2 and Yun-Hoon Choung, MD2

Abstract

Meningioma's account for around 15% of all primary brain tumors

with some 10% of meningioma's arising in the posterior fossa. In

rare cases, a meningioma can form around the endolymphatic

sac. When formed in the posterior fossa, meningioma tumors can

produce vague, non-specific vertiginous symptoms. Research

has observed that a subset of these lesions could produce

symptoms indistinguishable from those of Meniere's disease.

Therefore, we described the clinical features of a case of

posterior petrous meningioma with recurrent vertigo as well as

the substantial resolution of symptoms after tumor removal via

transmastoid approach.

NEOPLASMA: Acoustic Neuroma (vestibular schwannoma)

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 174

Cerebellum: the Brain Behind the

Brain

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC. 175

Clinical Manifestations, (DDX)

▪ Tilting –

▪ Falling forward or backward –

▪ Exocentric Yaw axis (spinning) –

▪ Egocentric Yaw axis (spinning) -

▪ Most likely cortical

▪ Mesencephalic, medullary, Cb

▪ Peripheral Nerve i.e. BPPV or vestibular nerve loss

▪ Most likely cortical

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 176

Case report Rotational vertigo caused by cerebral lesions: Vertigo and areas

3av, 2v, and 7

▪ Eiichirou Urasaki, Akira Yokota

▪ Source Journal of Clinical Neuroscience > 2006 > 13 > 1 > 114-116

Abstract - We describe two patients complaining of vertigo

associated with a small supra-tentorial convexity

meningioma. Symptoms disappeared after tumor removal,

providing evidence for an association between the vertigo

and the cerebral cortical lesions. Tumors were located in the

central and parietal areas, respectively, which are probably

analogous to the vestibular cortex in the areas designated

3av, 2v, and 7 in animal studies

*** Why you must check for non-vestibular cortical

findings

Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 2/1/2020 177

Van GoghIn an acute right sided process

such as vestibular neuritis, the

nuclei are initially excited, and

the eyes exhibit a slow phase of

nystagmus pushing the eyes to

the left, the fast phase of

nystagmus to the right. But, as

time passes and the nerve dies

the right side, is no longer an

acute problem and the Left side

that is no longer being inhibited

through the commissure appears

overly active. The fast phase of

nystagmus then switches, and

the eyes beat Slow phase to the

right with a Fast phase back tothe left.

So, In Vincent's case on which

side is the probable lesion?

The Right side. The slow phase

gives an illusion that you are

moving to the right while the

world is moving left.

Assuming that in his case it was

no longer an acute problem, the

Left side was no longer being

inhibited by the right vestibular

nuclei and the left side appears

overly active.

The same is true in the acute

stage of a vascular insult

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 178

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 179

Sir Gordon Morgan Holmes, (22 February 1876 – 29 December 1965) was a

British neurologist. He is best known for his pioneering research into

the cerebellum

Gordon Holmes, M.D.

1917, Dr. Holmes talked about the symptoms of acutecerebellar lesions due to WWI gun shot wounds andwhat he talked about is this,

“the brain (cortex) is fine but these people have thesepresentations that are very severe and involveaberrancies’ in the frontal cortex. It is also increasinglyclear that there are extensive connections between theCb and frontal associative areas of the cerebral cortexthat fall well outside the classical sensory-motor circuit.”

▪ The Cerebellum. 2007; 6: 268-279

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 180

Functional ConceptsA “BAD” Cb is known to be involved with:

Cognitive functions (ataxia of thought and represents erratic attempts to correct errors of thought or behavior)

Psychiatric Disturbances

Autonomic concomitants

Sensory Disturbances

Maintenance of Equilibrium

Breakdown in Coordination/Sequenced motor activity – walking, intention and terminal tremors (not at rest), eye movements w/ diminished pursuits and overshooting saccades. Intention tremors and terminal tremors.

Motor learning – motor skills

Monitor & predict

Horizontal & Vertical nystagmus w/ & w/o fixation

Scoliosis – genetic calcium channel mutation affecting midline Cb

Head tilt

Ocular deviations

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 181

Functional Concepts

▪ A “Bad” cerebellum may develop as a result of:

Alcohol degeneration

Thiamine deficiencies

Toxins

Concussion

Inflammation

Acute and hemorrhagic stroke

Inherited gene changes

Paraneoplastic disorders

2/1/2020Larry E. Masula, D.C.DACNB, FABVR, FAFICC 182

The cerebellum is organized anatomically

and physiologically

▪ “ArchiCerebellum”

Floculonodular Lobe

▪ “Paleocerebellum”

Anterior Lobe

▪ “Neocerebellum”

Posterior Lobe

Larry E. Masula, D.C, DACNB, FABVR, FAFICC. 2/1/2020 183

Floculonodular Lobe Aka (ancient)ArchiCerebellum

Aka Vestibulocerebellum▪ Receives Input from the

labyrinthine system with noinvolvement of the deep Cbnuclei

▪ This has influence over theaxial musculature, someinfluence over VestibularOcular Reflexes andVestibular Reflexes

▪ Flocculus/paraflocculusmodulates the smoothnessof pursuits and calibratesthe rotational VOR

▪ Nodulus – calibrates VOR(from otoliths)

Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 2/1/2020 184

Anterior Lobe Paleocerebellum (old-not ancient)

Spinocerebellum

▪ Associated with upright

stance, posture and

bipedalism

▪ Limb coordination and

feedback from extremities

▪ Controls proprioception

related to postural muscle

tone

▪ Axons extend to the deep

Cb nuclei

Larry E. Masula, D.C, DACNB, FABVR, FAFICC. 2/1/2020 185

Medial Zone (Vermis)▪ Lesions in midline Cb (aka:

Spinocerebellum)

▪ Gait instability

▪ Ataxia of trunk

▪ Titubation

▪ Breakdown in movements

▪ Saccadic dysmetria

▪ Vertiginous activity

▪ Note: findings may improve when

lying down or with an increase in

integrity into the system

▪ Ex: distract the patient’s neck and

this fires midline Cb structures and

the symptoms of the lesion reduce

(ddx midline lesion versus lateral)

Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 2/1/2020 186

Lateral Zone (aka

Neocerebellum)Input: from the parietal cortex via the ponto-cerebellar mossy fiber projections

▪ The information is specific to the location of the body in space

▪ Integration of body position information, strength and speed

Output: Dentate nucleus projects to the cortex for cognition of movement. Aids in timing and planning and higher cognitive functions

Note: no balance, equilibrium or gait disorders associated with the Neocerebellum

Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 2/1/2020 187

Comparing and Contrasting

2/1/2020Larry E. Masula, D.C. DACNB, FABVR, FAFICC 188

Normal Cb Alcoholic Cb

Note the folia atrophy

Cerebellar Function

▪ Maintenance of Equilibrium

Balance, posture, eye movements

▪ Coordination/Sequenced motor activity

Walking gait

▪ Adjustment of Muscle Tone

▪ Motor Learning-Motor Skills

▪ Monitor & Prediction of Movement

▪ Cognitive Function-learning

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 189

Cerebellar Stroke

▪ A cerebellar stroke is one of the least common types

of strokes. It occurs when a blood vessel is blocked or

bleeding, causing complete interruption to a portion of

the cerebellum. This type of stroke typically affects only

one side or section of the cerebellum. It's also referred to

as cerebellar stroke syndrome.

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 190

Cerebellar Stroke

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 191

Clinical Signs:

Ipsilateral Cerebellar Disease

(Flocculonodular Zone/Spinocerebellar lesions)

Abnormal Stance/Gait: a. Wide based, stumbling gait with truncal tremor, Falling/veering to side of the lesion, activities w/ increased speed/difficulty (tandem gait).

Titubation: rhythmic tremor of the body(trunk) and head. Note: must rule out BG lesion

Rotated/tilted head: not specific for side of lesion but related to eye movements

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 192

Clinical Signs: Cerebellar

Disease

Dysdiadochokinesia: error in the rate of movements and

completion of movement (rapid alternating) vs loss of

smooth movement

Dysrhythmokinesis: errors in timing out a beat. Note:

Interactive metronome used for both testing and rehab.

Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 2/1/2020 193

Clinical Signs: Cerebellar Disease

Dysarthria: tremulous voice with errors in prosody and

intonation (Vermal - medial zone lesions) Interference with

articulation, respiration and phonation; slowness, scanning

(stretch syllables)

Kinetic Tremor: (Cerebrocerebelar lateral zone lesions)

greatly increases as movement nears target, when accuracy

is most essential. Worse with fatigue

Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 2/1/2020 194

Clinical Signs: Cerebellar Disease

Abnormal Tone: Hypotonia, joint laxity and pendular reflexes

Relates to the alpha-gamma co-activation

Abnormal check and rebound Check - arms outstretched and tap wrist. Should

return quickly to initial point

Rebound is excessive excursion during the attempted

return to initial point

Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 2/1/2020 195

Clinical Signs: Cerebellar

DiseaseAbnormal Ocular Motor Function:

(Flocculonodular lobe lesions)Nystagmus: Gaze evoked

Skew Deviation: in primary position, oneeye is elevated () and other is depressed(hypotropia)

Saccadic dysmetria: usually hypermetriadue to failure to terminate the movementsecondary to lesions in the CerebellarFastigium

Impaired Smooth Pursuit

Glissades (post saccadic drift)

Alteration in VOR (due to improper termination/hypermetria)

2/1/2020Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 196

Cerebellar Tests

▪ Middle – Sharpened

Romberg’s, tandem gait,

finger-nose-finger, saccade

hypermetria, nystagmus,

post rotational nystagmus,

head thrust tests, smooth

pursuits

▪ Lateral – piano playing,

RAM w/ fingers, finer nose

finger

▪ Intermediate - rapid

alternating movements w/

arms front, bent utilizing

rapid pronation/supination,

then windshield wiper

motion, finger-nose-finger,

heel to shin

2/1/2020Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 197

Head tilts often have Cb lesions affecting

their otolithic pathways

2/1/2020Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 198

Normally, tilt in the (YAW) roll plane to the right normally produces a reflex

counter roll and Skew (hypertropic eye movement) towards the opposite

side. If I lose my Cb Pathways on the Rt. the right eye remains extorted

and what do I do to compensate for the extorsion? Tilt my head to the

(left) opposite side.

NormalOcular tiltReflex

Head tilt

▪ You can no longer say that a left head tilt means a bad

left Cb. I know some people instruct that from classes

you may have taken but there are too many factors

involved and that assumption is incorrect

2/1/2020Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 199

Central Vestibular Disorders J Neurol (2007) 254:559-568

A tonic imbalance in YAW (rotation) is characterized by horizontal(torsional) nystagmus, lateralpulsion of the eyes, past-pointing,rotational and lateral body falls, and lateral deviation of theperceived straight-ahead. (Implicates a horizontal VOR type problem, i.e. vestibularnerve loss, Meniere’s, post vestibular neuronitis, or a Cb - fastigial n.). Turning ~ 35° in Fakuda test.DDX- CN8 entry into medulla, MVN, SVN, NPHypo., PPRF demyelination or ischemia)

A tonic imbalance in ROLL is defined by torsional nystagmus,skew deviation, ocular torsion, head tilt, body, and the perceivedvertical. (Central...remember Van Gogh?, midbrain, paramedian thalamus or PIVC –parieto-insular- vestibular cx lesions)

Finally, a tonic imbalance in PITCH can be characterized by someforms of upbeat or downbeat nystagmus, for-aft tilts and falls, andvertical deviation of the perceived straight-ahead. (Central problemsomething in the midline dying off i.e. central flocculus, PPRF or bilat. medullary)WARNING…NOT GOOD!!!

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 200

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 201

EXAMINATION - VESTIBULAR

ASSESSMENT

Tests performed in lighted room

Various tests are performed to

evaluate the where and the

why the patient suffers

vertigo. The following tests

are performed in a lighted

room.

▪ Identify any Spontaneous nystagmus

▪ Identify any (Gaze holding) nystagmus

▪ Skew deviation

▪ Vergence

▪ Decreased VOR

i. Head thrust test

ii. Dynamic visual acuity

Visual tracking

i. Smooth pursuit

ii. Saccadic eye movement

iii. VOR cancellation

Gait and balance

i. Feet together

ii. Tandem

iii. Single leg stance

2/1/2020Larry E. Masula, D.C.,DACNB, FABVR, FAFiCC 202

Tests performed in dark

Tests performed using Frenzel lenses or infrared goggles

(Real Eyes®)

Spontaneous nystagmus

Gaze holding nystagmus

Decreased vestibular ocular reflex

Head thrust (head shaking nystagmus)

2/1/2020Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 203

VOR▪ The VOR maintains foveal fixation on a target during head movement.

▪ Head movement will not normally result in excessive eye movementand the eyes will remain focused on a target. This reflex functionsto stabilize images on the retinas (when gaze is held steady on atarget) during head movement by producing eye movements in thedirection opposite to head movement, thus preserving the image onthe center of the visual field(s). For example, when the head moves tothe right, the eyes move to the left, and vice versa.

▪ Since slight head movement is present all the time, the VOR isnecessary for stabilizing vision: patients whose VOR is impaired find itdifficult to read print, because they cannot stabilize the eyes duringsmall head movements, and also because damage to the VOR cancause vestibular nystagmus

▪ Patient symptoms of a bad VOR are therefore typically triggered bychanges in head and or body position/movement in specific directions atspecific speeds (frequencies)

▪ When Head and Eye coordination are out of sync during movement it islikely a sign of vestibulopathy.

2/1/2020Larry E. Masula, D.C.DACNB, FABVR, FAFICC 204

VOR (vestibulo-ocular reflex)

▪ A good Cb (flocculonodular lobe) is necessary for both

suppression of the VOR during head movement and for

slip-induced gain change i.e. OPK stimulation and head-

thrust testing.

▪ VOR suppression. It can be suppressed by focusing on

an object e.g., motion sickness, sea-sickness or ice

skating. It is effective for peripheral lesions and has no

effect on central pathologies

Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 2/1/2020 205

2 Forms of Nystagmus. Peripheral

and Central

Peripheral Induced Nystagmus - Vertigo of peripheral origin

generally manifests by horizontal nystagmus, rotatory

nystagmus, or absent nystagmus, but

horizontal nystagmus is not a specific sign

of peripheral vertigo.

Direction changing nystagmus (Central Induced Nystagmus)

is the most common type of nystagmus observed in

patients with cerebellar infarction. Vertical nystagmus is

always considered specific for central pathology.

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 206

Peripheral Causes of Nystagmus and

VertigoBPPV-otoconia most often in the PC w/ down beating nystagmus

Acute Viral Labyrinthitis

Alcohol- lighter than blood so the haircells float in the endolymph and thinsblood affecting the anterior

Meniere’s Disease

Toxins – especially antibiotics such as streptomycin and gentamycin

Sequeala of Peripheral Vestibular Dysfunction

Head tilt

Cb dysfunction

Vestibular system dysfunction

Ipsi Neocortex dysfunction

Torticollis

Difficulty compensating for perturbations of head position-functional imbalance

Worse with eyes closed because a normal Cb and Frontal lobes can use vision to suppress the nystagmus

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 207

2/1/2020Larry E. Masula, D.C.DACNB, FABVR, FAFICC 208

Here we seen in the far-left diagram, equal tonic input from both vestibular

nuclei, equal 100 spikes/second, thus no perceived movement. In the middle

diagram, during right head rotation, the right canal system and the right

vestibular nuclei become excited and motion is detected rightward. In the far-

right diagram there is a left sided vestibular deficit. The right side is no longer

being inhibited and again the perception is a rightward rotation.

Physiologic vs. Pathologic

Nystagmus

PhysiologicRotation-induced

Caloric-Induced (cows) remember fast phase names the nystagmus

Optokinetic stimulation induced

End Point- there is a point at which it usually slows and stops. The exception is a cupulolithiasis

Fixating on a target suppresses the nystagmus

PathologicSpontaneous-the nystagmus isspontaneous and is best seen indarkness w/ goggles, becausethe patient cannot fixate onobjects in the room. The slowphase points to or looks at thelesion

Central Nystagmus is not suppressed by fixating eyes on a target

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 209

Central vs. Peripheral induced

Nystagmus and vertigo▪ Example – a patient presents with no nystagmus in light

during fixation, but you see nystagmus in darkness

without fixation

▪ Central or Peripheral lesion?

▪ Answer : fixation in light indicates central is ok therefore

problem is peripheral

▪ If they cannot suppress it in the light with fixation= a

central lesion

2/1/2020Larry E. Masula, D.C. DACNB, FABVR, FAFICC 210

Oculomotor ExaminationEye movement ROM (Cardinal Fields of Gaze)

Eye movement ROM Procedure (CFG): Hold patient’s head

with one hand. Ask the patient to follow your finger

(keeping it 18-24 inches away from the patient’s face) to test

for full vertical and horizontal eye movements. Look for: •

ROM • Conjugate eye movement

Note: •

Vertical movements decrease slightly in older people

A small amount of “end point” nystagmus may be

seen at the point of full ocular range in all directions,

minimal in young people and increases with age

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 211

Tests performed in room light Spontaneous Nystagmus Procedure:

Hold patient’s head with one hand. Ask patient to look straight ahead at a point several feet away. Look for: Nystagmus and note direction.

Gaze Holding Nystagmus Procedure:

Hold patient’s head with one hand. Ask patient to follow your finger(keeping it 18-24 inches away from the patient’s face) while you moveyour finger 30 degrees to the left, right, up and down. Pause in eachposition to observe nystagmus, note direction.

Skew Deviation Procedure:

Hold patient’s head with one hand. Cover one eye. Switch the coverfrom one eye to the other eye. Look for: a vertical corrective movementof the eye as it is uncovered. Note: Effect of direction of gaze on the skewdeviation • Any spontaneous tilt of the head and the effect of tilt on theskew deviation

Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 2/1/2020 212

Oculomotor ExaminationVergence

Hold the patient’s forefinger in your hand about 2 feet away from thepatient’s face. Ask the patient to focus on the finger while you move ittoward the patient’s nose. Look for : Convergence of the eyes •Conjugate eye movement • Pupillary constriction

Head thrust test

Used for evaluation of a decreased vestibular ocular reflex (VOR)

Seated slow and fast-abnormal start pt. supine, progress to seated,then standing. Inform the patient that you will be moving their headvery quickly, but only through a small range. Grasp patient’s headfirmly with both hands on the sides of the head. Tilt the head forward30 degrees so that the horizontal semicircular canal is level in thehorizontal plane. Instruct the patient to look at your nose. Move thepatient’s head side to side slowly. Then, suddenly move the patient’shead in one direction and stop. The head movement should be smallamplitude with the position held at the end.

Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 2/1/2020 213

Vestibular Ocular Pathway

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 214

2/1/2020Larry E. Masula, D.C/, DACNB, FABVR, FAFICC. 215

As each FEF drive the eyes to the contralateral side, a lesion

on the right will result in the eyes being deviated toward the side

of the lesion

Dynamic Visual Acuity

While moving the patient’s head side to side at a frequency

of 2Hz (2 complete side to side cycles per second) through a

ROM of 1-2 inches in each direction, (so as to not restrict

the visual field which may occur in patients who wear

glasses) ask them to read the lowest line that they can until

they cannot correctly identify all the letters on a given line.

Note the line and where this occurs and or the number of

incorrect letters. A difference of less than or equal to 2

lines is normal. A difference of greater than or equal to 3

lines is abnormal. (likely vestibular deficit). If the patient has

restriction of the cervical movement which limits your ability

to perform the head movement the test cannot be properly

performed and should be ceased.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 216

Smooth Pursuit eye movements Smooth-pursuit movements allow

clear vision of a moving target by

holding the image steady on the

fovea.

Smooth pursuit may be “jerky,” (ie,

inability to maintain the target on the

fovea requiring a “catch-up”

saccade).

Patients with vestibular hypofunction

who also have a central lesion exhibit

impaired smooth pursuits.

Impaired smooth pursuit and

optokinetic nystagmus is mainly seen

ipsilateral to pontine damage which

is a crucial relay area between the

cerebral cortex and the cerebellum .

Ask the patient to follow your slowlymoving finger (< 20 degrees per second)horizontally, 30 degrees from the centerto the left and to the right

Ask the patient to follow your slowly moving finger (< 20 degrees per second) horizontally, 30 degrees from the center to the left and to the right

Repeat vertically, moving 30 degrees above and below the horizontal.

Abnormal is jerky (or saccadic) Note: Eye movements may be saccadic if you are moving your finger too fast. Slow the speed of your finger to see if the person can follow smoothly.

Smooth pursuit eye movements become more and more saccadic with age. Vertical eye movement is often interrupted by a saccades in younger individuals.

2/1/2020Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 217

Saccadic eye movements

Hold the patient’s head with one hand. Hold your finger

about 15 degrees to one side of your nose. Ask the

patient to look at your finger and then at your nose

several times. Perform this left, right, up and down.

Look for: The number of eye movements it takes for

the patient’s eyes to reach the target, normal is less

than 2. Abnormal is several small movements or a big

movement with an overshoot. (Hypermetria)

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 218

VOR Cancellation

The test is used principally to assess whether patient

symptoms are attributable to a vestibulocerebellar lesion.

Remember visual fixation cancels the VOR if it is of

peripheral causation. The nystagmus can often times be

suppressed by visual fixation if the cause is peripheral

The VOR is essential for maintaining stable vision on a

target when the head is moving but the brain must also have

a mechanism for suppressing the VOR when it is necessary

to move the head and eyes in the same direction. This task

is managed by the vesstibulocerebellum (Flocculonodular

lobe). Failure to suppress the VOR indicates probable

vestibulocerebellar (central) contribution to the patient's

vertigo.

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 219

VOR Cancellation

Grasp the sides of the patient’s head firmly with both hands.

Tilt the head forward 30 degrees so that the horizontal

semicircular canal is level in the horizontal plane. Instruct

the patient to look at your nose. Move the patient’s head

from side to side approximately 30 degrees while you move

in the same direction so that your face remains directly in

front of the patient’s face. Look for: Patient’s ability to

maintain visual fixation and/or if the patient makes saccadic

eye movements.

Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 2/1/2020 220

BESS Test

The Balance Error ScoringSystem: provides a portable,cost‐effective, and objectivemethod of assessing staticpostural stability. In theabsence of expensive,sophisticated postural stabilityassessment tools, the BESScan be used to assess theeffects of mild head injury onstatic posturalstability. Information obtainedfrom this clinical balance toolcan be used to assistclinicians in making return toplay decisions following mildhead injury.

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 221

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 222

While this is most often used for concussion assessment, it provides great patient

feedback as to the integrity of their balance system

Optokinetic Eye Movements

The optokinetic (OPK) tape is

an essential part of the

functional neurologist's toolkit.

It can be used to evaluate

optokinetic nystagmus, which

provides a window of

assessment into the

functionality of the frontal

lobe, parietal lobe, cerebellum

and other brain regions

involved in the generation and

control of optokinetic eye

movements.

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 223

Tests best performed using Frenzel lenses or IR

goggles

Look for any horizontal nystagmus which is the most

common form of nystagmus observed with cerebellar

infarction.

Spontaneous nystagmus denotes movement of the eyes

without a cognitive, visual or vestibular stimulus.

Most commonly spontaneous nystagmus is caused by a

vestibular imbalance. Normally, both vestibular nerves fire

equally at a tonic rate.

Hold patient’s head with one hand. Ask patient to look

straight ahead. Look for: Nystagmus and note direction.

Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 2/1/2020 224

Head Shaking Nystagmus Test

Used to determine the presence of a decreased VestibularOcular Reflex (VOR)

Procedure: Inform the patient you will be moving their headfrom side to side. Grasp patient’s head firmly with one handon either side of the head. Tilt the head forward 30 degreesso that the horizontal semicircular canal is level in thehorizontal plane. Have the patient close their eyes. Move thehead side to side 20 times, asking the patient to help withthe movement.

Ask patient to open their eyes quickly. Look for: Nystagmus,noting direction . 1 or 2 beats of nystagmus is notsignificant. If horizontal head shaking induces persistentnystagmus the procedure should be repeated vertically, butonly moving the patient’s head 10 times.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 225

Positional Testing

▪ Can help identify peripheral or central causes of vertigo.

▪ The most common positional vertigo is BPPV due to free-floating calcium carbonate debris from the otolithic organswhich enters one of the semicircular canals – usually inthe posterior semicircular canal – occasionally horizontalcanal and rarely the anterior canal

▪ The characteristic burst of upbeat torsional nystagmus istriggered in patients with BPPV by a rapid change fromthe sitting-up position to supine head-hanging left orhead-hanging right (Dix-Hallpike test for BPPV).

▪ A burst of nystagmus in the opposite direction (downbeattorsional) occurs when the patient sits up

2/1/2020, Larry E. Masula, D.C., DACNB, FABVR, FAFICC 226

Dix Hallpike Test for Posterior Canal

BPPV

Patient seated on table and head is rotated 450 The head

and trunk are quickly taken straight back so the head is over

the edge of the table. Hold 30-45 seconds, observing for

nystagmus and question for vertigo. (latency of 5-10 sec.).

Patient is then brought up slowly to a sitting position with the

head maintained in 450 rotation. Again, observe for

nystagmus and question for vertigo. Test is repeated with

head rotated 450 in opposite direction. Look for: Up beating

or down beating Nystagmus, indicative of central lesion.

Note: Critical element is position of the head in space (not

relative to the body).

Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 2/1/2020, 227

Head roll test for Horizontal canal

BPPV

Procedure: patient is supine with the headflexed 20 degrees. Head is turned quickly toone side. Hold 30 seconds, observing fornystagmus and question for vertigo. Rollthe head slowly back to the supine position,hold for 30 seconds. Roll the head quicklyto the other side. Observe fornystagmus/vertigo. Observe nystagmus,noting direction, latency and duration. Askthe patient which side is worse.

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 228

Imaging

▪ To rule out central causes of vertigo

▪ CT scan can rule out a large mass withexception of smaller lesions due to infarct andpoor resolution in the posterior fossa. (Chalela etal. 2007)

▪ MRI imaging is the modality of choice especiallyif the patient has focal neurological symptoms oris having unexplained neurological deficits,direction changing nystagmus, or an otherwiserapid, unexplained progression of symptoms.

▪ BPPV, vestibular neuritis, or Meniere’s diseasedo not require imaging

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 229

Additional Testing

▪ Berg Balance Scale

▪ Dynamic Gait Index

▪ Modified Clinical Test of Sensory Interaction in Balance

(mCTSIB)

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 230

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 231

VESTIBULAR ASSESSMENT

AND TREATMENT

VRT(vestibular rehabilitation therapy)

Therapeutic Goals▪ Enhance existing vestibular capabilities

▪ Strengthen compensatory mechanisms

By improving Proprioceptive input

By increasing Visual Input

Other sensory systems

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 232

Vestibular Adaptation and

Compensation Thomas P. Wellings*, Alan M. Brichtaand Rebecca Lim

School of Biomedical Sciences and Pharmacy, The University of Newcastle, and Hunter Medical

Research Institute, NSW, Australia

The balance or vestibular system is often overlooked as a

major sensory system (Goldberg et al. 2012). Even less

appreciated is the vestibular system’s inherent plasticity

and capacity for self repair.

2/1/2020Larry E. Masula, D.C, DACNB, FABVR, FAFICC. 233

Vestibular Adaptation

(compensation) Exercises▪ Vestibular adaptation describes the routine changes in

sensitivity (gain) of reflexive eye movements (VOR)

responsible for stabilizing images on the retina during

head movements.

▪ This may not be possible with an MS patient who

develops demyelination of the vestibular nerve and the

medial longitudinal fasciculus which yokes eye

movements and may result in (Yaw) rotation

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 234

Vestibular Habituation ExercisesA large amount of end point

nystagmus may be seen with

increasing age.

The goal

of habituation exercise is to

reduce the dizziness through

repeated exposure to specific

movements or visual stimuli that

provokes the patients'

dizziness.

These exercises are designed

to mildly, or at the most

moderately, provoke the

patients' symptoms of dizziness.

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 235

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 236

Benign Positional Vertigo (BPPV)There are Two Forms: Canalithiasis and Cupulolithiasis.

Canalithiasis (otoconia is free in the canal) and is the single

most common cause of vertigo lasting less than 30 seconds

with position change-typically when turning over in bed,

getting in and out of bed, bending over and straightening up,

and extending the neck to look up. Cupulolithiasis (otoconia

stuck to the cupula) causes immediate vertigo and

nystagmus and does not fatigue.

Barany- found lesions of the otolith organs. Dix-Hallpike-

found unilateral degeneration of the utricular macula at

necropsy. Schuknecht-found basophilic deposits on the

cupulae of the posterior canal proposing otoconia from

degenerating utricular macula settles on the cupula of the

posterior canalsLarry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 237

BPPV

▪ Most common cause of vertigo in the general population

▪ Patients typically experience brief episodes of vertigo

when getting in and out of bed, turning in bed, bending

down and straightening up, or extending the head back to

look up

▪ Repositioning maneuvers are highly effective

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 238

2/1/2020Larry E. Masula, D.C., FABVR, FAFICC 239

It is important to realize that eye movement alone or head movements alone, will

have extremely limited benefit. Introduction of head movement together with

visual acuity, (within the frequency of the VOR) , is extremely beneficial at repairing a

damaged system.

Management

He following therapies are specific for lesions in

the affected canal system

1. Epley Maneuver - PC

2. Semont Maneuver – PC

3. Lempert Maneuver – HC

4. Gufoni Maneuver – HC

5. Reverse Dix Hallpike – AC

6. Reverse Epley - AC

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 240

Posterior Canal BPPV

Two most convincing pieces of clinical evidence supporting a posterior canal are:

▪ 1. The positional nystagmus is in the plane of the posterior canal

▪ 2. Sectioning of the ampullary nerve from the posterior canal stops BPPV

▪ Schuknecht’s cupulolithasis theory is supported byany type of damage to the inner ear (trauma,infection, ischemia, age related degeneration) whichcan lead to dislodging of the calcium carbonatecrystals from the otolith and deposition on the cupulaof the posterior semicircular canal

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 241

Posterior Canal BPPV

Diagnosis-

1. Rests on finding the characteristic fatigable paroxysmal positional nystagmus. The Nystagmus is torsional and in the plane of the affected canal.

2. Caloric hypo excitability is seen on the ipsilateral side presumably involving both the horizontal and posterior canals

3. Canals may also be tested w/o eye fixation in a Dis-Halpike position (Frenzel lenses) for better optimization

▪ Management- positional exercises. Epley or Semont. Resume upright position once the vertigo has ceased. Repeat x 3 - t.i.d.

Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 2/1/2020 242

Dix-Hallpike Test for posterior canal

BPPVExplain procedure to patientbeforehand that it mightinduce vertigo. Ensure thatthere are no neck/backproblems that would beaggravated by sudden changein posture. Stand to the sideof the patient • Pt sitting withhead turned to examiner • Ptsat so that when supine, thehead will be beyond the endof the couch • Patient lain flatin one quick, smoothmovement • Eyes must stayopen • Repeat on other side.

Positive test: – Rotatory (torsional) nystagmus (& vertigo): • Diseased ear downmost

3 important features include:

▪ Latency – delay of up to 20 seconds before onset of nystagmus

▪ Fatigueability – nystagmus fades if head held in provoking position

▪ Habituation – Repeating DH test produces less vigorous response

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 243

Interpretation of Dix Hallpike Test

Consider central problem if

any of the following occur:

▪ Non-rotatory nystagmus

▪ No latency

▪ No fatiguability

▪ No habituation

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 244

Posterior Canal Rehab.

▪ Semont

▪ Epley

2/1/2020Larry E. Masula, D.C, DACNB, FABVR, FAFICC. 245

Epley Maneuver-posterior canal

Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 2/1/2020 246

Semont Maneuver - Right PC

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 247

Roll Test for Horizontal Canal

BPPV(Herdman, 2007)

Patient lies supine with neck flexed 20º, head is quickly

rolled 90º to one side to orient the horizontal canal. Hold for

up to one minute and observe presence & direction of

nystagmus, and then return slowly to midline; maintaining

the neck flexion, the procedure is repeated to the other side.

Note patient report of vertigo.

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 248

Roll Test, Interpretation

Horizontal canalithiasis –nystagmus is geotropic(toward the earth) when thehead is rolled to the right andleft, and lasts a short duration(approximately <60 seconds)

Horizontal cupulolithiasis –nystagmus is apogeotropic(away from the earth) whenthe head is rolled right andleft, and it is persistent (>60seconds)

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 249

Horizontal Canal Rehab.

▪ Gufoni Maneuver

▪ Lempert Maneuver

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 250

Gufoni Maneuver - Horizontal Canal rehab.

Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 2/1/2020 251

Lempert Maneuver (BBQ Roll)

Horizontal Canal rehab.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 252

Rehab. Gem

▪ Vestibular rehabilitation utilizing Otolith stimulation (A/P

and Up/down) also provides lot of frontal lobe stimulation.

This application may also useful for ADD kids with right

frontal lobe problems.

▪ Special Note: All the testing maneuvers previously

mentioned are aides to identify the canal most likely to be

generating the vertigo, but they are also extremely

beneficial and frequently used for canal rehabilitation as

well.

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 253

VOR Gaze stabilization rehab.

X1 viewing exercise, may be

used for rehabilitating the

dizzy patient with gaze

holding failure. While seated

keep eyes fixed on single

stationary target held in hand

or placed on wall move head

side to side. Repeat while

moving head up and down.

This like all tests should be

performed both sitting and

standing.

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 254

VOR rehab: X1 viewing

Head/eyes moving in same

direction Holding a single

target, keep eyes fixed on

target. Slowly move target,

head and eyes in same

direction up-down/ side to

side/diagonally

2/1/2020Larry E. Masula, D.C, DACNB, FABVR, FAFICC. 255

VOR rehab: X2 viewing

Head/eyes moving in opposite

direction Holding a single

target, keep eyes fixed on

target. Slowly move target up-

down/side to side/diagonally

while moving head in opposite

direction of target

2/1/2020Larry E. Masula, D.C, DACNB, FABVR, FAFICC. 256

Saccades Rehabilitation

Holding two stationary targets

placed inches apart side-to-

side/up-down/diagonally,

move eyes quickly from target

to target as head stays still.

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 257

Cawthorne Cooksey Exercises

▪ Were devised in the 1940’s

▪ Mainly for vestibular lesions

▪ Initially, the exercises performed are slow gradually

increasing speed as patient tolerates the movement

▪ The patient should experience an increase in symptoms

with movement

▪ Exercises performed for at least 1 minute several times

each day for adaptation to occur

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 258

Have a Vestibular Questionnaire

2/1/2020Larry E. Masula, D.C., DACNB, FABVR, FAFICC 259

Additional Rehab. Strategies

▪ OPK

▪ Cb Rehab Exercises

▪ Head Laser Maze

▪ NSI Unit

▪ Metronome

▪ Simon

▪ Gaze Stability - Dots on Wall

▪ Wii

▪ Fit Ball

▪ Wobble Board

▪ Mini Trampoline

2/1/2020Larry E. Masula, D.C, DACNB, FABVR, FAFICC. 260

2/1/2020Larry E. Masula, D.C.DACNB, FABVR, FAFICC 261

Thanks for taking Online Courses with Back To Chiropractic CE Seminars.

I hope you enjoyed the course. Please feel free to provide feedback.

Check out: Back To Chiropractic Resource Pages

Chiropracticpedia Informational website for chiropractic patients

Free Materials Over 200 files: Posters, newsletters & more

Adjusting & Office Skills Free help from DCs that care

DCs Looking For DCs Looking to hire, or for a job?

Chiropractic Neurologists

Classifieds Looking to buy or sell a Practice

Memorials Tributes to great DCs who have passed

Marcus Strutz DC

Back To Chiropractic CE Seminars

33000 North Highway 1

Ft Bragg CA 95437

707.972.0047