The absolute most important part amazonaws com
Subjec,ve (What the pa,ent is feeling)) The absolute most important part: • Ask pa,ent to describe symptoms. (Dizzy, dys-‐equilibrium, lightheaded). • Ask when the symptoms started, what provokes the complaints, what makes complaints go away. How long do they last? • Ask if there is any ringing in the ears, hearing loss, possible, or any other trauma. • Ask barotraumaabout cogni,ve func,on. • Ask about cranial nerve func,on • Ask about peripheral func,on. • Ask about drug history. Also include social history. • Ask about other health condi,ons. • Be comprehensive. AVer pa,ent interview you should be about 80% sure where the problems are, or have an idea.
Ul,mate ini,al ques,ons! • • • • •
Is the ves,bular lesion central or peripheral? Is it acute or exacerba,on of a chronic condi,on? Is the ves,bular lesion leB or right? Is the lesion abla%ve, physiological, or both? Is the pa,ent in immediate danger?
Peripheral lesions • • • • • • • • •
Does the problem involve cranial nerve 8? Does the problem involve infec%on? Does the problem involve vasculature? Does the problem involve the canals? Does the problem involve the cochlea? Does the problem involve the middle or outer ear? Does the problem involve trauma? Does the problem involve autoimmunity? Does the problem involve ototoxicity?
The Peripheral Nerve Show: Meet the Cast
• • • • • • • •
Benign Paroxysmal Posi,onal Ver,go Ves,bular neuroni,s Otosclerosis Meniere’s Disease / Hydrops Infec,ons / labryrinthi,s Fistulas / Dehiscence Nerve Compression (Acous,c Neuromas) Bilateral ves,bular disorders
When Do I suspect Peripheral lesions? • Subjec,ve! • With a peripheral lesion, fixa%on decreases it. With central, fixa%on either does not change it or makes it worse. • With a peripheral lesion, nystagmus is increased with gaze towards the direc,on of the quick phase. With a central lesion, the nystagmus either does not change or reverses direc%ons. • With peripheral lesion, the nystagmus is usually mixed torsional and horizontal, with central it is usually in a single plane, torsional or ver,cal.
Degree of Nystagmus • First degree: Nystagmus is only present when looking in the direc,on of the fast phase. • Second degree: Nystagmus is present when looking in the direc,on of the fast phase and looking straight ahead. • Third degree: Present in all planes. It is always indica,ve of a central disorder, regardless of direc,on.
Old or New? • • • • • • • • • •
Acute unilateral ves%bular loss leads to spontaneous and gaze evoked that is present in the light and dark. Head shaking induces the nystagmus. The VOR is abnormal with slow and rapid thrusts. Romberg may be and typically is posi,ve. Cannot perform a sharpened Romberg. Cannot perform a Fakuda without rota,on. Typically has a wide based gait that is slow and cau,ous. May need some help for a while with ambula,ng. Cannot turn the head and walk without falling. Compensated unilateral ves%bular nystagmus is spontaneous in the dark and may be induced with head shake. VOR is not typically only abnormal when done rapidly in the direc,on of the loss. Romberg is nega,ve as well as Fakuda, walking with head turn and sharpened Romberg.
Time to Learn the Anatomy • Lets walk through basic func,on and anatomy.
14
Otosclerosis & Stapedectomy
23
24
Eye movements • Its ,me to review eye movements. • KEEP IT SIMPLE!
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Ul,mate ini,al ques,ons! • • • • •
Is the ves,bular lesion central or peripheral? Is it acute or exacerba,on of a chronic condi,on? Is the ves,bular lesion leB or right? Is the lesion abla%ve, physiological, or both? Is the pa,ent in immediate danger?
Peripheral lesions • • • • • • • • •
Does the problem involve cranial nerve 8? Does the problem involve infec%on? Does the problem involve vasculature? Does the problem involve the canals? Does the problem involve the cochlea? Does the problem involve the middle or outer ear? Does the problem involve trauma? Does the problem involve autoimmunity? Does the problem involve ototoxicity?
The Peripheral Nerve Show: Meet the Cast
• • • • • • • •
Benign Paroxysmal Posi,onal Ver,go Ves,bular neuroni,s Otosclerosis Meniere’s Disease / Hydrops Infec,ons / labryrinthi,s Fistulas / Dehiscence Nerve Compression (Acous,c Neuromas) Bilateral ves,bular disorders
When Do I suspect Peripheral lesions? • Subjec,ve! • With a peripheral lesion, fixa%on decreases it. With central, fixa%on either does not change it or makes it worse. • With a peripheral lesion, nystagmus is increased with gaze towards the direc,on of the quick phase. With a central lesion, the nystagmus either does not change or reverses direc%ons. • With peripheral lesion, the nystagmus is usually mixed torsional and horizontal, with central it is usually in a single plane, torsional or ver,cal.
Degree of Nystagmus • First degree: Nystagmus is only present when looking in the direc,on of the fast phase. • Second degree: Nystagmus is present when looking in the direc,on of the fast phase and looking straight ahead. • Third degree: Present in all planes. It is always indica,ve of a central disorder, regardless of direc,on.
Old or New? • • • • • • • • • •
Acute unilateral ves%bular loss leads to spontaneous and gaze evoked that is present in the light and dark. Head shaking induces the nystagmus. The VOR is abnormal with slow and rapid thrusts. Romberg may be and typically is posi,ve. Cannot perform a sharpened Romberg. Cannot perform a Fakuda without rota,on. Typically has a wide based gait that is slow and cau,ous. May need some help for a while with ambula,ng. Cannot turn the head and walk without falling. Compensated unilateral ves%bular nystagmus is spontaneous in the dark and may be induced with head shake. VOR is not typically only abnormal when done rapidly in the direc,on of the loss. Romberg is nega,ve as well as Fakuda, walking with head turn and sharpened Romberg.
Time to Learn the Anatomy • Lets walk through basic func,on and anatomy.
14
Otosclerosis & Stapedectomy
23
24
Eye movements • Its ,me to review eye movements. • KEEP IT SIMPLE!
28
