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Evaluation and Management of Vestibular Disorders, S Bittel LP [10]47 Evaluation and Management of Vestibular Disorders Texas Academy of Audiology Samuel N. Bittel, Au.D. Slide 1 LP [10]47 Option 1 Cover (I think this is my preference) Lindsay Peters, 3/27/2017 Course Outline • Anatomy and physiology review • Vestibular reflex pathways • Vestibular disorders and case studies o Peripheral o Central • Case Hx, Sx, and potential Dx • Brief introduction to VRT and BRT Laws That Govern Vestibular Science o Ewald’s 1st Law endolymph moves in opposite direction of head, causing eyes to move in same direction as endolymph; eyes move in same plane as stimulated canal o Ewald’s 2nd Law excitation stronger than inhibition; will address more in VOR section Importance of Ewald’s Laws • Ewald’s 1st Law o Premise of VOR o Slow phase of nystagmus driven by ear • Ewald’s 2nd Law o With movement, unequal contribution at level of vestibular nucleus o Excited ear drives reflex o What happens right vs. left rotary chair or head impulse? Basic Vestibular A&P • Equilibrium is most basic sense • Vestibular system evolves earlier • Hearing arises from vestibular system • Not just ear and peripheral system: o Cerebellum (ascending/descending) o Eyes (ascending/descending) o Muscles of postural stability o Ascending sensory tracts o Descending motor tract Basic Vestibular A&P • Vestibular system consists of a number of complex anatomical structures and reflex pathways • Structures code a change in acceleration of the head and/or body • They also interpret the pull of gravity • NOT sensitive to a consistent speed/motion Basic Vestibular A&P • Important definitions: o With hearing o Peripheral = cochlea, ME o Central = VIIIth nerve and up o With vestibular o Peripheral = end organ (ear), VIIIth nerve o Central = cerebellum, brainstem, brain • Question: o Is a vestibular schwannoma a central or peripheral lesion? Peripheral A&P Anatomy Semi-Circular Canals • Sensitive to angular change in acceleration = yaw, pitch, and roll • Oriented at right angles to one another • Horizontal canal sits at 30-degrees • Ampulated ends contain crista ampullaris Semi-Circular Canals The semicircular canals lie perpendicular to each other Superior/Anterior A n te r io r The canals are actually Posterior/ tilted at about 30 degrees I n fe rio r L a t er a l/ H o r izo n a l Semi-Circular Canals Semi-Circular Canals Semi-Circular Canals • Cupula has mass o Lags behind endolymph w/ initial movement o Will eventually catch up to endolymph o After movement stops, endo will stop and cupula will continue to move Semi-Circular Canals • Oriented in matched pairs o Ears work in tandem = push-pull system o One stimulatory response, other inhibitory o Neural homeostasis achieved (when not moving) if equal response from both ears (clinical correlate: vn) Semi-Circular Canals • Thoughts o Ears have a spontaneous firing rate o Vestibular nucleus (central) is comparing/contrasting firing rate from both sides o Difference between sides = perception of movement Utricle and Saccule • Sensitive to linear acceleration • Gravity detector • Utricle oriented in horizontal plane • Saccule oriented in vertical plane • Each structure has slight curvature, which allows different sections to be stimulated by slightly different motions Utricle and Saccule • Each contain a sensory structure- macula o Hair cells imbedded in a gelatinous layer o This layer contains otoconia, which add weight and create drag Utricle and Saccule •Macula of the utricle is oriented in a horizontal plane •Macula of the saccule is oriented in a vertical plane Otoliths Otoliths Utricle & Saccule Biomechanics • Otoliths are made from calcium carbonate (Latin for “ear stones”) • The endolymph in the utricle and saccule are calcium deficient • The otoliths have a life span and are being constantly recycled – they dislodge from macula and float in endolymph Utricle & Saccule Biomechanics • As we age: o Our calcium absorption slows (vitamin D) o Protein matrix around otoliths break down and become less “sticky” • This may cause a higher concentration of free-floating otoliths • More free-floating otoliths = higher calcium concentration = poorer absorption of newly dislodged otoliths Cranial Nerve VIII and Blood Supply Vestibular Branch of VIII •Superior branch innervates HC, AC, and utricle •Inferior branch innervates PC and saccule Cranial Nerve VIII • Differentiating which branches are involved helps with diagnosis • We have tests that look at each branch individually o Calorics, oVEMP, RC, etc. = superior branch o cVEMPs = inferior branch o ABR, hearing, etc. = cochlear branch • If you see deficits in all 3 branches unilaterally, a mass lesion should be r/o Cranial Nerve VIII • Bony canal of superior nerve is longer and has less space (with nerve and blood supply) • Superior nerve more susceptible to “entrapment” and damage due to inflammation • VN more often causes superior nerve damage • Goebel, JA (2001), et al. Anatomic considerations in vestibular neuritis, Otol Neurotol, 22(4), 512-518. Blood Supply •Inner ear fed by posterior circulation = vertebral arteries join to form basilar artery •Common blood supply between cochlea and vestibular system at level of basilar artery (and outward) •Differentiate after AICA Blood Supply • Food for thought o A lot of talk about identifying damage in specific canals, otolithic organs, etc. o vHIT, oVEMP, cVEMP o Although possible, how common? o Is vestibular damage typically localized to the end organ or VIIIth nerve? Blood Supply • Food for thought: o If peripheral vestibular system is fed by posterior circulation, can a pathology effecting cortical blood flow (migraine) damage the ear???? o We will talk more about migraines during the pathologies section Central A&P Central Vestibular System • Vestibular system multisensory o Vestibular input o Visual input o Somatosensory input o Motor input • Information from each system is integrated in the vestibular nuclei • Equilibrium and postural control information sent to other brain structures Central Vestibular System • Balance information sent from midbrain to multiple regions of the cortex • Connections to a multitude of brain areas • Diffuse pathways are difficult to study • However, it is generally agreed upon that there are 4 major brain regions for balance Central Vestibular System • Four major areas of the brain for balance: o Voluntary motor movement = frontal lobe, specifically precentral cortex and connections to pyramidal system o Visual information = occipital lobe w/ connections to frontal cortex o Deep brain basal ganglia = help coordinate muscle movement o Cerebellum = control of posture, coordinate sensory and motor information Central Vestibular System • Efferent and afferent connections between systems o Information from each sensory system is received and integrated in the vestibular nuclei o Corrective postural and visual control information is sent to the muscles of the neck, trunk, legs, arms, and eyes • Also connections with reticular formation (autonomic nervous system) Reflex Pathways • Three primary pathways measured clinically: o Vestibulo-Ocular Reflex (VOR) o VNG, VAT, CD-VAT o Vestibulospinal Reflex (VSR) o SOT o Vestibulocollic Reflex (VCR) o cVEMP Vestibulo-Ocular Reflex Vestibulo-Ocular Reflex (VOR) • VOR o Helps with gaze stabilization during head/body movement o Allows desired object to stay on fovea, even when walking/running or moving head o Deficit = oscillopsia Semi-Circular Canals • Each SCC is connected to extra-ocular muscles • Excitation: o Horizontal canal: o Ipsilateral medial rectus o Contralateral lateral rectus o Anterior canal: o Ipsilateral superior rectus o Contralateral inferior oblique o Posterior Canal: o Ipsilateral superior oblique o Contralateral inferior rectus • Inhibition in corresponding antagonist muscles Eye Muscle Anatomy Vestibulo-Ocular Reflex (VOR) • Limited range of eye deflection o Eyes can only move so far o If body continues to rotate, eyes will eventually reach limit o CNS will cause eyes to rapidly move back to center to establish new focal point = saccade Vestibulo-Ocular Reflex (VOR) • If body continues to rotate after eyes have moved to center: o Repeat of slow movement in direction opposite of head/body movement o Eyes will again reach their limit, and have saccadic rapid movement back to center o This alternating slow and rapid eye movement is called nystagmus o Note: slow movement of eyes occurs at same speed as head/body movement (equal and opposite) Nystagmus • We describe nystagmus in reference to the fast phase (direction “beating”) • Remember: o Slow phase is driven by the ears o Fast phase is driven by the CNS o Nystagmus beats towards a stimulated ear o Nystagmus beats away from an inhibited ear Back to Ewald’s 2nd Law • Excitation is stronger than inhibition • Let’s measure a patient’s nystagmus o Patient has a deficit in the right vestibular system o Spin the patient right o Spin the patient left o How would the nystagmus compare between directions? Why? Nystagmus • How does nystagmus look with a deficit on one side? • The vestibular nucleus does not understand that one side is lesioned when integrating sides • Nystagmus beats away from the side with a deficit-causing lesion • Nystagmus beats towards the side with an irritative lesion. Example???? Clinical Correlate • If we know our ear anatomy and the specifics of the VOR, we can identify the side of lesion by watching a patient’s eyes for nystagmus • We have clinical tests (calorics) that can stimulate/inhibit an ear individually, and we can measure nystagmus
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