Download Results: OPKs - Illinois Academy of Audiology

Results: OPKs
-- 20deg/sec: Normal
gain
-- 40deg/sec:
Symmetrical but reduced
gain in both directions
CALORIC TESTING
Wait a second…..we’re
not done yet!
ICE CALORIC Results
•  Brief, low-velocity (4 deg/sec), right-beating nystagmus
•  Extinguished quickly & did not reverse upon patient’s
movement to sitting
•  Suggests possible presence of residual high-frequency
vestibular function in the left ear
–  Not considered definitive:
  Short response duration
  Failure to reverse with a change in position
Moo. That’s Right!
Image retrieved from: http://pureluxury.com
VNG Results Summary
-- Left caloric weakness
-- Right-beating component of post-headshake nystagmus
Left peripheral vestibular lesion.
-- Oblique (down beating) component of post-headshake
nystagmus
-- Prolonged saccadic latencies
-- Reduced gain in smooth pursuit testing
-- Reduced gain in OPK testing at 40deg/sec
Central vestibular dysfunction?
--Effect of centrally acting medications & neurological
conditions (Parkinson’s/TIA) is unknown
Left Peripheral Vestibular Lesion
What Pathology is Responsible?
Unilateral Weakness
+
Unilateral Hearing Loss
Vestibular Labyrinthitis
•  Labyrinthitis is an inflammation of the inner ear
and vestibular and auditory portion of the 8th nerve.
Viral- caused by a viral infection
Bacterial-caused by a bacterial infection
Image taken from: vestibulopathy.com
•  Infection of the inner ear or 8th nerve as a whole that
causes a vestibular imbalance, vertigo and hearing
loss.
(Maire & Melle, 2004)
Viral Labyrinthitis Symptoms
•  Usually unilateral
•  Very sudden onset
–  During the day.
–  Upon awakening in the morning
•  Vestibular symptoms:
–  Can be mild or severe
•  Auditory symptoms:
–  Sudden SSNHL (usually unilateral)
•  Tinnitus
(Vestibular Disorders Association (VEDA), 2011)
Common Diagnostic Findings
•  Audiometric Testing:
–  Asymmetric hearing loss involving the affected ear
–  Differential Diagnosis!
•  Caloric Testing:
– Decreased response in the affected ear
Possible:
•  Gaze Nystagmus
•  Spontaneous Nystagmus
–  Horizontal and beating away from affected ear
(Maire & Melle, 2004) & (Hain, 2010)
Treatment: 3 Parts
• Part I Treat the Infection
– Steroids (Prednisone) Anti-inflammatory
– Antiviral Drugs (Acyclovir) Herpes infections
– Antibiotics (Amoxicillin) Bacterial infections
• Part II Treat the Symptoms
– Antivert (Meclizine) Symptoms of vertigo
– Benadryl (Antihistamine) Motion sickness
– Ativan (lorazepam) Valium (diazepam) Anxiety
• Part III: Vestibular and Aural Rehabilitation
Why No Spontaneous Nystagmus?
•  The patient’s initial episode of vertigo was in
January 2012
•  Seen for VNG in March 2012
•  After a severe peripheral lesion, nystagmus intensity
declines rapidly as days pass due to…
CNS COMPENSATION!
(Jacobson & Shepard, 2008)
Types of Compensation
•  Compensation Goal: Reset the VOR so that it can
respond accurately to head movements
•  Static: The cerebellum uses the intact labyrinth as a
reference point to reset the level of activity of vestibular
nuclei on the impaired side
–  Eliminates spontaneous nystagmus
–  Asymmetry no longer perceived without head movement
•  Dynamic: Helps to restore the normal gain asymmetry
that occurs with head movement
–  Eliminates oscillopsia
–  Reduces complaints of dizziness with head movement
(Jacobson & Shepard, 2008)
Types of Compensation
•  VNG testing revealed no spontaneous
nystagmus
–  Static compensation complete
•  Patient complaint of imbalance exacerbated
with head movement consistent with postheadshake nystagmus
–  Dynamic compensation incomplete!
Patient Prognosis
What do we anticipate for the
patient’s balance moving forward?
Patient Prognosis
•  Residual high frequency vestibular function  better
prognosis in rehabilitation
•  Moderate to strong evidence that vestibular rehabilitation
(VR) is a safe, effective management for unilateral
peripheral vestibular dysfunction (UPVD)
–  Provides a resolution to symptoms in the medium term
•  Exercise based interventions containing balance and
strength training exercises effectively reduced falls
(Telian et al, 1991), (Hiller & McDonnell, 2011) & (Gillespie et al, 2010)
Impairments
• Visual System
–  Cataracts
–  Glaucoma
–  Legally blind in left eye
•  Peripheral Vestibular System
–  Unilateral peripheral vestibular weakness
• Somatosensory System
–  Arthritis
–  Peripheral Neuropathy (left foot)
–  Right lower leg amputation
–  Parkinson’s Disease
Realistic Expectations
Patient was counseled on realistic expectations
given that the three inputs to balance are
impaired
• Our patient also experiences:
–  Anxiety
–  Depression
Realistic Expectations
•  Patients with UPVD who demonstrate the greatestmagnitude self-report of disability/handicap also
demonstrate concominant impairments of supporting
senses
•  The magnitude of psychological comorbid conditions is
predictive of self-reported dizziness handicap
•  Decreased balance confidence is associated with actual
balance performance, duration of vestibular symptoms,
general health related quality of life, and treatment for
anxiety, depression or both, and visual impairments
(Jacobson, 2002), (Piker et al, 2008) & (Marchetti et al, 2011)
Realistic Expectations
•  The Dizziness Handicap Inventory (DHI) was developed
to evaluate the self-perceived handicapping effects
imposed by vestibular system disease
•  Three content domains representing aspects of dizziness
–  Functional
–  Emotional
–  Physical
•  Our patient has a DHI of 52 indicating a moderate/
borderline severe self-perceived handicap
–  16-34 (mild)
–  36-52 (moderate)
–  54+ (severe)
(Jacobsen & Newman, 1990)
Moving Forward…
•  Single Sided-Deafness:
–  Not interested in audiologic intervention
  No CROS
  No BAHA
•  Permanent Unilateral Weakness:
–  Continue with PT with emphasis on vestibular
rehabilitation & fall prevention.
•  Follow up with ENT/Neurotology consult.
•  If additional information needed: consider rotary chair
testing
•  Patient JK has not followed up at this time
References:
Gillespie, L. D., Robertson, M. C., Gillespie, W. J., Lamb, S. E., Gates, S.,
Cumming, R. G., et al. (2010). Interventions for preventing falls in older people
living in the community. The Cochrane Library (10).
Hain, T.C. (2010). Labyrinthitis case. Retrieved from http://www.dizziness-andbalance.com/disorders/unilat/case%20labyrinthitis.html
Hain, T.C. (2010). Vestibular neuritis and labyrinthitis. Retrieved from http://
www.dizziness-and-balance.com/disorders/unilat/vneurit.html
Hiller, S.L., McDonnel, M.(2011).Vestibular Rehabilitation for Unilateral Peripheral
Vestibular Dysfunction. Cochrane Database of Systemic Reviews, Issue 2. Art. No.:
CD005397. DOI: 10.1002/14651858.CD005397.pub3.
Jacobsen G.P. (2002). Development of a clinic for the assessment of risk of falls in
the elderly. Seminars in Hearing, 23; 161-178.
Jacobsen, G.P. & Newman , C.W..(1990). The development of the dizziness
handicap inventory. Arch Otolaryngological Head Neck Surgery. 116(4); 424-427.
References:
Maire,R.& Melle, G.V. (2004). Horizontal Vestibulo-Ocular Reflex Dynamics in
Acute Vestibular Neuritis and Viral Labyrinthitis:evidence of Otoloth-Canal
Interation. Acta Otolaryngol, 124, 36-40.
Marchetti, G.F., Whitney, S.L., Redfern, M.S., Furman, J.M. (2011). Factors
Associated With Balance Confidence in Older Adults With Health Conditions
Affecting the Balance and Vestibular System. Arch Physical and Mental
Rehabilitation, 92; 1884-91.
Piker, E. G., Jacobson, G.P., McCaslin, D.L., Grantham, S.L. (2008). Psychological
comorbidities and their relationship to self-reported handicap in samples of dizzy
patients. Journal of the American Academy of Audiology. 19; 337-347.
Telian, S.A., Shepard, N.T., Smith-Wheelock, M., Hoberg, M. (1991). Bilateral
vestibular paresis: diagnosis and treatment. Official Journal of Otolaryngology -Head & Neck Surgery, 104(1); 67-71.
Vestibular Disorders Association (VEDA). (2011). Labyrinthitis and vestibular
neuritis Retrieved from http://www.vestibular.org/vestibular-disorders/specificdisorders/labyrinthitisvest-neuritis.php