2. The Human Ear
The inner ear/labyrinth houses both the
organs of hearing and balance
Hearing=cochlea
Balance=semicircular canals and otolith
Balance is the ability to maintain the body’s
center of gravity over its base of support
5. Anatomy
•Semicircular Canals
•Detect rotation in the different planes
•3 canals
•Superior, Horizontal, Posterior
•Otolith Organs: contain otoconia (“ear
rocks”) in a gelatinous membrane to
stimulate hair cells to detect linear
accelerations
•Utricle: horizontal plane (side-to-side)
•Saccule: vertical plane (up and down,
front to back)
6. The VOR
Vestibulo-Ocular Reflex
stabilizes images on the retina during head
movement by producing an eye movement in the
opposite direction of the head movement
This eye movement is called nystagmus
Preserves the image on the center of the visual
field
head moves right, eyes move left
7. Three Inputs to the Brain
Our brain integrates information from the
following systems to help us keep our
balance:
Vision
Vestibular
Proprioception (sensors in our feet)
9. Dizziness
For patients of all ages, the three most
common complaints to physicians are:
Headache
Back Pain
Dizziness
Dizziness is the #1 medical complaint in patients
over the age of 70
10. “Dizziness” is a vague term
Describe how you feel without using the word
“dizzy”
Swimmy feeling
Lightheaded
Heavy head
Off-balance
Dysequilibrium
VERTIGO
11. Vertigo
Sensation of spinning
Subjective vertigo=the patient feels like they are
spinning
Objective vertigo=the patient feels like the room
is spinning
Vertigo is most commonly associated with a true
vestibular disorder
13. Most Common Vestibular
Disorders
Benign paroxysmal positional vertigo (BPPV)
Meniere’s disease
Vestibular neuritis
Vestibular labyrinthitis
Migraine
Or, if you are a college student…alcohol!
Alcohol is lighter than blood, so the hair cells float in the
endolymph. This causes the “bed spins” when you close
your eyes (take aways vision) and lay down (feet off
ground=no proprioceptive cues)
14. BPPV
Benign Paroxysmal Positional Vertigo
Most common complaint: “I get dizzy when I roll
over in bed”
Due to loose otoconia floating in the semicircular
canals
Diagnosed with Dix-Hallpike Test
characterized by rotary nystagmus and vertigo which
lasts several seconds
Treatment
Canalith repositioning =putting loose otoconia back
where they belong
Epley manuever
15. Meniere’s Disease
Due to cochlear hydrops=overaccumulation
of endolymph in the cochlea
Usually characterized by 4 symptoms:
Periodic episodes of rotary vertigo or dizziness
(lasts hours to days)
Fluctuating, progressive, low-frequency hearing
loss (SNHL)
Tinnitus (often a “roar” or “buzz”)
A sensation of "fullness" or pressure in the ear
16. Incidence
0.5 to 7.5/1000 persons
Affects men and women equally
Most common in the patient’s 40s and 50s
Diagnosed based on case
history, audiogram, other specialized tests
that look specifically at vestibular function
18. Neuritis vs. labyrinthitis
Usually viral inflammation of inner ear cavity
Vestibular Neuritis=inflammation of nerve
Sudden onset vertigo (hours to
days), nausea, and vomiting
Vestibular Labyrinthitis=inflammation of inner
ear/labyrinth
Same symptoms as neuritis AND otologic
symptoms
Hearing Loss
Tinnitus
19. Treatment for VN or VL
Patient will spontaneously recover after a
period of days to weeks
Medications to reduce dizziness and nausea
Antibiotics won’t help because this is not ususally
a bacterial infection
BPPV is very common after a case of VN or
VL (Epley manuever)
For those patient’s that do not recover
spontaneously:
VESTIBULAR REHABILITATION
20. Vestibular Rehabilitation
May be performed by an audiologist
More commonly performed by a physical
therapist
Aids in compensation of the brain after a
vestibular insult, which makes the patient feel
better faster
Uses exercises that result in varying inputs to
the visual, vestibular and somatosensory
systems
Improves functional balance
21. Migraine-Associated Dizziness
Very common cause of dizziness
Approximately 35% of migraine patients have
some vestibular syndrome at one time or another
May not get a physical headache, but instead
the migraine manifests itself as vestibular
symptoms (vertigo, ear pressure, tinnitus,
nausea)
Commonly misdiagnosed as Meniere’s disease
Commonly accompanied by sound and light
sensitivity
22. Other Otologic Conditions that
Cause Dizziness
Superior Semicircular Canal Dehiscence
Perilymph Fistula
Vestibular schwannoma/acoustic neuroma
These conditions may result in:
Tullio Effect = sound-induced vertigo/nystagmus
Hennebert’s Phenomenon = pressure-induced
vertigo/nystagmus
23. How do we know if vertigo is
due to a vestibular weakness?
Case History
Onset, duration, ear symptoms, nausea
Audiologic and vestibular evaluation
Puretone and immittance audiometry
Video- or electro-nystagmography
Rotary chair testing
Computerized dynamic posturography
Vestibular-evoked myogenic potential (VEMP)
Electrocochleography (ECoG)
24. Testing for Vestibular
Disorders
The following slides contain “nice to know”
information
You will NOT be responsible for learning
these assessment tools
25. Videonystagmography (VNG)
Most common tool to assess vestibular function.
Consists of 3 subtests:
Oculomotor testing: the patient follows a visual
target with their eyes . Looking for nystagmus and
abnormal patterns.
Positional testing: checking for BPPV
Caloric testing: irrigate ears with water of calibrated
temperature, which stimulates the horizontal SCC
so we can see how well the vestibular system
works. The GOLD STANDARD for identifying the
affected ear in a vestibular disorder.
26. Rotary Chair Testing
Preferred test method
for children
Cannot provide ear
specific information
27. Computerized Dynamic
Posturography
Sensory Organization
Test
Varying inputs to the 3
systems: vision, vestibular,
proprioception
Motor Control Test
Measures reaction time to
disturbance of the platform
(pulling the rug out from
under them)
Assesses fall risk
28. VEMP (vestibular-evoked
myogenic potential)
Loud click sound in
test ear and we
measure resulting
muscle reflex in
neck
Abnormal VEMP in
patient’s with
Meniere’s, perilymph
fistula, SSCD
29. ECoG (electrocochleography)
Loud click in test
ear and we record
the electrical
potential from the
cochlea
Abnormal ECoG in
pt with Meniere’s,
perilymph fistula,
SSCD