This document discusses testing of vestibular function. It begins by providing statistics on dizziness complaints. The rest of the document describes various office examinations and tests that can be used to evaluate vestibular function, including cranial nerve exams, positional tests like Dix-Hallpike and Fukuda stepping, and oculomotor function tests like head thrust and head shake nystagmus. It then reviews quantitative vestibular testing methods like electronystagmography (ENG), which can test individual labyrinths, and rotational chair testing, which is considered the gold standard for identifying bilateral vestibular lesions.
Auditory brainstem response (ABR)
Approximately 1 of every 1000 children is born deaf. Many more are born with less severe degrees of hearing impairment, while others may acquire hearing loss during early childhood.
combination of technological advances in ABR and otoacoustic emissions (OAE) testing methods are used for evaluation of hearing in newborns.
Auditory brainstem response (ABR)
Approximately 1 of every 1000 children is born deaf. Many more are born with less severe degrees of hearing impairment, while others may acquire hearing loss during early childhood.
combination of technological advances in ABR and otoacoustic emissions (OAE) testing methods are used for evaluation of hearing in newborns.
Videonystagmography is also known as VNG, is a most advanced diagnostic test for a balance disorder. Individuals who feel dizzy and face difficulty in maintaining their balance and equilibrium should undergo the videonystagmography diagnostic test.
Mechanism of balance & vestibular function test Dr Utkal MishraDr Utkal Mishra
This powerpoint elaborates the mechanism of balance & anatomy of vestibular apparutus. It also depicts the anatomy & physiology of haircells in detail. I also explained the vestibular function tests used for diagnosis of various vestibular disorders.
BRAINSTEM EVOKED RESPONSE AUDIOMETRY (BERA), AUDIOTORY BRAINSTEM RESPONSE (ABR)Girish S
Neurologic objective, noninvasive test of auditory brainstem function in response to auditory (click) stimuli. It’s a set of seven positive waves recorded during the first 10 milli seconds after a click stimuli. They are labeled as I - VII. Also called Jewet bumps.
Videonystagmography is also known as VNG, is a most advanced diagnostic test for a balance disorder. Individuals who feel dizzy and face difficulty in maintaining their balance and equilibrium should undergo the videonystagmography diagnostic test.
Mechanism of balance & vestibular function test Dr Utkal MishraDr Utkal Mishra
This powerpoint elaborates the mechanism of balance & anatomy of vestibular apparutus. It also depicts the anatomy & physiology of haircells in detail. I also explained the vestibular function tests used for diagnosis of various vestibular disorders.
BRAINSTEM EVOKED RESPONSE AUDIOMETRY (BERA), AUDIOTORY BRAINSTEM RESPONSE (ABR)Girish S
Neurologic objective, noninvasive test of auditory brainstem function in response to auditory (click) stimuli. It’s a set of seven positive waves recorded during the first 10 milli seconds after a click stimuli. They are labeled as I - VII. Also called Jewet bumps.
What is Subjective visual vertical diagnosis test (SVV Test)? Aditi Arora
Millions of people around the world suffer from Vertigo. Vertigo arises out of a dis-balance in the inner ear nerves, resulting in dizziness, a spinning sensation, loss of balance, headache & nausea. The Vertigo test that can very accurately measure this dysfunction in the otolithic functioning is the Subjective Visual Vertical Test.
Epilepsy is a common neurological illness. Systematic evaluation and management leads to successful outcomes in most patients with epilepsy. Clinical description along with brain imaging and EEG would lead to accurate diagnosis.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
2. Testing Vestibular FunctionTesting Vestibular Function
Four percent of patients18-65 yo visitFour percent of patients18-65 yo visit
clinic with complaint of “dizziness”clinic with complaint of “dizziness”
Three percent consider it “SeverelyThree percent consider it “Severely
incapacitating”incapacitating”
Third most common complaint in elderlyThird most common complaint in elderly
3. Testing Vestibular FunctionTesting Vestibular Function
Otolaryngologist is considered balanceOtolaryngologist is considered balance
specialistspecialist
Private practice physicians often quotedPrivate practice physicians often quoted
“I wish I knew more about dizzy patients”“I wish I knew more about dizzy patients”
4. ObjectivesObjectives
Describe office examinations of dizzyDescribe office examinations of dizzy
patientspatients
Describe vestibular function studiesDescribe vestibular function studies
Review indications for vestibular functionReview indications for vestibular function
studiesstudies
Review efficacy of office and vestibularReview efficacy of office and vestibular
function studiesfunction studies
5. ClassificationClassification
cranial nerve evaluationcranial nerve evaluation
Positional testsPositional tests
Postural control testPostural control test
Oculomotor function testOculomotor function test
8. Dix-Hallpike ManeuverDix-Hallpike Maneuver
Used to provoke nystagmus and vertigoUsed to provoke nystagmus and vertigo
commonly associated with BPPVcommonly associated with BPPV
Head turned 45 degrees to maximallyHead turned 45 degrees to maximally
stimulate posterior semicircular canalstimulate posterior semicircular canal
Head supported and rapidly placed into headHead supported and rapidly placed into head
hanging positionhanging position
Frenzel glasses eliminate visual fixationFrenzel glasses eliminate visual fixation
suppression of responsesuppression of response
10. Dix-Hallpike ManeuverDix-Hallpike Maneuver
Positive testPositive test
Up-beating nystagmusUp-beating nystagmus
Nystagmus to the stimulated sideNystagmus to the stimulated side
Rotary component to the affected earRotary component to the affected ear
Lasts 15-45 secondsLasts 15-45 seconds
Latency of 2-15 secondsLatency of 2-15 seconds
Fatigues easilyFatigues easily
11. Dynamic Visual AcuityDynamic Visual Acuity
Used for bilateral vestibular weaknessUsed for bilateral vestibular weakness
Visual acuity checked on Snellen chartVisual acuity checked on Snellen chart
Rechecked while rotating head back andRechecked while rotating head back and
forth at 1-2 Hz.forth at 1-2 Hz.
Loss of 2-3 lines considered abnormalLoss of 2-3 lines considered abnormal
12. Postural control testPostural control test
Romberg testRomberg test
Fukoda stepping testFukoda stepping test
Tandem gait testTandem gait test
Pastpointing testPastpointing test
13. Romberg TestRomberg Test
Patient asked to stand with feet togetherPatient asked to stand with feet together
and eyes closedand eyes closed
Fall or step is positive testFall or step is positive test
Equal sway with eyes open and closedEqual sway with eyes open and closed
suggests proprioceptive or cerebellar sitesuggests proprioceptive or cerebellar site
More sway with eyes closed suggestsMore sway with eyes closed suggests
vestibular weaknessvestibular weakness
15. Fukuda Stepping TestFukuda Stepping Test
Originally described by Fukuda using 100 stepsOriginally described by Fukuda using 100 steps
on a marked floor.on a marked floor.
Patients are asked to step with eyes closed andPatients are asked to step with eyes closed and
hands out in fronthands out in front
Rotation by more than 45 degrees is abnormalRotation by more than 45 degrees is abnormal
Rotation usually occurs to the side of the lesionRotation usually occurs to the side of the lesion
Rotation often found in asymptomatic patientsRotation often found in asymptomatic patients
16. DysdiadochokinesiaDysdiadochokinesia
Testing(pastpointing test)Testing(pastpointing test)
Most commonly tested with the handMost commonly tested with the hand
slapping testslapping test
Abnormalities seen in patients withAbnormalities seen in patients with
cerebellar dysfunctioncerebellar dysfunction
Poor sensitivity and specificityPoor sensitivity and specificity
17. Tandem Gait TestTandem Gait Test
Patients are asked to walk heal to toe in aPatients are asked to walk heal to toe in a
straight line or in a circlestraight line or in a circle
Complex function evaluates many aspectsComplex function evaluates many aspects
of balanceof balance
Poor performance seen in cerebellarPoor performance seen in cerebellar
lesions, but can be seen in manylesions, but can be seen in many
disordersdisorders
Poor sensitivity and specificityPoor sensitivity and specificity
Normal: more than 10step withoutNormal: more than 10step without
deflectiondeflection
18. Oculomotor function testsOculomotor function tests
Fistula testing(pneumatic otoscopy)Fistula testing(pneumatic otoscopy)
Nonlineary testingNonlineary testing
Nystegmus testing Head-shaking testNystegmus testing Head-shaking test
Head-thrust testHead-thrust test
spontaneous nystagmusspontaneous nystagmus
gaze nystagmusgaze nystagmus
19. Pneumatic OtoscopyPneumatic Otoscopy
Positive and negative pressure applied toPositive and negative pressure applied to
middle earmiddle ear
Hennebert’s sign/symptom – nystagmusHennebert’s sign/symptom – nystagmus
and vertigo with pressure, alternates withand vertigo with pressure, alternates with
positive and negative pressurepositive and negative pressure
Can be present in patients withCan be present in patients with
perilymphatic fistula, syphilis, Meninere’sperilymphatic fistula, syphilis, Meninere’s
disease, SCC dehiscence syndromedisease, SCC dehiscence syndrome
20. Head Thrust TestHead Thrust Test
Inhibitory response not as robust as theInhibitory response not as robust as the
stimulatory response to stimulate VORstimulatory response to stimulate VOR
Movements that overcome the inhibitoryMovements that overcome the inhibitory
response of vestibule will result in VOR lagresponse of vestibule will result in VOR lag
Head tilted 30 degreesHead tilted 30 degrees
Rapid head movements to either side with focusRapid head movements to either side with focus
on examiner’s noseon examiner’s nose
Patients have catch-up saccade when rotated toPatients have catch-up saccade when rotated to
side of weaknessside of weakness
Sensitivity 75%, Specificity of 85%Sensitivity 75%, Specificity of 85%
21. Head Shake NystagmusHead Shake Nystagmus
Evaluates unilateral vestibular weaknessEvaluates unilateral vestibular weakness
Head tilted back 30 degreesHead tilted back 30 degrees
Shake back and forth for 30 seconds asShake back and forth for 30 seconds as
quickly as possiblequickly as possible
Unilateral vestibular deficit causes slowUnilateral vestibular deficit causes slow
phase nystagmus to the side of lesionphase nystagmus to the side of lesion
Low sensitivity (27%)Low sensitivity (27%)
Good specificity (85%)Good specificity (85%)
24. Quantitative VestibularQuantitative Vestibular
Testing(static positional tests)Testing(static positional tests)
indicationsindications
Diagnosis unclearDiagnosis unclear
Prolonged symptoms unresponsive toProlonged symptoms unresponsive to
conservative treatmentconservative treatment
Screen for central disordersScreen for central disorders
Evaluate prior to surgical ablationEvaluate prior to surgical ablation
proceduresprocedures
Documentation of vestibular deficitsDocumentation of vestibular deficits
25. Electronystagmography (ENG)Electronystagmography (ENG)
Divided into oculomotor tests, positionalDivided into oculomotor tests, positional
and positioning tests, and caloric testsand positioning tests, and caloric tests
Only vestibular test with the ability to testOnly vestibular test with the ability to test
individual labyrinths separatelyindividual labyrinths separately
Relies on the vestibulo-ocular reflexRelies on the vestibulo-ocular reflex
(VOR) to test the peripheral vestibular(VOR) to test the peripheral vestibular
functionfunction
29. Electronystagmography (ENG)Electronystagmography (ENG)
Oculomotor testsOculomotor tests
All test eye movements that originate in theAll test eye movements that originate in the
cerebellumcerebellum
Saccadic trackingSaccadic tracking
Smooth pursuit trackingSmooth pursuit tracking
Optokinetic testingOptokinetic testing
30. Oculomotor TestsOculomotor Tests
Saccadic trackingSaccadic tracking
Patients concentrates on a randomly movingPatients concentrates on a randomly moving
targettarget
Latency – difference in time betweenLatency – difference in time between
movement of object and eye (150-250 ms)movement of object and eye (150-250 ms)
Velocity – speed of saccade 200-400Velocity – speed of saccade 200-400
degrees/second low end of normaldegrees/second low end of normal
Accuracy – amount of undershoot/overshootAccuracy – amount of undershoot/overshoot
of target (75-120%)of target (75-120%)
34. Smooth Pursuit TestSmooth Pursuit Test
Tests ability to accurately and smoothlyTests ability to accurately and smoothly
pursue a targetpursue a target
Gain of eyes compared to movement ofGain of eyes compared to movement of
targettarget
Saccade movements eliminated fromSaccade movements eliminated from
calculationscalculations
Asymmetrical pursuit highly suggestive ofAsymmetrical pursuit highly suggestive of
central disorderscentral disorders
35. Optokinetic TestsOptokinetic Tests
Vestibular system and optokineticVestibular system and optokinetic
nystagmus allow steady focus on objectsnystagmus allow steady focus on objects
Target is rapidly passed in front of subjectTarget is rapidly passed in front of subject
in one direction, then the otherin one direction, then the other
Eye movements are recorded andEye movements are recorded and
compared in each directioncompared in each direction
Asymmetry suggestive of CNS lesionAsymmetry suggestive of CNS lesion
High rate of false positive resultsHigh rate of false positive results
39. Positional and Positioning TestingPositional and Positioning Testing
Positional testPositional test
Insults to vestibular system are compensated byInsults to vestibular system are compensated by
stimulationstimulation
Maximal compensation in head up positionMaximal compensation in head up position
Tests for nystagmus in static head positionsTests for nystagmus in static head positions
Vertical or direction changing nystagmus suggestsVertical or direction changing nystagmus suggests
central disordercentral disorder
Positioning testPositioning test
Used to determine presence of BPPVUsed to determine presence of BPPV
Quantitative Dix-Hallpike maneuverQuantitative Dix-Hallpike maneuver
40. Caloric TestingCaloric Testing
Established and widely accepted methodEstablished and widely accepted method
of vestibular testingof vestibular testing
Most sensitive test of unilateral vestibularMost sensitive test of unilateral vestibular
weaknessweakness
Patient positioned 30 degrees from pronePatient positioned 30 degrees from prone
(HSCC vertical allowing max stim)(HSCC vertical allowing max stim)
Cold and warm water/air flushed into EACCold and warm water/air flushed into EAC
41. Caloric TestingCaloric Testing
COWS (cold opposite, warm same) –COWS (cold opposite, warm same) –
direction of the nystagmusdirection of the nystagmus
Stimulation in 0.002-0.004 Hz rangeStimulation in 0.002-0.004 Hz range
(Head movements in 1-6 Hz range)(Head movements in 1-6 Hz range)
Visual fixation should reduce strength ofVisual fixation should reduce strength of
caloric responses 50-70%caloric responses 50-70%
% caloric paresis = 100 * [(LC + LW) –% caloric paresis = 100 * [(LC + LW) –
(RC + RW)/(LC + LW + RC + RW)](RC + RW)/(LC + LW + RC + RW)]
42. Rotational Chair TestingRotational Chair Testing
““Gold standard” in identifying bilateral vestibularGold standard” in identifying bilateral vestibular
lesionslesions
Used to monitor for progressive bilateralUsed to monitor for progressive bilateral
vestibular loss (gentamicin toxicity)vestibular loss (gentamicin toxicity)
Used to quantify bilateral vestibular loss –Used to quantify bilateral vestibular loss –
vestibular rehab vs. balance trainingvestibular rehab vs. balance training
Useful in testing children that will not allowUseful in testing children that will not allow
caloric irrigationscaloric irrigations
Used with borderline caloric tests when waterUsed with borderline caloric tests when water
calorics cannot be usedcalorics cannot be used
44. Rotational Chair TestingRotational Chair Testing
Sinusoidal Harmonic Acceleration TestSinusoidal Harmonic Acceleration Test
Most commonly performedMost commonly performed
Rotates patients at frequencies from 0.01-Rotates patients at frequencies from 0.01-
1.28 Hz1.28 Hz
Unilateral lesions have gain and phaseUnilateral lesions have gain and phase
asymmetries to the affected sideasymmetries to the affected side
Reduced gain across all frequencies or phaseReduced gain across all frequencies or phase
leads suggests bilateral vestibular lesionsleads suggests bilateral vestibular lesions
45. Rotational Chair TestingRotational Chair Testing
Kaplan et al.Kaplan et al.
198 adults tested198 adults tested
29 patients with bilateral loss by chair testing29 patients with bilateral loss by chair testing
25/29 with bilateral caloric weakness by ENG25/29 with bilateral caloric weakness by ENG
3/29 with unilateral caloric weakness by ENG3/29 with unilateral caloric weakness by ENG
3/45 patients with unilateral caloric weakness3/45 patients with unilateral caloric weakness
by ENG had abnormal chair testsby ENG had abnormal chair tests
46. PosturographyPosturography
Used to tests integration of balanceUsed to tests integration of balance
systemssystems
Useful in quantification of fall riskUseful in quantification of fall risk
Most useful in following conditions:Most useful in following conditions:
Chronic disequilibrium and normal examsChronic disequilibrium and normal exams
Suspected malingeringSuspected malingering
Suspected multifactorial disequilibriumSuspected multifactorial disequilibrium
Poorly compensated vestibular injuriesPoorly compensated vestibular injuries
48. PosturographyPosturography
5/6 – Vestibular dysfunction5/6 – Vestibular dysfunction
2,3,5,6 – somatosensory and vestibular dysfunction2,3,5,6 – somatosensory and vestibular dysfunction
3,6 – visual preference3,6 – visual preference
1,2,3,4 or any combination with normal 5/6 - aphysiologic1,2,3,4 or any combination with normal 5/6 - aphysiologic
49. Vestibular Evoked MyogenicVestibular Evoked Myogenic
Potentials (VEMP’s)Potentials (VEMP’s)
Utricle and saccule detect linearUtricle and saccule detect linear
accelerationacceleration
Saccule slightly responsive to sound do toSaccule slightly responsive to sound do to
its position near the oval windowits position near the oval window
VEMP’s stimulate the saccule and recordVEMP’s stimulate the saccule and record
EMG output in the SCMEMG output in the SCM
50. Vestibular Evoked MyogenicVestibular Evoked Myogenic
Potentials (VEMP’s)Potentials (VEMP’s)
Clicks or tones presentedClicks or tones presented
to the ear stimulateto the ear stimulate
saccule, inferiorsaccule, inferior
vestibular nerve,vestibular nerve,
vestibular nucleus, medialvestibular nucleus, medial
vestibulospinal tract,vestibulospinal tract,
accessory nucleus,accessory nucleus,
cranial nerve XIcranial nerve XI
EMG of SCM recordsEMG of SCM records
output after clickoutput after click
stimulation of earstimulation of ear
Allows unilateral testingAllows unilateral testing
51. Vestibular Evoked MyogenicVestibular Evoked Myogenic
Potentials (VEMP’s)Potentials (VEMP’s)
VEMP’s may be absent in patients withVEMP’s may be absent in patients with
vestibular neuritisvestibular neuritis
Patients with lower threshold VEMP’s and aPatients with lower threshold VEMP’s and a
conductive hearing loss same side may haveconductive hearing loss same side may have
SCC dehiscence syndromeSCC dehiscence syndrome
Absent in bilateral vestibular loss inAbsent in bilateral vestibular loss in
aminoglycoside ototoxicityaminoglycoside ototoxicity
VEMP‘s show higher thresholds and are absentVEMP‘s show higher thresholds and are absent
in patients with Meniere’s diseasein patients with Meniere’s disease
Absent in acoustic neuromasAbsent in acoustic neuromas
May be used in failed vestibular nerve sectionMay be used in failed vestibular nerve section
52. Dr. Peltier’s Dizzy EvaluationDr. Peltier’s Dizzy Evaluation
History – will give diagnosis in majority of disordersHistory – will give diagnosis in majority of disorders
PhysicalPhysical
Head and Neck ExamHead and Neck Exam
Spontaneous nystagmus on trackingSpontaneous nystagmus on tracking
• Vertical or direction changing nystagmus =Vertical or direction changing nystagmus =
MRI and neurology referralMRI and neurology referral
Pneumatic OtoscopyPneumatic Otoscopy
• If positiveIf positive considerconsider diagnosis of fistula, Meninere’s, syphilisdiagnosis of fistula, Meninere’s, syphilis
Dix HallpikeDix Hallpike
• If positive, Eply maneuver twice, if still dizzy, ENGIf positive, Eply maneuver twice, if still dizzy, ENG
Head thrust test alone or with head shake nystagmusHead thrust test alone or with head shake nystagmus
• If positive, start vestibular exercisesIf positive, start vestibular exercises
• If no response - ENGIf no response - ENG
Rhomberg TestRhomberg Test
• If equal sway with eyes closed and open neurology referral, ENGIf equal sway with eyes closed and open neurology referral, ENG
53. Dr. Peltier’s Dizzy EvaluationDr. Peltier’s Dizzy Evaluation
• Fukuda stepping test if suspected vestibularFukuda stepping test if suspected vestibular
dysfunction and normal head shake/head thrustdysfunction and normal head shake/head thrust
tests, or proceed to ENGtests, or proceed to ENG
• Orthostatic measurements if directed by historyOrthostatic measurements if directed by history
• Dynamic visual acuity if possibility of bilateral lossDynamic visual acuity if possibility of bilateral loss
AudiogramAudiogram
• Obtain in every dizzy patient. Cost effective examObtain in every dizzy patient. Cost effective exam
for acoustic neuroma, useful in other diagnosisfor acoustic neuroma, useful in other diagnosis
54. Dr. Peltier’s Dizzy EvaluationDr. Peltier’s Dizzy Evaluation
ENGENG
• Patients unresponsive to conservative treatmentPatients unresponsive to conservative treatment
• Severe symptoms and not suspicious of acute vestibularSevere symptoms and not suspicious of acute vestibular
infectioninfection
• Diagnosis uncertain and chronic symptomsDiagnosis uncertain and chronic symptoms
• Pre-op when vestibular ablation procedure consideredPre-op when vestibular ablation procedure considered
• When documentation of vestibular function is necessaryWhen documentation of vestibular function is necessary
• When referred from neurology for evaluationWhen referred from neurology for evaluation
MRIMRI
• Any suspicion of central lesions by physicial, or objectiveAny suspicion of central lesions by physicial, or objective
testingtesting
Posturography/Chair testing/VEMPPosturography/Chair testing/VEMP
• Not available at UTMBNot available at UTMB
• Of questionable clinical utilityOf questionable clinical utility
55. ReferencesReferences
Kroenke, Lucas, Rosenberg et al.Kroenke, Lucas, Rosenberg et al. Causes of persistent dizziness: a prospectiveCauses of persistent dizziness: a prospective
study of 100 patients in ambulatory care.study of 100 patients in ambulatory care. Ann Intern Med, 117Ann Intern Med, 117 (11), 898-905.(11), 898-905.
Allum, H.J., & Shepard, N. T. (1999), An overview of the clinical use of dynamicAllum, H.J., & Shepard, N. T. (1999), An overview of the clinical use of dynamic
posturography in the differential diagnosis of balance disorders. J Vestib Res, 9, 223-posturography in the differential diagnosis of balance disorders. J Vestib Res, 9, 223-
252252
Kaplan, Marais et. al. (2001), Does High-Frequency Pseudo-random Rotational ChairKaplan, Marais et. al. (2001), Does High-Frequency Pseudo-random Rotational Chair
Testing Increase the Diagnostic Yield of the ENG Caloric Test in Detecting BilateralTesting Increase the Diagnostic Yield of the ENG Caloric Test in Detecting Bilateral
Vestibular Loss in the Dizzy Patient? Laryngoscope, 111: 959-963Vestibular Loss in the Dizzy Patient? Laryngoscope, 111: 959-963
Hain, Timothy, Vestibular Evoked Myogenic Potential (VEMP) TestingHain, Timothy, Vestibular Evoked Myogenic Potential (VEMP) Testing
http://www.dizziness-and-balance.com/testing/vemp.htmlhttp://www.dizziness-and-balance.com/testing/vemp.html
Hajioff, D et. al. Is electronystagmography of diagnostic value in the elderly? ClinicalHajioff, D et. al. Is electronystagmography of diagnostic value in the elderly? Clinical
Otolaryngology, 27(1) Feb. 2002 pp 27-31Otolaryngology, 27(1) Feb. 2002 pp 27-31
Desmond, Alan. Vestibular Function: Evaluation and Treatment. Thieme MedicalDesmond, Alan. Vestibular Function: Evaluation and Treatment. Thieme Medical
Publishers, INC New York, NY 2004. pp 65-111.Publishers, INC New York, NY 2004. pp 65-111.
Stockwell, Charles. Introduction to ENG. ICS Medical, Schaumburg, Illinois, 2001,Stockwell, Charles. Introduction to ENG. ICS Medical, Schaumburg, Illinois, 2001,
multiple pages.multiple pages.
Stockwell, Charles. Catalog of ENG abnormalities.Stockwell, Charles. Catalog of ENG abnormalities. ICS Medical, Schaumburg,ICS Medical, Schaumburg,
Illinois, 2001, multiple pages.Illinois, 2001, multiple pages.
Editor's Notes
Vestibular rehab vs. reliance on somatosensory and visual clues