Neuro-otology Examination

Overview

A neurological examination evaluates sensory neuron and motor responses, particularly reflexes, to determine if the nervous system is damaged. This usually consists of a physical examination and a review of the patient's medical history, but no further testing, such as neuroimaging. It may be used as a screening tool as well as an investigative tool, with the former being utilized when there is no predicted neurological impairment and the latter when there is an expected neurological deficit. If a problem is discovered during an investigation or screening procedure, further tests might be performed to focus on a specific element of the nervous system (such as lumbar punctures and blood tests).

In general, a neurological examination is performed to determine whether there are lesions in the central and peripheral nervous systems or if the patient is suffering from another diffuse condition. After properly testing the patient, it is the physician's responsibility to assess if these results combine to constitute a recognizable medical condition or neurological ailment, such as Parkinson's disease or motor neurone disease. Finally, it is the physician's responsibility to determine the etiology of a condition, such as whether it is caused to inflammation or is congenital.

General medical conditions, such as postural hypotension, vasovagal syncope, cardiac valvar disease, and hyperventilation, may also contribute to dizziness, so a neuro-otology examination is required, with special attention to the eyes, ears, nervous system, cardiovascular system, and locomotor system. General medical investigations should also be considered.

What is Neuro-otology Tests?

They refer to a combination of clinical and technical tests that may be used to determine whether or not there is a problem with the vestibular system of the inner ear, which is linked to balance.

Among the main tests are:

Audiometry and logoaudiometry.
Videonystagmography and electronystagmography.
Rotational tests.
Computerized dynamic posturography and impedance audiometry.

Why Neuro-otology Examination?

Some signs and symptoms that may indicate problems in the vestibular system are:

Instability.
Dizziness.
Facial paralysis.
Hearing loss that is transient, permanent, and usually in one ear.
Vertigo.
Ear ringing, tinnitus.

A neuro-otology exam, which lasts around 35 to 45 minutes, is indicated if you have any balance concerns. There is no special preparation necessary. If you have cerumen in your ear canals, you must physically remove it. Fasting for at least eight hours is required, as is discontinuing vertigo medications for 48 hours prior to the test (with your treating physician's permission), wearing comfortable clothing to allow for the necessary movements, bringing your glasses (if applicable), and avoiding the use of lotions and makeup.

At the Neurophysiology Clinic, the doctors are prepared to offer you the most advanced neurophysiological tests to diagnose the various pathologies that affect your nervous system, which represent a quantitative, reproducible, and generally non-invasive measure that enriches the neurological examination, providing an interaction platform and support in the diagnosis and treatment of neurologically affected patients.

The tests we perform include all the tools of a comprehensive neurophysiology service:

Electroencephalogram.
Electromyography.
Evoked potentials.
Outpatient polysomnography.
Hospital polysomnography.
Transcranial doppler.
Neuro-otology tests.
Otoacoustic emissions.
Intraoperative monitoring.
Magnetic stimulation.

Physical Examination

General Medical Examination:

It is critical to get a brief general medical evaluation. Identifying orthostatic blood pressure can be diagnostic in the right clinical setting, thus every patient with orthostatic symptoms should have their blood pressure examined for this pattern. The most prevalent general medical cause of dizziness among patients referred to neurologists is orthostatic hypotension. Detecting an irregular cardiac rhythm may also be useful. A visual evaluation (adequate eyesight is vital for balance) and a musculoskeletal check are two more general screening procedures to evaluate in individual individuals (significant arthritis can impair gait).

General Neurological Examination:

The general neurological examination is critical in patients who complain of dizziness because dizziness can be the first symptom of a neurodegenerative condition and an important symptom of stroke, tumor, demyelination, or other nervous system disorders.

Patients who complain of dizziness should have their cranial nerves carefully examined. The most significant aspect of the test is assessing ocular motor function. It is critical to verify that the patient has complete ocular function. On one side, a posterior fossa tumor might impede face feeling and the corneal reflex. Because of the intimate physical association between the seventh and eighth cranial nerves, assessing face strength and symmetry is critical. Lower cranial nerves should be closely examined as well, with palate elevation, tongue protrusion, and trapezius and sternocleidomastoid strength being observed.

The general motor examination examines muscular strength in each muscle group as well as size and tone. The key finding in a patient with an early neurodegenerative condition might be increased tone or cogwheel stiffness.

A peripheral sensory examination is necessary because peripheral neuropathy can result in nonspecific dizziness or imbalance. Temperature, discomfort, vibration, and proprioception should all be evaluated. The existence and symmetry of reflexes should be checked.

The natural reduction in vibratory feeling and the absence of ankle jerks that might occur in older persons must be considered. Because diseases defined by ataxia might present with the primary symptom of dizziness, coordination is an essential aspect of the neurological evaluation in patients with dizziness. Extremity coordination is assessed by observing the patient's ability to do the finger-nose-finger test, the heel-knee-shin test, and quick alternating movements.

Neuro-otological Examination:

The neuro-otological examination is a specialized examination that incorporates an audio-vestibular evaluation as well as certain parts of the regular neurological examination.

Ocular Motor:

The initial stage in evaluating ocular motor function is to look for spontaneous involuntary eye movements. The examiner instructs the patient to maintain a straight face while looking for nystagmus or saccadic intrusions.

Nystagmus is defined by a slow- and fast-phase component and can be spontaneous, gaze-evoked, or positional. The direction of nystagmus is traditionally defined by the fast phase, which is the direction it seems to "beat" toward.

It is vital to note if the nystagmus is vertical, horizontal, torsional, or a combination of these. The pattern of spontaneous nystagmus might be either peripheral or central. Although central lesions can imitate a "peripheral" pattern of nystagmus, peripheral lesions must generate "central" patterns of nystagmus under highly exceptional and unlikely situations. A unidirectional peripheral pattern of spontaneous nystagmus occurs when the eyes beat solely to one side.

The direction of peripheral spontaneous nystagmus never changes. Because of the physiology of the asymmetry in firing rates within the peripheral vestibular system, the vertical canals cancel each other out, it is generally a horizontal larger than torsional pattern. The unopposed horizontal channel causes the conspicuous horizontal component. Other features of peripheral spontaneous nystagmus include suppression with visual fixation, an increase in velocity with look in the fast phase, and a reduction with gaze in the opposite fast phase.

Some patients are able to suppress this nystagmus so successfully at the bedside, or have healed so well from the beginning incident, that spontaneous nystagmus may only arise when visual fixation is removed. To reduce the patient's capacity to fixate, several basic bedside approaches might be performed. Frenzel glasses use +30 diopter lenses to eliminate visual fixation. To prevent fixation, an ophthalmoscope can be employed. While one eye's fundus is being examined, the patient is requested to cover the other eye. The most basic method includes holding a blank piece of paper close to the patient's face (to prevent visual fixation) and looking for spontaneous nystagmus from the side.

Gaze Testing:

The examiner should instruct the patient to look to the left, right, up, and down, and search for gaze-evoked nystagmus in each position. End-gaze nystagmus is a few beats of unsustained nystagmus with a gaze greater than 30 degrees that occurs in normal persons. The craniocervical junction and midline cerebellum are the sites of gaze-evoked downbeating nystagmus and vertical nystagmus that increases with lateral gaze. Saccadic oscillations may also be triggered by gaze testing.

Nystagmus induced by gaze and impeded smooth pursuit A horizontal nystagmus in the direction of sight is initiated by a look to either side. Additionally, the patient exhibits impaired or "saccadic" pursuit when he or she attempts to trace an item back and forth.

Vestibular Nerve Examination:

Important localizing information on the functioning of the vestibular nerve may be gained at the bedside, which is sometimes ignored as part of the cranial nerve examination in general neurology literature. The head-thrust test can detect unilateral or bilateral vestibulopathy. The physician stands immediately in front of the patient, who is seated on the exam table, to perform the head-thrust test. The examiner holds the patient's head in his hands and instructs the patient to focus on the examiner's nose.

The head is then abruptly shifted to one side by 5 to 10 degrees. In individuals with normal vestibular function, the VOR causes eye movement in the opposite direction of head movement. As a result, the patient's gaze remains fixed on the examiner's nose following the abrupt shift. The test is then carried out in the reverse way. If the examiner notices a corrective saccade bringing the patient's eyes back to the examiner's nose following the head push, the VOR is impaired in the direction of the head movement.

The doll's eye test induces compensatory eye movements as well, but because this low-velocity test activates both the visual and vestibular systems, a patient with complete vestibular function loss and normal visual pursuit will have normal-appearing compensatory eye movements on the doll's eye test. This slow rotation of the head, on the other hand, is useful in a comatose patient who is unable to make voluntary visual tracking eye movements. Slowly rotating the head can also be a useful test in individuals with smooth-pursuit system impairment, because smooth movements of the eyes during slow rotation of the head suggest an intact VOR, but continuous saccadic motions during slow rotation indicate an associated VOR loss.

Gaze-evoked down beating nystagmus. Down beating nystagmus occurs with gaze to either side.

Smooth Pursuit:

The voluntary movement of the eyes required to monitor a thing moving at a low velocity is referred to as smooth pursuit. Its purpose is to maintain the moving item on the fovea in order to optimize vision. Smooth pursuit, although being an extremely smooth movement at low frequencies and speeds, always breaks down when evaluated at high frequencies and velocities. Though smooth chase is generally deteriorated with age, a recent study demonstrated no significant loss in smooth pursuit in a sample of healthy old people (>75 years) who were assessed yearly for at least 9 years. Patients with defective smooth pursuit require numerous tiny saccades to keep up with the target, which is why this result is referred to as saccadic pursuit.

Smooth pursuit abnormalities arise as a result of CNS illnesses, tranquilizing medications, alcohol, poor focus or eyesight, and exhaustion. Patients with widespread cortical disease, basal ganglia disease, or diffuse cerebellar disease consistently show bilaterally reduced smooth pursuit. Patients with early or moderate cerebellar degenerative diseases may have significantly reduced smooth pursuit with only mild or minimal truncal ataxia as the only findings.

Positional Testing:

Positional testing can aid in determining whether the source of vertigo is peripheral or central. BPPV, the most frequent kind of positional vertigo, is produced by free-floating calcium carbonate debris in the posterior semicircular canal, the horizontal canal on occasion, and the anterior canal on rare occasions. In patients with BPPV, a quick transition from an upright sitting position to supine head-hanging left or head-hanging right causes the distinctive burst of upbeat torsional nystagmus (the Dix-Hallpike test).

When nystagmus is present, it is normally activated solely in one of these places. When the patient returns to a sitting position, a burst of nystagmus in the opposite direction (downbeat torsional) ensues. To remove the debris clot from the posterior canal, a repositioning procedure might be employed. The modified Epley technique is employed.

Fistula Testing:

A defect of the bony capsule of the labyrinth can be checked for in patients experiencing sound- or pressure-induced dizziness by pushing and releasing the tragus (small flap of cartilage that can be used to occlude the external ear canal) and watching the eyes for brief related aberrations. Pneumatoscopy (the introduction of air into the external auditory canal through an otoscope) or Valsalva against pitched nostrils or a closed glottis can also cause related eye movements. The direction of the provoked nystagmus aids in locating the fistula.

Gait:

The initiation, heel strike, stride length, and base breadth of a casual gait are all evaluated. Patients are then monitored while walking in tandem and standing in the Romberg posture (with eyes open and closed). A reduced heel strike, stride length, curved posture, and arm swing all point to Parkinson's disease. Truncal ataxia is distinguished by a wide-based gait and the inability to walk in tandem. Patients suffering from acute vestibular loss will veer toward the damaged ear for several days following the occurrence. Patients suffering from peripheral neuropathy or bilateral vestibulopathy may find it difficult to stand in the Romberg posture with their eyes closed.

Auditory Examination:

The bedside examination of the auditory system begins with otoscopy. The tympanic membrane is generally transparent; changes in color suggest middle ear disease or tympanosclerosis, a semicircular crescent or horseshoe-shaped white plaque within the tympanic membrane. Tympanosclerosis is seldom connected with hearing loss, but it is a significant indicator of previous infections. The region immediately superior to the lateral process of the malleus should be carefully examined for signs of a retraction pocket or cholesteatoma. Otoscopy findings are largely unrelated to causes of dizziness since the observed abnormalities do not involve the inner ear.

Finger rubs at various intensities and distances from the ear are a quick, reliable, and valid screening test for hearing loss in the speech frequency range.

Conditions Need Specific Neuro-otology Check up

Otology and neurotology specialists employ cutting-edge technology and procedures like as microsurgery, reconstructive surgery, and implantable hearing devices. All ear conditions, from simple to complicated, are treated:

Hearing impairment: Conductive and nerve hearing loss (sensorineural) are the two most common forms of hearing loss. One in every 1,000 children is born with severe nerve hearing loss. The most prevalent cause of hearing loss in people is becoming older. Hearing aids are used to correct nerve hearing loss initially. If the hearing loss worsens, cochlear implants are a viable therapy option for many patients.
Otosclerosis: Otosclerosis is a disorder in which the third bone of hearing does not function properly. Conductive hearing loss happens as a result of this. Treatment may not be required if the condition is moderate. Hearing aids or surgery may be useful therapy choices as hearing loss develops. For the treatment of this problem, our specialists perform a surgical operation known as stapedectomy. A single outpatient procedure may frequently permanently and totally correct this kind of hearing loss, resulting in years of hearing improvement.
Chronic ear infections: Long-term (chronic) middle ear infections (otitis media) can arise as a result of a hole in the eardrum or an irregular growth of skin behind the eardrum (cholesteatoma). Eardrops, antibiotics, or surgery may be used to treat the condition. Our experts are skilled in a surgery known as tympanomastoidectomy. It entails removing the infection and, if necessary, repairing the small bones of hearing. The major aims of therapy are to limit the risk of future consequences from the current infection and, whenever possible, to enhance hearing.
Acoustic neuroma: Acoustic neuromas (vestibular schwannomas) are noncancerous (benign) tumors that develop from the hearing and balance nerve between the ear and the brain. We have a long history of effectively treating acoustic neuromas with various procedures, including observation, stereotactic radiosurgery, hearing preservation surgery, and nonhearing preservation surgery.
Benign paroxysmal positional vertigo (BPPV): It is one of the most prevalent causes of vertigo, which is the sudden sensation that you're spinning or that the inside of your head is spinning. BPPV produces short bursts of mild to severe dizziness. It is frequently induced by certain alterations in the posture of your head. This might happen when you turn your head up or down, lie down, or turn over or sit up in bed. Although BPPV might be annoying, it is rarely dangerous unless it raises the risk of falling. BPPV can be effectively treated at a doctor's office visit.
Face paralysis: It is defined as a lack of facial movement caused by nerve injury. Facial muscles may appear to droop or weaken. Facial paralysis can occur suddenly (as in Bell's palsy) or gradually over a period of months (in the case of a head or neck tumor). The paralysis might linger for a short or long time depending on the reason.
Vertigo: It is a symptom, not a sickness in and of itself. It is the sense that you or your surroundings are moving or spinning. This sensation might be mild or severe, making it difficult to maintain your balance and do daily duties. Vertigo attacks can occur quickly and last only a few seconds, or they might continue considerably longer. If you have severe vertigo, your symptoms may be continuous and linger for many days, making daily life challenging.
Migraine: It is a moderate to severe headache that causes throbbing pain on one side of the brain. Many patients also have symptoms such as nausea, vomiting, and heightened sensitivity to light or sound. Migraine is a frequent medical disorder that affects about 1 in every 5 women and 1 in every 15 men. They often start in early adulthood.

Conclusion

The history and physical exam are the most crucial components of determining what the problem is and how to come up with a treatment plan in otology and neurology, as in all of medicine.

So, if you have a major ear problem that is interfering with your balance and/or hearing, you don't have to put up with it. An otologist or neurotologist is a highly skilled ear, nose, and throat (ENT) doctor who may be able to diagnose and treat Complex ear disease,hearing loss that might be helped with an implanted hearing device, A tumor near or in your ear, Requirement for revision ear surgery Vertigo (dizziness) that is complicated and not improving, Ear infections that reoccur or are persistent.