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What Causes Dizziness, Poor Eye Balance And Concussions With A History Of Asthma?
Question: In 2014 I got very sick with asthma and GERD. I had a continual asthma flare for 6 weeks, being hospitalized and on steroids. When the asthma flare stopped, I was dizzy and imbalanced. I saw an ENT who had an MRI and VOG done. MRI was clear and he diagnosed peripheral vestibulopathy from VOG. Optometrist says convergence insufficiency and I started to wear progressive glasses. Had vestibular PT and symptoms improved. Able to square dance 4 nights a week for a year, until January 2016. Fell 2x in 24 hours, got 2 concussions (per neurologist). Now dizzy every day. Rhythmic trunk oscillations sitting and standing, esp with eyes closed. Vertical diploplia. Poor balance eyes closed on firm surface and on foam. Normal MRI, normal temporal bone CT. Stumped vertigo specialist ENT, PT, and Neurologist. To see neuro ophthalmologist in May. Really tired of being dizzy and off balance. Any ideas?
Brief Answer:
Please tell some more details:
Detailed Answer:
Hi XXXX,
Thanks for being on healthcaremagic.com.
I am Dr.Ajay Panwar,a neurologist,here to answer your query.
I have gone well through your historical details. As per your clinical details,your problems appear to have worsened since February 2016,when you had two episodes of fall within 24 hours.Now your prominent complaints are-dizziness,truncal titubations which worsen on eye closure and vertical diplopia.So,keeping the focus on these complaints,vertical diplopia is usually caused by the lesions of nerves innervating eye muscles(cranial nerve lesions), or may be a manifestation of other disease like thyroid disorder,myasthenia gravis or some ocular injury.Truncal titubation on the other hand, mostly occurs due to cerebellar disease,but otherwise may also occur as a manifestation of vestibular disease or sensory ataxia.The specific history of worsening titubation on eye closure is typically observed in sensory ataxia or bilateral vestibular impairment.However,if we consider,vertical diplopia along with titubation,cerebellar disorder should be ruled out first.Severe dizziness on the other hand,tilts the possibility towards vestibular lesion.
Bottom line is that your clinical description is not classical for any particular anatomical localization.So,physical examination becomes extremely important here.
Neurolo-ophthalmological examination will definitely of great value in diagnosing the disorder.
However,for now,I would be of better help and in a better position to think towards the diagnosis,if you can just click a short video clip of your titubation and upload it on google drive(and share the link here in the follow-up query).I shall have a look at it for better interpretation.
Further,I would also like to look at your neurological examination documents and medical reports.If possible,please upload them as scanned documents.
I shall be glad to have you in follow-up with further details.
Regards
Dr.Ajay Panwar,
MD,DM(Neurology)
Please tell some more details:
Detailed Answer:
Hi XXXX,
Thanks for being on healthcaremagic.com.
I am Dr.Ajay Panwar,a neurologist,here to answer your query.
I have gone well through your historical details. As per your clinical details,your problems appear to have worsened since February 2016,when you had two episodes of fall within 24 hours.Now your prominent complaints are-dizziness,truncal titubations which worsen on eye closure and vertical diplopia.So,keeping the focus on these complaints,vertical diplopia is usually caused by the lesions of nerves innervating eye muscles(cranial nerve lesions), or may be a manifestation of other disease like thyroid disorder,myasthenia gravis or some ocular injury.Truncal titubation on the other hand, mostly occurs due to cerebellar disease,but otherwise may also occur as a manifestation of vestibular disease or sensory ataxia.The specific history of worsening titubation on eye closure is typically observed in sensory ataxia or bilateral vestibular impairment.However,if we consider,vertical diplopia along with titubation,cerebellar disorder should be ruled out first.Severe dizziness on the other hand,tilts the possibility towards vestibular lesion.
Bottom line is that your clinical description is not classical for any particular anatomical localization.So,physical examination becomes extremely important here.
Neurolo-ophthalmological examination will definitely of great value in diagnosing the disorder.
However,for now,I would be of better help and in a better position to think towards the diagnosis,if you can just click a short video clip of your titubation and upload it on google drive(and share the link here in the follow-up query).I shall have a look at it for better interpretation.
Further,I would also like to look at your neurological examination documents and medical reports.If possible,please upload them as scanned documents.
I shall be glad to have you in follow-up with further details.
Regards
Dr.Ajay Panwar,
MD,DM(Neurology)
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Thank you so much for your response. I have uploaded a video of the titubation to google drive. Here is the link: https://drive.google.com/open?id=0B_Iogv5vYqD2MW4wNlBXWXlhRTQ
I have not done it like that before, so please let me know if you have trouble opening it. I have also uploaded my MRI results and CT results from this year along with the VOG from 2014. I do not yet have copies of the neurologist and ENT notes. Unfortunately, the neurologist did not seem interested in pursuing a diagnosis any further as my MRI was normal. Thank you again for your consideration.
I have not done it like that before, so please let me know if you have trouble opening it. I have also uploaded my MRI results and CT results from this year along with the VOG from 2014. I do not yet have copies of the neurologist and ENT notes. Unfortunately, the neurologist did not seem interested in pursuing a diagnosis any further as my MRI was normal. Thank you again for your consideration.
Brief Answer:
Some change in maneuver.
Detailed Answer:
Hi XXXX,
Thanks for being in follow-up.
Of course,the VOG report mentions about vestibular abnormalities and at the same time,keeping open a possibility of central cause.However,the MRI Brain has essentially ruled out a central cause.
I have carefully observed your video clip.Apparently,Romberg's test is positive.However,I would like to improve the specificity of the test by a slight modification. My suggestion is that-you should be in Romberg's position and keep somebody in front of you. You should engage yourself in talk with the person while your eyes are closed.See,whether the swaying remains the same,increase or improves with this maneuver.
Further,a review of your vestibular impairment is suggested.You should go to your ENT specialist for vestibular work-up as bilateral vestibular impairment can result in such imbalance,keeping in mind that the chances of sensory ataxia unlikely.Neuro-ophthalmological examination is needed for sure,to evaluate for vertical diplopia.
I shall be glad to have you in follow-up to continue the active discussion.
Regards
Dr.Ajay Panwar,
MD,DM(Neurology)
Some change in maneuver.
Detailed Answer:
Hi XXXX,
Thanks for being in follow-up.
Of course,the VOG report mentions about vestibular abnormalities and at the same time,keeping open a possibility of central cause.However,the MRI Brain has essentially ruled out a central cause.
I have carefully observed your video clip.Apparently,Romberg's test is positive.However,I would like to improve the specificity of the test by a slight modification. My suggestion is that-you should be in Romberg's position and keep somebody in front of you. You should engage yourself in talk with the person while your eyes are closed.See,whether the swaying remains the same,increase or improves with this maneuver.
Further,a review of your vestibular impairment is suggested.You should go to your ENT specialist for vestibular work-up as bilateral vestibular impairment can result in such imbalance,keeping in mind that the chances of sensory ataxia unlikely.Neuro-ophthalmological examination is needed for sure,to evaluate for vertical diplopia.
I shall be glad to have you in follow-up to continue the active discussion.
Regards
Dr.Ajay Panwar,
MD,DM(Neurology)
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Thank you. I did as you suggested, repeating the Romberg with someone in front of me, carrying on a conversation. It did not seem to make a difference, though if anything, it increased the sway. It may simply have been that I kept my eyes closed for a longer period with the conversation.
Do you have any ideas about the residual titubation that occurs after stimulating the vestibular system? After performing the romberg, sitting with eyes closed, performing vision exercises, performing VOR, etc., the rhythmic swaying is what is confusing my Physical Therapist and the ENT. Also, after eyes closed for 2 or 3 min, I am unable to walk safely for quite some time. I have continual "rocking" sensation in my head which worsens with vestibular stimulation. I have the rocking even when I lay down in bed if the room is dark and I close my eyes. I am negative for BPPV per ENT and therapist.
Yes, I will see the neuro opthalmologist on May 20 and the ENT on XXXXXXX 16.
Let me add that following the romberg with conversation, I have FAR more residual nausea and dizziness/headache, internal rocking sensation. It has been 10 min and I am still feeling poorly.
Do you have any ideas about the residual titubation that occurs after stimulating the vestibular system? After performing the romberg, sitting with eyes closed, performing vision exercises, performing VOR, etc., the rhythmic swaying is what is confusing my Physical Therapist and the ENT. Also, after eyes closed for 2 or 3 min, I am unable to walk safely for quite some time. I have continual "rocking" sensation in my head which worsens with vestibular stimulation. I have the rocking even when I lay down in bed if the room is dark and I close my eyes. I am negative for BPPV per ENT and therapist.
Yes, I will see the neuro opthalmologist on May 20 and the ENT on XXXXXXX 16.
Let me add that following the romberg with conversation, I have FAR more residual nausea and dizziness/headache, internal rocking sensation. It has been 10 min and I am still feeling poorly.
Brief Answer:
History is not conclusive of any specific disease etiology.
Detailed Answer:
Hi XXXX,
Thanks for being in follow-up and doing the further maneuver as I suggested.
However,with the clinical history and the little examination I could do,I am afraid to say that this is not reaching to any specific diagnosis.
I suggest that a meticulous physical examination by a clinical neurologist along with the neuro-ophthalmologist,as we discussed is must to arrive at a diagnosis.
Romberg's positive,implies that there is either b/l vestibular impairment or position sense impairment.Vertical diplopia is another question to be solved?Overall,this is a complex clinical situation which can't be resolved without examination.
Still,if I can be of any further help,I shall be glad to have you in follow-up else please close the thread,rate it and write a review.
Regards
Dr.Ajay Panwar,
MD,DM(Neurology)
History is not conclusive of any specific disease etiology.
Detailed Answer:
Hi XXXX,
Thanks for being in follow-up and doing the further maneuver as I suggested.
However,with the clinical history and the little examination I could do,I am afraid to say that this is not reaching to any specific diagnosis.
I suggest that a meticulous physical examination by a clinical neurologist along with the neuro-ophthalmologist,as we discussed is must to arrive at a diagnosis.
Romberg's positive,implies that there is either b/l vestibular impairment or position sense impairment.Vertical diplopia is another question to be solved?Overall,this is a complex clinical situation which can't be resolved without examination.
Still,if I can be of any further help,I shall be glad to have you in follow-up else please close the thread,rate it and write a review.
Regards
Dr.Ajay Panwar,
MD,DM(Neurology)
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
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