COHF 007: 11 year-old male presents with a history of vasovagal syncope and symptoms of dizziness, nausea, headaches, depression, anxiety, photophobia, and hyperacusis
We are describing 11-year-old male who presents to a functional neurology clinic with a history of vasovagal syncope and symptoms of dizziness, nausea, headaches, depression, anxiety, photophobia, and hyperacusis.
During this examination, the patient demonstrated positive Romberg’s, inability to stand unassisted with pulsivity in all directions with a predominance of leftward retropulsivity. The patient demonstrated decreased left patellar reflex, hyperacusis on the right, saccadic intrusions in leftward and upward as well as saccadic eye movements away from any light stimulus. All aberrant eye movements were confirmed by videonystagmography. The patient participated in a two-week vestibular rehabilitation program that included multi-axis labyrinth and otolithic stimulation paired with specific eye movements and exercises.
Let’s Hear From The Council!
So this is a pretty cool standard case, certainly not for the individual involved in it, but as a practitioner. To get in to work with people who suffer in this kind of way, it’s such a rewarding process to be able to help them. So this presentation sounds very cerebellar in nature. If I wasn’t aware that it was a TBI problem, I would definitely wanna establish if that was the case before we started doing anything. And once again, I wouldn’t do anything with the individual if it was in the acute phase of a concussion.
Obviously, in this situation, I have limited background in dealing with these types of individuals. I do work with neurological patients, but in terms of one with vasovagal syncope and at the age that we’re dealing with, just some of the questions and things that I would look at with the individual start off with, obviously just general history, birth, any issues happening with that. Simple things like blood pressure. Do they tend to have low blood pressure? Are there any heart arrhythmias? Really trying to rule out any more serious issues prior to going in and doing some testing and assessment. Simple things like dehydration, low blood sugar, what’s their oxygen saturations? Those types of things in those individuals is what I’d be looking at first before I really started looking into neurological things, which again is a little beyond my scope of knowledge.
So this probably isn’t something that’s in my area of specialty or something that I’d probably see walking to my clinic and such. But given that it’s an area that I’m probably not as confident with as some others, I’d be making sure as part of the assessment that I check their vital signs, probably did a full cranial nerve examination and neurological examination. And if I had any concerns from that, referring them off to the GP sort of physician and even for some potential imaging before I look to deal with that. Once anything sinister is ruled out, I’d probably be looking at incorporating a multi-disciplinary approach in with this as well.
Dr. Brandon Brock
Now this is definitely a complicated case. This is what I do pretty much every day and we’re looking at traumatic brain injury here, and you gotta realize that the brain is kinda like an orchestra, you know, and you’ve got the strings section, you’ve got the percussion section, you’ve got all these different sections and they have to all be playing in sync and in tune for the whole thing to be orchestrated and sound well, and the brain is very similar. So when you’ve had some sort of concussion or traumatic brain injury or some sort of blow to the head, you can lose frontal lobe integrity, you can lose parietal lobe integrity
Dr. Emily Splichal
So although this patient is presenting with a little bit more vestibular, cerebellar balance issues, this typically would not present into my office but if it would, my goal would be to rule out some sort of peripheral contributor as far as balance dysfunction, gait dysfunction, et cetera. My forte is particularly in peripheral neuropathies and the diagnosis and management of more peripheral neuropathy contributions to balance dysfunction. And the patients that do come in with more of a cerebellar, vestibular, post-stroke, cerebral palsy, Parkinson’s, any sort of CNS-based balance or movement dysfunction, I refer them out to specialists in that area.
I’m lucky working in a multi-functional clinic so my role in these situations is basically just to help relax the muscles in conjunction of what I’m hearing from my physios and my ATs. Basically, it’s light occipital work, going into some of the neck muscles as much as we’re able to work. We don’t wanna over-irritate or we don’t wanna inflame the muscles, so it’s basically just a light relaxation that does help a little bit with the signs and symptoms that he is presenting with, especially with the depression, and changing a little bit of the symptoms with some different… Changing some of the different aspects that he’s presenting with
Dr. Mark Wade
I’m gonna take this as a typical case that would come into my clinic with some balance issues, as compared to potentially somebody with more serious neurological issues that may present and do, for example, the functional neurologist. So this is actually something that’s kind of a common issue. We often see patients with balance and coordination issues, not necessarily to the degree of a neurological disorder and full blown, but it is most common cause for the hospital visits in the elderly is falls. And this issue can begin at any age, especially in today’s society. I’m gonna bring it with my PhD in Public Health back to a public health kind of point of view, that in today’s society with the lack of balance and coordination exercises being performed, this is becoming a common, if not an epidemic type of issue.
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