Otoneurological examination after TBI

The otoneurological examination that follows upon the diagnosis of traumatic brain injury. It is a detailed study of ENT organs, as well as the symptoms that occur in case of:

• Damage to the peripheral and central parts of the auditory, vestibular, olfactory or taste buds;
• Motor and sensory innervation of the larynx and pharynx.

Also, it examines the disorders of the cranial nerves that innervate the ENT organs: I, VIII, IX, XIII and, to some extent, V and X.

The current stage of otoneurology enables a wide introduction of methods that allow for dosing the maximum degree of irritation:

• Threshold and suprathreshold cupulometry;
• Otocalorimeters;
• Pendulum rotation test, which is an electronic controlled procedure performed on the vestibular stands;
• Comprehensive clinical audiometry;
• Electrometric taste examination.

In addition, it became possible to objectively record auditory and vestibular reflexes with the help of:

• Electromyography;
• Electronystagmography;
• Rheoencephalography;
• Electroencephalography;
• Transcranial Doppler ultrasound;
• Objective computer-based audiometry with the examination of auditory evoked potentials;
• Impedancemetry.

The data obtained in the course of an otoneurological examinations using modern methods of electronic examination to detect available disorders in 100% of cases. At the same time, the examinations provide accurate results for TBI of any severity, both in residual and in acute periods.

This information facilitates an objective clarification of the severity of the trauma, as well as the depth and degree of a coma, makes it possible to accurately assess the dynamics of stem symptoms, which is vital for the prognosis. When carried out in the residual period, the results of the otoneurological examination make it much easier to determine the patient's ability to work.

Methods of examination

A specific set of methods for conducting the otoneurological examination in case of TBI depends to a large extent on two factors:

• The patient’s state of consciousness and severity of the TBI;
• The period of time elapsed since the injury (acute, subacute or residual period).

Full examination

A full otoneurological examination can be carried out if:

• It is a minor traumatic brain injury or, in some cases, moderate injury;
• The patient is conscious;
• It is an acute period.

The full examination includes:

• Examination of the patient’s subjective feelings. Smell, hearing, taste, optokinetic nystagmus, nasal cavity sensitivity, dizziness;
• Examination of objective disorders. Spontaneous and caloric nystagmus, postrotatory nystagmus, reactive deviation of the hands and the examination of vestibulo-vegetative reactions.

The rotational testing in the acute and subacute period of TBI is contraindicated.

Partial Examination

If the patient has sustained either a moderate or severe TBI and is unconscious, the set of methods for conducting the examination is very limited. The doctor examines ENT organs, which are often damaged in case of severe traumatic brain injury, and checks spontaneous eye movements, especially caloric nystagmus. It is important that the caloric testing can be performed while the patient is in a healthy state, even if he/she is in a coma.

Should the patient remain in clear consciousness, the examination begins with the detection of complaints about the nervous system of the ENT organs. The patient may inform the doctor about:

• Noise in the head;
• Hearing loss;
• Dizziness manifested as a feeling of falling or rotational nature;
• Decreased or lost smell;
• Development of olfactory hallucinations;
• Development of swallowing or speech disorders;
• Numbness in the oral cavity.

Also, the doctor clarifies if the patient after a trauma had a discharge of fluids or bleeding from a nose or ears.

The doctor then examines ENT organs. The TBI quite often results in the damage to the cartilage and bones of the nose, which form the upper paranasal sinuses. Also, the bones of the pyramid of the temporal bone and the roof of the nasal cavity are damaged. The bleeding from the nose and ears, ruptures of the skin of the external auditory canal, small petechiae on the tympanic membrane, discharge of cerebral detritus from the nasal cavity, liquorrhea from the ear and nose are very common.

The sensitivity in the oral cavity and nose is examined by conducting a button probe on the inner surface of the cheeks, tongue and mucous of the inferior nasal concha. This procedure is followed by the examination of the position of the soft palate in a state of tension and at rest. When performing this test, specialists pay attention to the palate asymmetry and the intensity of palate muscle contraction. During the acute stage of TBI, the patient is in a recumbent position, and therefore it is not always possible to examine the larynx by indirect laryngoscopy.

Symptoms in the residual period of traumatic brain injury

During the residual period of TBI, the otoneurological examination makes it possible to objectively detect the residual organic local CNS lesions. The detection of local vestibular, auditory and/or olfactory disorders at this stage is very important for determining the degree of social rehabilitation and potential work capacity of the patients.

Even after severe TBI in the residual period, the specialist note a general tendency of regression in most of the stem vestibular symptoms, which again indicates their functional, secondary origin. In this case, local otoneurological symptoms, observed in 94% of cases, come in the foreground. According to audiometric data, hearing disorders develop in 94% of cases, about 80% of cases involve vestibular symptoms, in 48% of cases people suffer from smell disorders and in 13% of cases they develop taste disorders.

The compensation for vestibular disorders most commonly occurs during the residual period of TBI. This manifests itself in the symmetric inhibition of vestibular reactions, including those cases when the peripheral part of the taste buds was affected as well. The vestibular testing often results in the increased sensory and vegetative reactions. This is especially manifested in elderly patients, who in addition to the sustained injury suffer from the age-related cerebral vascular disorders.

The disorder of optokinetic nystagmus is one of the most persistent residual hemispheric symptomatic manifestations of TBI. With subcortical foci, it changes into a contralateral affected side. In rare cases, the pronounced damage to the stem structures, the optokinetic nystagmus in the residual period may be weakened in all directions.

During the residual TBI period, severe hearing disorders are especially common in fractures of the temporal bone pyramid. As a rule, lateral cracks on the affected side result in complete deafness, while longitudinal fractures cause hearing loss that has a sound-conducting or mixed character. The patients with TBI over the age of 50 experience a more pronounced decrease in hearing than younger patients. The previously suffer neuritis of the VIII nerve and old age os, as well as vascular disorders facilitate the reduced compensatory capabilities in the restoration of vestibular function and hearing.

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Here you can also read other articles on this topic:

• The onset of TBI
• Classification of TBI
• Hearing after TBI

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