1- Ears (Balance disorders + Tinnitus) Flashcards
balance disorders
- Vertigo
- Menieres disease
- Benign paraoxysmal positional vertigo
- Vestibular migraine
- Acute vestibular neuronitis
- Acute labyrinthitis
vertigo background
- Descriptive term for a sensation that there is movement between the patient and their environment
- May feel they are moving of that the room is moving
- Prevalence: male: female 1:3
Dizziness and vertigo
True vertigo is most often associated with a sensation of ‘spinning’ and movement of the surrounding environment. It is important to distinguish this from the more generalised dizziness of disequilibrium
The sensory inputs that are responsible for maintaining balance and posture are:
- Vision
- Proprioception
- Signals from the vestibular system
types of vertigo
o Peripheral vertigo
o Central vertigo
pathophysiology of vertgio
problems with either: vision, proprioception or signals from the vestibular system
- The vestibular system is the most important sensory system to understand when learning about vertigo. The vestibular apparatus is located in the inner ear. It consists of three loops called the semicircular canals that are filled with a fluid called endolymph. These semicircular canals are oriented in different directions to detect various movements of the head. As the head turns, the fluid shifts inside the canals. This fluid shift is detected by tiny hairs called stereocilia found in a section of the canal called the ampulla. This sensory input of shifting fluid is transmitted to the brain by the vestibular nerve and lets the brain know that the head is moving in a particular direction.
- The vestibular nerve carries signals from the vestibular apparatus to the vestibular nucleus in the brainstem and the cerebellum. The vestibular nucleus then sends signals to the oculomotor, trochlear and abducens nuclei that control eye movements and the thalamus, spinal cord and cerebellum. The cerebellum is responsible for coordinating movement throughout the body. Therefore, the vestibular signals help the central nervous system coordinate eye movements and other movements throughout the body.
vertgio often associated with
o Nausea
o Vomiting
o Sweating
o Feeling generally unwell
history for vertigo
- Distinguish between vertigo and light-headedness
- Differentiate between symptoms of peripheral and central vertigo
Key features that may point to a specific cause are:
- Recent viral illness (labyrinthitis or vestibular neuronitis)
- Headache (vestibular migraine, cerebrovascular accident or brain tumour)
- Typical triggers (vestibular migraine)
- Ear symptoms, such as pain or discharge (infection)
- Acute onset neurological symptoms (stroke)
Examination for vertigo
- Ear examination to look for signs of infection or other pathology
- Neurological examination to assess for central causes of vertigo (e.g., stroke or multiple sclerosis)
- Cardiovascular examination to assess for cardiovascular causes of dizziness (e.g., arrhythmias or valve disease)
- Special tests (see below)
Cerebellar examination
is an important part of a full neurological examination in patients with vertigo. The components can be remembered with the DANISH mnemonic:
- D – Dysdiadochokinesia
- A – Ataxic gait (ask the patient to walk heel-to-toe)
- N – Nystagmus (see below for more detail)
- I – Intention tremor
- S – Speech (slurred)
- H – Heel-shin test
special tests for vertigo
Special tests that may be helpful in patients with dizziness or vertigo include:
- Romberg’s test (screens for problems with proprioception or vestibular function)
- Dix-Hallpike manoeuvre (to diagnose BPPV)
- HINTS examination (to distinguish between central and peripheral vertigo)
which examination used to differentiate between peripheral and central causes of vertigo
HINTs exam
presentation of peripheral vertigo vs central vertigo
HINTS examintion
The HINTS examination can be used to distinguish between central and peripheral vertigo. It stands for:
- HI – Head Impulse
- N – Nystagmus
- TS – Test of Skew
causes of peripheral vertigo
- benign paroxysmal positional vertigo (BPPV)
- head injury.
- labyrinthitis.
- vestibular neuronitis.
- Ménière’s disease
causes of central vertigo
causes by disease or injury to the brain
- Head injuries
- Illness or infection
- Multiple sclerosis
- Migraines
- Brain tumors
- Strokes
- Transient ischemic attacks
patients with suspected central vertigo need to be
referred for further investigation (e.g., CT or MRI head) to establish the cause.
symptom management for peripheral vertigo
- Antiemetic e.g. Prochlorperazine
- Antihistamines (e.g., cyclizine, cinnarizine and promethazine)
Menieres: betahistine
BPPV: Epley manoeuvre
vestibular migraine
a type of migraine where people experience a combination of vertigo, dizziness or balance problems with other migraine symptoms.
Presentation
Rotatory vertigo can last minutes to hours to days
* Headaches
* Photophobia
* Visual disturbance
* Phonophobia
- Not always a headache or visual symptoms
- Can sometimes overlap (e.g. hearing loss) – hard to differentiate between conditions such as Meniere’s
vestibular migraine triggers
- Stress
- Bright lights
- Strong smells
- Certain foods (e.g. chocolate, cheese and caffeine)
- Dehydration
- Menstruation
- Abnormal sleep patterns
vestibular migraine management
Similar as normal migraine
1) Avoid triggers
2) Medication:
- Preventative : amitriptyline, propranolol, candesartan and flunarizine
- Acute attack: Paracetamol/NSAIDs and triptans
Benign paroxysmal positional vertigo
Background
- A common cause of recurrent episodes of vertigo triggered by head movement
- A peripheral cause of vertigo, meaning the problem is located in the inner ear rather than the brain
- More common in adults
BPPV pathophysiology
Pathophysiology
- Caused by calcium carbonate crystals (otoconia) that forms within the semi-circular canals (usually posterior) of the vestibular apparatus -> crystal dislodge -> create movement in the fluid -> movement of stereocilia -> signals via AP when we are still
causes of BPPV
viral infection, head trauma, ageing, idiopathic
presentation of BPPV
- Vertigo only (most common cause)- no hearing loss or tinnitus
-> Only upsets vestibular apparatus - Short lived episodes (seconds): triggered by movement of head e.g. tuning over in bed, bending down
-> 20-60 seconds (asymptomatic between attacks)
-> Cluster of attacks
BPPV investigation
- Dix-Hallpike manoeuvre
Management of BPPV
- Epley manoeuvre-> dislodging crystals
-
Brandt-Daroff exercises
->Can be performed by patient at home to improve symptoms of BPPV
Dix-Hallpike Manoeuvre
The Dix-Hallpike manoeuvre can be used to diagnose BPPV (Dix for Dx – diagnosis)
It involves moving the patient’s head in a way that moves endolymph through the semicircular canals and triggers vertigo in patients with BPPV. Check the patient can do the manoeuvre safely before performing it, for example, ensuring they have no neck pain or pathology.
Procedure:
* The patient sits upright on a flat examination couch with their head turned 45 degrees to one side (turned to the right to test the right ear and left to test the left ear)
* Support the patient’s head to stay in the 45 degree position while rapidly lowering the patient backwards until their head is hanging off the end of the couch, extended 20-30 degrees
* Hold the patient’s head still, turned 45 degrees to one side and extended 20-30 degrees below the level of the couch
* Watch the eyes closely for 30-60 seconds, looking for nystagmus
* Repeat the test with the head turned 45 degrees in the other direction