1- Ears (Balance disorders + Tinnitus) Flashcards

1
Q

balance disorders

A
  • Vertigo
  • Menieres disease
  • Benign paraoxysmal positional vertigo
  • Vestibular migraine
  • Acute vestibular neuronitis
  • Acute labyrinthitis
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2
Q

vertigo background

A
  • 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

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3
Q

The sensory inputs that are responsible for maintaining balance and posture are:

A
  • Vision
  • Proprioception
  • Signals from the vestibular system
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4
Q

types of vertigo

A

o Peripheral vertigo
o Central vertigo

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5
Q

pathophysiology of vertgio

A

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.
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6
Q

vertgio often associated with

A

o Nausea
o Vomiting
o Sweating
o Feeling generally unwell

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7
Q

history for vertigo

A
  • 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)

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8
Q

Examination for vertigo

A
  • 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)
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9
Q

Cerebellar examination

A

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
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10
Q

special tests for vertigo

A

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)
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11
Q

which examination used to differentiate between peripheral and central causes of vertigo

A

HINTs exam

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12
Q

presentation of peripheral vertigo vs central vertigo

A
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13
Q

HINTS examintion

A

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
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14
Q

causes of peripheral vertigo

A
  • benign paroxysmal positional vertigo (BPPV)
  • head injury.
  • labyrinthitis.
  • vestibular neuronitis.
  • Ménière’s disease
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15
Q

causes of central vertigo

A

causes by disease or injury to the brain

  • Head injuries
  • Illness or infection
  • Multiple sclerosis
  • Migraines
  • Brain tumors
  • Strokes
  • Transient ischemic attacks
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16
Q

patients with suspected central vertigo need to be

A

referred for further investigation (e.g., CT or MRI head) to establish the cause.

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17
Q

symptom management for peripheral vertigo

A
  • Antiemetic e.g. Prochlorperazine
  • Antihistamines (e.g., cyclizine, cinnarizine and promethazine)

Menieres: betahistine
BPPV: Epley manoeuvre

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18
Q

vestibular migraine

A

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

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19
Q

vestibular migraine triggers

A
  • Stress
  • Bright lights
  • Strong smells
  • Certain foods (e.g. chocolate, cheese and caffeine)
  • Dehydration
  • Menstruation
  • Abnormal sleep patterns
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20
Q

vestibular migraine management

A

Similar as normal migraine
1) Avoid triggers
2) Medication:
- Preventative : amitriptyline, propranolol, candesartan and flunarizine
- Acute attack: Paracetamol/NSAIDs and triptans

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21
Q

Benign paroxysmal positional vertigo
Background

A
  • 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
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22
Q

BPPV pathophysiology

A

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

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23
Q

causes of BPPV

A

viral infection, head trauma, ageing, idiopathic

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24
Q

presentation of BPPV

A
  • 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
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25
Q

BPPV investigation

A
  • Dix-Hallpike manoeuvre
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26
Q

Management of BPPV

A
  • Epley manoeuvre-> dislodging crystals
  • Brandt-Daroff exercises
    ->Can be performed by patient at home to improve symptoms of BPPV
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27
Q

Dix-Hallpike Manoeuvre

A

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

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28
Q

Dix- Hallpike findings if BPPV

A
  • Manoeuvre will trigger rotational nystagmus and symptoms of vertigo.
  • The eye will have rotational beats of nystagmus towards the affected ear (clockwise with left ear and anti-clockwise for right ear BPPV).
29
Q

Epley manoeuvre

A

Used to treat BPPV by moving crystals in semi-circular canal into a position that does not disrupt endolymph flow.
Procedure
* Follow the steps of the Dix-Hallpike manoeuvre, having the patient go from an upright position with their head rotated 45 degrees (to the affected side) down to a lying position with their head extended off the end of the bed, still rotated 45 degrees
* Rotate the patient’s head 90 degrees past the central position
* Have the patient roll onto their side so their head rotates a further 90 degrees in the same direction
* Have the patient sit up sideways with the legs off the side of the couch
* Position the head in the central position with the neck flexed 45 Used to treat BPPV by moving crystals in semi-circular canal into a position that does not disrupt endolymph flow.
Procedure
* Follow the steps of the Dix-Hallpike manoeuvre, having the patient go from an upright position with their head rotated 45 degrees (to the affected side) down to a lying position with their head extended off the end of the bed, still rotated 45 degrees
* Rotate the patient’s head 90 degrees past the central position
* Have the patient roll onto their side so their head rotates a further 90 degrees in the same direction
* Have the patient sit up sideways with the legs off the side of the couch
* Position the head in the central position with the neck flexed 45 degrees, with the chin towards the chest
* At each stage, support the patient’s head in place for 30 seconds and wait for any nystagmus or dizziness to settle

30
Q

Brandt-Daroff Exercises

A

Brandt-Daroff exercises can be performed by the patient at home to improve the symptoms of BPPV. These involve sitting on the end of a bed and lying sideways, from one side to the other, while rotating the head slightly to face the ceiling. The exercises are repeated several times a day until symptoms improve.

31
Q

Vestibular neuronitis
Background

A
  • Inflammation of the vestibular nerve
  • Usually due to viral infection
32
Q

The vestibular system

A

The inner ear is comprised of three parts:
* Semicircular canals
* Vestibule (middle section)- containing the utricles and saccule
* Cochlea

33
Q

The semicircular canals and otolith organs within the vestibule (the utricle and saccule) are responsible for

A

Detecting movement of the - head. Together they form the vestibular system:
* The semicircular canals detect rotation of the head
* The otolith organs detect gravity and linear acceleration

34
Q

The cochlea is responsible for

A

Hearing
- The vestibular nerve transmits signals from the vestibular system (the semicircular canals and vestibule) to the brain to help with balance.
- The cochlear nerve transmits signals from the cochlea to provide hearing.
- Together they form the vestibulocochlear nerve (the 8th cranial nerve).

35
Q

Pathophysiology of Vestibular neuronitis

A

VN refers to inflammation of the vestibular nerve.
- A viral infection may trigger this inflammation.
- It distorts the signals travelling from the vestibular system to the brain, confusing the signal required to sense movements of the head.
- This results in episodes of vertigo, where the brain thinks the head is moving when it is not.

36
Q

Pathophysiology of Vestibular neuronitis

A

VN refers to inflammation of the vestibular nerve.
- A viral infection may trigger this inflammation.
- It distorts the signals travelling from the vestibular system to the brain, confusing the signal required to sense movements of the head.
- This results in episodes of vertigo, where the brain thinks the head is moving when it is not.

37
Q

Presentation of vestibular neuronitis

A
  • Acute onset vertigo
    o Not accompanied by tinnitus or hearing loss
  • URTI symptoms
  • Symptoms are most severe in the first few days
  • Associated with N and V
  • Balance problems
38
Q

investigations for vestibular neuronitis

A

Head impulse test:

Essential to differentiate between peripheral (inner ear) and central (brain) causes of vertigo -> should be assumed central cause until proven otherwise
e.g. could be posterior circulation infarction (stroke)

Procedure

  • The head impulse test involves the patient sitting upright and fixing their gaze on the examiner’s nose.
  • The examiner holds the patient’s head and rapidly jerks it 10-20 degrees in one direction while the patient continues looking at the examiner’s nose.
  • The head is slowly moved back to the centre before repeating in the opposite direction.
  • Ensure they have no neck pain or pathology before performing the test.
39
Q

normal vs abnormal Head impulse tests

A

Normal response: Eyes remain on the target after the examiners movement

Abnormal response:
Eyes are dragged off the target by the turning of the head, followed by a corrective saccade back to the target after the turning of head.

Findings

  • A patient with a normally functioning vestibular system will keep their eyes fixed on the examiner’s nose.
  • In a patient with an abnormally functioning vestibular system (e.g., vestibular neuronitis or labyrinthitis), the eyes will saccade (rapidly move back and forth) as they eventually fix back on the examiner.
  • The head impulse test helps diagnose a peripheral cause of vertigo but will be normal if the patient has no current symptoms or a central cause of vertigo.
40
Q

management vestibular neuronitis

A

Supportive and symptom management
- IV hydration if dehydrate due to N and V
- Prochlorperazine
- Antihistamines e.g. Cyclizine, cinnarizine and promethazine
- If symptoms do not improve after a week or resolve after 6 weeks: vestibular rehabilitation therapy (VRT)

41
Q

prognosis for vestibular neuronitis

A

Prognosis
- Symptoms most severe for first few days -> should resolve over 2-6 weeks
- BPPV may develop. After vestibular neuronitis

42
Q

Labyrinthitis
Background

A
  • Inflammation of the bony labyrinth of the inner ear including
    o Semi-circular canals
    o Vestibule
    o Cochlea
43
Q

Causes of acute labyrinthitis

A
  • Inflammation usually due to viral URTI
  • Rarely bacterial
    o Usually secondary to otitis media or meningitis
44
Q

presentation of acute labyrinthitis

A
  • Acute onset vertigo
  • Unlike vestibular neuronitis which also presents with acute onset vertigo
    o Hearing loss
    o Tinnitus
  • Coryzal symptoms
45
Q

investigations for labyrinthitis

A

Investigation
- Clinical diagnosis
- Head impulse tests
o Diagnose peripheral cause of vertigo e.g. vestibular neuronitis or labyrinthitis

46
Q

management of labyrinthitis

A

Management is the same as with vestibular neuronitis, with supportive care and short-term use (up to 3 days) of medication to suppress the symptoms. Options for managing symptoms are:
* Prochlorperazine (antiemetic)
* Antihistamines (e.g., cyclizine, cinnarizine and promethazine)

If bacterial labyrinthitis (think meningitis)
- Antibiotics

47
Q

prognosis of labyrinthitis

A

Prognosis/complications
- Rarely have lasting symptoms
- If bacterial labyrinthitis more likely to have lasting symptoms

48
Q

Menieres disease background

A
  • Long term condition of the inner-ear
  • Causes recurrent attacks of
    1) Vertigo
    2) Hearing loss
    3) Tinnitus
    4) Aural fullness
49
Q

pathophysiology of Menieres disease

A
  • Usually unknown
  • General view that abnormal endolymph production and / absorption in the labyrinth
  • Causes higher pressure than normal and disrupts sensory signals ‘endolymphatic hydrops’
50
Q

Risk factors for Menieres

A

Autoimmunity, genetic susceptibility, metabolic disturbances, vascular factors, viral infection, head trauma

51
Q

Menieres Presentation

A

HEARING LOSS, VERTIGO, TINNITUS

  • 40-50 yo’s
  • Unilateral episodes of vertigo, tinnitus, hearing loss, aural fullness
  • Comes in episodes that last 20 mins to several hours
    o Clusters over several weeks
  • Hearing loss can become more permanent -> sensorineural, unilateral and low frequencies first
  • Tinnitus also becomes more permanent
  • Spontaneous nystagmus during acute attacks
  • H and N finding normal
  • Romberg test negative
  • Vertigo not triggered by movement or psoture
52
Q

Menieres investigations

A

Investigations
- To confirm diagnosis refer to ENT
- Audiology assessment

53
Q

Management of Menieres

A

For acute attacks, short-term options for managing symptoms include:
* Prochlorperazine
* Antihistamines (e.g., cyclizine, cinnarizine and promethazine)

Prophylaxis is with:
* Betahistine

advise not to drive during attack

54
Q

infections causing vertigo

A

Infections (upper resp tract infection)

1) Acute labyrinthitis
- Involvement of all inner ear structures, associated with hearing loss/tinnitus, vomiting and vertigo

2) Acute vestibular neuronitis
- Just affects the vestibular
- No hearing disturbances or tinnitus
- Sudden onset of vomiting and severe vertigo (lasting days)

55
Q

which vestibular disorder lasts seconds and is not associated with hearing loss and tinnitus

A

BBPV

56
Q

which vestibular disorder lasts hours to a day and is associated with hearing loss and tinnitus

A

Menieres disease

57
Q

which vestibular disorder lasts days to weeks and is not associated with hearing loss and tinnitus

A

Vestibular neuitis

58
Q

which vestibular disorder lasts days to weeks and is associated with hearing loss and tinnitus

A

Labyrinthitis

59
Q

summary of vestibular conditions

A
60
Q

tinnitus background

A
  • Persistent additional sound that is heard but is not present in the surrounding environment
  • May be described as ‘ringing in the ears’, buzzing, hissing or humming
61
Q

Pathophysiology of tinnitus

A

Thought to be due to the result of background sensory signal produced by the cochlea that is not effectively filtered out by the central auditory system.
- In a quiet enough environment, almost everyone will experience some background noise (tinnitus)
- Become more prominent with the more attention it is given

62
Q

Risk factors tinnitus

A

Tinnitus may also be associated with systemic conditions:
* Anaemia
* Diabetes
* Hypothyroidism or hyperthyroidism
* Hyperlipidaemia

63
Q

types of tinnitus

A

primary
secondary
objective

64
Q

primary tinnitus

A

has no identifiable cause and often occurs with sensorineural hearing loss.

65
Q

Secondary tinnitus

A

Refers to tinnitus with an identifiable cause.

Causes include:
- Impacted ear wax
- Ear infection
- Ménière’s disease
- Noise exposure
- Medications (e.g., loop diuretics, gentamicin and chemotherapy drugs such as cisplatin)
- Acoustic neuroma
- Multiple sclerosis
- Trauma
- Depression

66
Q

Objective tinnitus

A

refers to when the patient can objectively hear an extra sound within their head. This sound can also be observable on examination by auscultating with a stethoscope around the ear.

Actual additional sounds may be caused by:
- Carotid artery stenosis (pulsatile carotid bruit)
- Aortic stenosis (radiating pulsatile murmur sounds)
- Arteriovenous malformations (pulsatile)
- Eustachian tube dysfunction (popping or clicking noises)

67
Q

red flags for tinnitus

A

Red flags
* Unilateral tinnitus
* Pulsatile tinnitus
* Hyperacusis (hypersensitivity, pain or distress with environmental sounds)
* Associated unilateral hearing loss
* Associated sudden onset hearing loss
* Associated vertigo or dizziness
* Headaches or visual symptoms
* Associated neurological symptoms or signs (e.g., facial nerve palsy or signs of stroke)
* Suicidal ideation related to the tinnitus

68
Q

investigations for tinnitus

A

Ask about the pattern of symptoms:
* Unilateral or bilateral
* Frequency and duration
* Severity
* Pulsatile or non-pulsatile (pulsatile may indicate a cardiovascular cause, such as carotid artery stenosis with a bruit)

A focused history and examination can be used to identify any underlying causes, including:
* Contributing factors, such as hearing loss or noise exposure
* Associated symptoms (e.g., hearing loss, vertigo, pain or discharge)
* Stress and anxiety
* Otoscopy to look for causes such as ear wax or infection
* Weber’s and Rinne’s tests for hearing loss

Bloods
- FBC, glucose, TSH, lipids
- Audiology
- Imaging rarely required to look for acoustic neuromas

69
Q

Management
of tinnitus

A

Tinnitus tends to improve or resolve over time without any interventions.
Underlying causes of tinnitus can be treated, such as impacted ear wax or infection.
Several measures can be used to help improve and manage symptoms:
* Hearing aids
* Sound therapy (adding background noise to mask the tinnitus)
* Cognitive behavioural therapy