Balance

Question 1

Why might cholesteatoma cause vertigo?

Answer 1

Breach of the otic capsule bone causing dizziness on pressure change transmitted from the middle ear to the vestibular system

Question 2

What should be asked when a patient presents with dizziness?

Answer 2

Is the room spinning around the patient?
When did it start?
Eposodic?
How long does it last
How often does it happen
Positional? - lying down, head turning
Other specific triggers
Associated hearing loss
Associated tinnitus
Loss of conciousness with episodes
If it has happened before - resolution: spontaneous? treatment?

Question 3

What contributes to balance (in terms of inputs)

Answer 3

Input from vestibular system
Proprioceptive input
Visual inputs

Question 4

Central causes of vertigo?

Answer 4

Stroke
Migraine
Neoplasms
Demyelination e.g. MS
Drugs

Question 5

Peripheral causes of vertigo?

Answer 5

BPPV
Menieres disease
Vestibular neuronitis

Question 6

What test can be used to diagnose peripheral causes of vertigo (problems with vestibular system)?

Answer 6

Head impulse test

Question 7

How to perform head impulse test?

Answer 7

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.

Question 8

Head impulse test: results

Answer 8

Normal: eyes remain fixed on examiners nose - no problem with vestibular system - either no vertigo or central cause

Abnormal: Eyes will saccade (rapidly move back and forth) and will eventually fix back on examiner - abnormally functioning vestibular system - ie. vestibular neuronititis, labrythitis

Question 9

Peripheral causes of vertigo?

Answer 9

BPPV
Meniere’s disease
Labyrinthitis
Acute vestibular neuronitis

Trauma to the vestibular nerve
Vestibular nerve tumours (acoustic neuromas)
Otosclerosis
Hyperviscosity syndromes
Varicella zoster infection (often with facial nerve weakness and vesicles around the ear – Ramsay Hunt syndrome)

Question 10

Causes of central vertigo?

Answer 10

Posterior circulation infarction (stroke)
Tumour
Multiple sclerosis
Vestibular migraine

Question 11

Clues that vertigo might have central rather than peripheral aetitology?

Answer 11

All the central causes of vertigo will cause sustained, non-positional vertigo.

Posterior circulation infarction will have a sudden onset and may be associated with other symptoms, such as ataxia, diplopia, cranial nerve defects or limb symptoms.

Tumours in the cerebellum or brainstem will have a gradual onset with associated symptoms of cerebellar or brainstem dysfunction.

Multiple sclerosis may cause relapsing and remitting symptoms, with other associated features of multiple sclerosis, such as optic neuritis or transverse myelitis.

Vestibular migraine will cause symptoms lasting minutes to hours, often associated with visual aura and headache. Attacks may be triggered

Question 12

Where might a tumour causing vertigo be locateted?

Answer 12

cerebellum or brainstem

Question 13

Peripheral vs central vertigo - onset

Answer 13

Peripheral: Sudden onset

Central: Gradual onset (except stroke)

Question 14

Peripheral vs. central vertigo: Duration

Answer 14

Peripheral: Short (seconds or minutes)

Central: Persistent

Question 15

Peripheral vs. central vertigo: hearing loss or tinnitus?

Answer 15

Peripheral: often present

Central: Usually not

Question 16

Peripheral vs. central vertigo: coordination

Answer 16

Peripheral: intact

Central: lost

Question 17

Peripheral vs. central vertigo: nausea?

Answer 17

Peripheral: serve
Central: mild

Question 18

Key features which may point to a specific cause of vertigo?

Answer 18

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)

Question 19

What should be examined when a patient presents with vertigo?

Answer 19

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)

Cerebellar examination

Cardiovascular examination to assess for cardiovascular causes of dizziness (e.g., arrhythmias or valve disease)

Special tests:
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)

Question 20

Components of cerebellar examination?

Answer 20

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

Question 21

Peripheral vs central vertigo: nystagmus

Answer 21

Unilateral horizontal nystagmus is more likely to be a peripheral cause. Bilateral or vertical nystagmus suggests a central cause.

Question 22

Test of skew

Answer 22

The test of skew (also called the alternate cover test) involves the patient sitting upright and fixing their gaze on the examiner’s nose. The examiner covers one eye at a time, alternating between covering either eye. The eyes should remain fixed on the examiner’s nose with no deviation. If there is a vertical correction when an eye is uncovered (the eye has drifted up or down and needs to move vertically to fix on the nose when uncovered), this indicates a central cause of vertigo.

Question 23

Vertigo management

Answer 23

Patients with suspected central vertigo need referral for further investigation (e.g., CT or MRI head) to establish the cause.

For peripheral vertigo, short-term options for managing symptoms include:

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

Betahistine may be used to help reduce the attacks in patients diagnosed with Ménière’s disease.

Epley manoeuvre can be effective in treating BPPV.

Vestibular migraine is usually managed by avoiding triggers and lifestyle changes (e.g., getting enough sleep and staying hydrated). Medical management is similar to migraines, with triptans for the acute symptoms and propranolol, topiramate or amitriptyline to prevent attacks.

The DVLA guide for medical professionals (updated March 2021) states that patients must not drive and must inform the DVLA if they are liable to “sudden and unprovoked or unprecipitated episodes of disabling dizziness”.

Question 24

What are the three cardinal features of Ménière’s disease?

Answer 24

Vertigo
Tinnitus
Hearing loss