Balance Flashcards
What controls balance and what does it contain
Vestibular system
3 semicircular canals which contain hair cells that activated by movement of endolymph
Otolith organs
What movement do semicircular canals detect
Roational
How do they do this
Hair cells stuck on matrix in ampulla at bottom of canals Fluid in canal moves as you down Pushes cilia Opens ion channels Message sent along vestibular nerve
What makes up otolith organs
Utricle
Saccule
How does otolith organ work
Hair cells in cilia sit in matrix with K bicarb crystals on top
Difficult to move
Hair moves in direction of head
What type of movement does utricle an saccule detect
Utricle = horizontal Saccule = vertical
What is the vestibulo-ocular reflex
Stabilises gaze by moving eyes in order to compensate for head and body movement
Fixes image on retina for clear sight
What is vertigo
Hallucination of movement in the absence of movement
Usually rotatory
Always ask what patient means
What is associated with vertigo
Difficulty walking or standing Relief lying or sitting still N+V Pallor Sweating Hearing loss Tinnitus Nystagmus
If hearing loss or tinnitus as well what does this suggest
Labyrinth or VIII nerve involvement
What are the 4 categories of vertigo
Spontaneous acute
Spontaneous chronic
Movement provoked
Positional
What causes acute and chronic spontaneous vertigo
Acute
Vestibular neuritis
Labyrinthiits
Neuro event although rare - posterior stroke or MS
Chronic Migraine = most common Meniere's Vestibular neuritis Hyperventilation
What causes movement provoked vertigo
Central brain stem or cerebellar
Visual
Vestibular system issue
What causes positional vertigo
BPPV
Vertebrobasilar ischaemia - elderly on neck extension but BBV more common
When should you consider posterior stroke
If other posterior / cerebellar signs
Numbness
Diplopia
Dysarthria
What is peripheral nystagmus (caused by problem with ear NOT brain)
Always accompanied with vertigo
Disappears within 2 days of acute vestibular episode
NEVER vertical
Does not change with direction
If patient with dizzy spell suggestive of vertigo what should you ask / examine
If pain or discharging ear If deafness or tinnitus Oscillopsia Sensory impairment DM
Full neuro exam Asses CN and ears Test cerebellar function and reflexes Look for abnormal eye movement / nystagmus Assess gait Romberg test
What does painful ear suggest
Middle ear disease
What does deafness or tinnitus suggest
Inner ear disease
What should you do if deafness or tinnitus
Refer to exclude Schwannoma
What is important to know about the episode of vertigo
Constant Single episode Multiple episodes Spontaneous Movement provoked Positional Duration of attack Important to work out DDX
What is other common causes of recurrent and chronic dizzy which is NOT vertigo
Orthostatic hypo Arrhythmia Drugs Prochlorperazine Hypotensive Anti-depressant Anaemia Anxiety Motion sickness Epilepsy Alcoho
What symptoms suggest not vertigo
LOC - think epilepsy or syncope
Fainting
Lightheaded
Palpitations
What are red flags
Unilateral tinnitus or hearing loss Unilateral otorrhoea Neuro S+S Nystagmus has central features Spontaneous nystagmus >48 hours Positional vertigo or nystagmus not BPPV Significant vertigo / imbalance >1 month Any suspicion of central disorder
What are causes of vertigo
Vestibular Migraine BPPV Meniere's Vestibular neuritis Viral labrynthitis Acoustic neuroma Posterior circulation stroke Trauma MS Ototoxicity Ramsay hunt
What is migrainous vertigo
Recurrent spontaneous vertigo which varies duration minutes to days May have associated symptoms Headache Photophobia Hearing loss Tinnitus NO neuro FH or history of migraine
What is it misDx as
BPPV - the most common cause of peripheral vertigo
What causes BPPV
Otoconia in semi-circular canals
Idiopathic
Head injury
What are the symptoms
Vertigo precipitated by changes in head position Duration = seconds Often notice if turn head fast May have associated nausea May have nystagmus
No other Sx e/.g. tinnitus / headache / ataxia / dysphagia/ palsy / no vertical nystagmus
How do you Dx
+ve Dix-Hallpike test
Fatiguable nystagmus
How do you treat
Vestibular physio for Epley manoeuvre to remove otoconia
When do you refer
If Sx persist after 3-4 weeks
Rx not successful
What is Meniere’s disease
Raised pressure in inner ear caused by endolymphatic hydrops
What are the symptoms
Attacks of spontaneous recurrent vertigo >20mins - hours
Occurs regularly
Hearing loss - Fluctuating progressive unilateral sensorineura
Horizontal nystagmus ALWAYS present
Tinnitus
Sensation of aural fullness
+ve Romberg
How do you Rx acutely
ENT to confirm Inform DVLA Bed rest and reassurance Anti-histmaine Buccal proclorphreazine as vestibular sedative in acute Vestibular physio
What do you give to prevent
Anti-histmaine
Betahistine to improve blood supply
Bendofluazide - reduce pressure as diuretic
Vestibular rehab
Intratympanic dexamethasone - for inflammatory response
What is last resort
Intratymapnic gentamicin
Kills nerve cells
Will already have hearing loss so saving patient from dizzy is good
What causes ototoxicity
Aminoglycoside
Loop diuretic
NSAID / aspirin
What does this cause
Vertigo
Sensorineural deafness
What is vestibular neuritis
Inflammation of the vestibular nerve
Usually due to viral infection - HSV
Can be vascular
When is it not neuritis
If >3 in a year
More likely migraine
What are the symptoms
Spontaneous vertigo lasting hours to days
Horizontal nystagmus
N+V
No deafness or tinnitus
How do you Rx acute
Prochlorperazine / anti-histamine if mild in acute phase
Vestibular sedative
Anti-emetic
AX if bacterial
How do you Rx chronic
Vestibular rehab
Promotes compensation of brain
What is viral labrynthitis
Inflammation of labyrinth - both vestibular and cochlear nerve
Viral = most common
Can get bacterial after middle ear infection
Systemic disease
What are the symptoms
Sensorineural hearing loss Tinnitus \+ symptoms of vestibular neuritis - sudden attack of unilateral vertigo and vomiting May have URTI proceeding Nystagmus away from affected side
How do you Dx and Rx
Clinical
Exclude hypoglycaemia
Rx = bed rest + vestibular suppressants
If Dx if uncertain or suspecting sinister cause what do you do
Full neuro exam - rule out cerebellar stroke
Pure tone audiometry
FBC + culture
Temporal bone CT or MRI to look for shcwannoma
What is acoustic neuroma
Schwannoma from vestibular nerve (not cochlear)
What does it cause
Unilateral hearing loss Tinnitus Vertigo if vestibular becomes involved Facial nerve may become involved - Absent corneal reflex Headache Raised ICP = late sign and suggests a large tumour
How do you dx
MRI
What is Ramsay hunt
Reactivation of HSV. in seventh cranial nerve
What are the features
Auricular pain Facial nerve palsy Vestibular rash around ears / tongue Deafness Tinnitus Vertigo
How do you Rx
Acyclovir
Corticosteroid
What does balance assessment involve
History Tympanography Hearing test Videonystagmography Caloric test to test R+L balance organ separately by putting different temps of water
What causes peripheral vertigo i.e. vestibular
Migraine
Meniere’s
BPPV
Labrynthitis
What causes central vertigo
Acoustic neuroma MS Head injury Migraine Vertebrobasillar insufficiency
What is less associated with central vertigo
Hearing loss
Tinnitus
If unilateral sensorineural hearing loss
Pure tone audioemtry
MRI to exclude schwannoma
