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ENT > Balance > Flashcards

Balance Flashcards

1
Q

What controls balance and what does it contain

A

Vestibular system
3 semicircular canals which contain hair cells that activated by movement of endolymph
Otolith organs

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2
Q

What movement do semicircular canals detect

A

Roational

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3
Q

How do they do this

A 
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
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4
Q

What makes up otolith organs

A

Utricle

Saccule

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5
Q

How does otolith organ work

A

Hair cells in cilia sit in matrix with K bicarb crystals on top
Difficult to move
Hair moves in direction of head

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6
Q

What type of movement does utricle an saccule detect

A 
Utricle = horizontal 
Saccule = vertical
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7
Q

What is the vestibulo-ocular reflex

A

Stabilises gaze by moving eyes in order to compensate for head and body movement
Fixes image on retina for clear sight

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8
Q

What is vertigo

A

Hallucination of movement in the absence of movement
Usually rotatory
Always ask what patient means

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9
Q

What is associated with vertigo

A 
Difficulty walking or standing
Relief lying or sitting still 
N+V
Pallor
Sweating
Hearing loss
Tinnitus 
Nystagmus
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10
Q

If hearing loss or tinnitus as well what does this suggest

A

Labyrinth or VIII nerve involvement

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11
Q

What are the 4 categories of vertigo

A

Spontaneous acute
Spontaneous chronic
Movement provoked
Positional

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12
Q

What causes acute and chronic spontaneous vertigo

A

Acute
Vestibular neuritis
Labyrinthiits
Neuro event although rare - posterior stroke or MS

Chronic 
Migraine = most common
Meniere's
Vestibular neuritis
Hyperventilation
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13
Q

What causes movement provoked vertigo

A

Central brain stem or cerebellar
Visual
Vestibular system issue

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14
Q

What causes positional vertigo

A

BPPV

Vertebrobasilar ischaemia - elderly on neck extension but BBV more common

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15
Q

When should you consider posterior stroke

A

If other posterior / cerebellar signs
Numbness
Diplopia
Dysarthria

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16
Q

What is peripheral nystagmus (caused by problem with ear NOT brain)

A

Always accompanied with vertigo
Disappears within 2 days of acute vestibular episode
NEVER vertical
Does not change with direction

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17
Q

If patient with dizzy spell suggestive of vertigo what should you ask / examine

A 
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
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18
Q

What does painful ear suggest

A

Middle ear disease

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19
Q

What does deafness or tinnitus suggest

A

Inner ear disease

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20
Q

What should you do if deafness or tinnitus

A

Refer to exclude Schwannoma

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21
Q

What is important to know about the episode of vertigo

A 
Constant
Single episode
Multiple episodes
Spontaneous
Movement provoked 
Positional
Duration of attack 
Important to work out DDX
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22
Q

What is other common causes of recurrent and chronic dizzy which is NOT vertigo

A 
Orthostatic hypo 
Arrhythmia
Drugs
Prochlorperazine
Hypotensive
Anti-depressant 
Anaemia 
Anxiety 
Motion sickness
Epilepsy 
Alcoho
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23
Q

What symptoms suggest not vertigo

A

LOC - think epilepsy or syncope
Fainting
Lightheaded
Palpitations

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24
Q

What are red flags

A 
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
25
Q

What are causes of vertigo

A 
Vestibular Migraine
BPPV
Meniere's
Vestibular neuritis
Viral labrynthitis
Acoustic neuroma 
Posterior circulation stroke
Trauma
MS
Ototoxicity 
Ramsay hunt
26
Q

What is migrainous vertigo

A 
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
27
Q

What is it misDx as

A

BPPV - the most common cause of peripheral vertigo

28
Q

What causes BPPV

A

Otoconia in semi-circular canals
Idiopathic
Head injury

29
Q

What are the symptoms

A 
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

30
Q

How do you Dx

A

+ve Dix-Hallpike test

Fatiguable nystagmus

31
Q

How do you treat

A

Vestibular physio for Epley manoeuvre to remove otoconia

32
Q

When do you refer

A

If Sx persist after 3-4 weeks

Rx not successful

33
Q

What is Meniere’s disease

A

Raised pressure in inner ear caused by endolymphatic hydrops

34
Q

What are the symptoms

A

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

35
Q

How do you Rx acutely

A 
ENT to confirm
Inform DVLA
Bed rest and reassurance
Anti-histmaine 
Buccal proclorphreazine as vestibular sedative in acute 
Vestibular physio
36
Q

What do you give to prevent

A

Anti-histmaine
Betahistine to improve blood supply
Bendofluazide - reduce pressure as diuretic
Vestibular rehab
Intratympanic dexamethasone - for inflammatory response

37
Q

What is last resort

A

Intratymapnic gentamicin
Kills nerve cells
Will already have hearing loss so saving patient from dizzy is good

38
Q

What causes ototoxicity

A

Aminoglycoside
Loop diuretic
NSAID / aspirin

39
Q

What does this cause

A

Vertigo

Sensorineural deafness

40
Q

What is vestibular neuritis

A

Inflammation of the vestibular nerve
Usually due to viral infection - HSV
Can be vascular

41
Q

When is it not neuritis

A

If >3 in a year

More likely migraine

42
Q

What are the symptoms

A

Spontaneous vertigo lasting hours to days
Horizontal nystagmus
N+V
No deafness or tinnitus

43
Q

How do you Rx acute

A

Prochlorperazine / anti-histamine if mild in acute phase
Vestibular sedative
Anti-emetic
AX if bacterial

44
Q

How do you Rx chronic

A

Vestibular rehab

Promotes compensation of brain

45
Q

What is viral labrynthitis

A

Inflammation of labyrinth - both vestibular and cochlear nerve
Viral = most common
Can get bacterial after middle ear infection
Systemic disease

46
Q

What are the symptoms

A 
Sensorineural hearing loss 
Tinnitus 
\+ symptoms of vestibular neuritis - sudden attack of unilateral vertigo and vomiting 
May have URTI proceeding
Nystagmus away from affected side
47
Q

How do you Dx and Rx

A

Clinical
Exclude hypoglycaemia
Rx = bed rest + vestibular suppressants

48
Q

If Dx if uncertain or suspecting sinister cause what do you do

A

Full neuro exam - rule out cerebellar stroke
Pure tone audiometry
FBC + culture
Temporal bone CT or MRI to look for shcwannoma

49
Q

What is acoustic neuroma

A

Schwannoma from vestibular nerve (not cochlear)

50
Q

What does it cause

A 
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
51
Q

How do you dx

A

MRI

52
Q

What is Ramsay hunt

A

Reactivation of HSV. in seventh cranial nerve

53
Q

What are the features

A 
Auricular pain 
Facial nerve palsy 
Vestibular rash around ears / tongue
Deafness
Tinnitus
Vertigo
54
Q

How do you Rx

A

Acyclovir

Corticosteroid

55
Q

What does balance assessment involve

A 
History
Tympanography
Hearing test
Videonystagmography
Caloric test to test R+L balance organ separately by putting different temps of water
56
Q

What causes peripheral vertigo i.e. vestibular

A

Migraine
Meniere’s
BPPV
Labrynthitis

57
Q

What causes central vertigo

A 
Acoustic neuroma 
MS 
Head injury 
Migraine
Vertebrobasillar insufficiency
58
Q

What is less associated with central vertigo

A

Hearing loss

Tinnitus

59
Q

If unilateral sensorineural hearing loss

A

Pure tone audioemtry

MRI to exclude schwannoma

ENT (14 decks)

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