Constitutional problems: Fatigue, headache, dizziness Flashcards

Question

BPPV Specific clinical test for diagnosis Treatment

Answer 1

Diagnosis: Dix- Hallpike’s maneuver Series of postural changes: - settling particles from otoconia in posterior semicircular canal should stimulate ampulla - eyes should have torsional nystagmus (down-beating vertically towards the ground) Treatment: - Epley’s Maneuvre: make crystals in semicircular canal move anteriorly and drop into utricle - Reassurance - Spontaneous recovery: o 45deg propped up or 2 high pillows o Not to sleep on the side of the bad ear o Keep the head still at vertical position (i.e. not bent forward/backward)

Answer 2

idiopathic syndrome of endolymphatic hydrops: - overaccumulation of endolymph fluid in inner ear increase endolymphatic pressure + malabsorption of endolymph - physical distortion (bulging) of membranous labyrinth (distension of scala media) Distension of saccule causes: i. Hennebert’s sign (pressure on tragus induces vertigo) ii. Tullio phenomenon (sound induce vertigo) Micro-ruptures of membranous labyrinth causes episodic, recurrent attacks

Answer 3

triad: vertigo, tinnitus, hearing loss +/- aural fullness Rule out DDx of endolymph hydrops first: Metabolic  Hyperglycemia  Hyperlipidemia  Hypothyroidism Infectious  Syphilis  Viral – measles, mumps Autoimmune: SLE, RA Development: Mondini dysplasia Advanced otosclerosis with cochlear involvement

Answer 4

 >2 spontaneous episodes of vertigo lasting 20 min to 12 hours  Audiometrically (pure tone audiogram) documented low- to medium-frequency sensorineural hearing loss in one ear around vertigo episode  Fluctuating aural symptoms (hearing, tinnitus or aural fullness) in the affected ear  Not better accounted by another vestibular diagnosis Prognosis: High spontaneous remission rate: >50% within 2 years; >70% after 8 years

Answer 5

 >2 episodes of vertigo or dizziness, each lasting 20 minutes to 24 hours (longer duration than definite Dx)  Fluctuating aural symptoms (hearing, tinnitus or aural fullness) in the affected ear (same as definite dx)  Not better accounted for by another vestibular diagnosis (same as definite dx)  no pure tone audiogram = cannot make definite Dx

Answer 6

Acute treatment:  Vestibular sedatives: cinnarizine, diazepam (benzodiazepine)  Antiemetics: maxolon (= metoclopramide, dopamine receptor antagonist)), stemetil, ondansetron (5HT3 receptor antagonist)  Intratympanic steroid injection Chronic prophylaxis: Lifestyle:  Avoid caffeine  Quit smoking  Low salt diet, diuretics to reduce sodium load Betahistine:  Inner ear vasodilation = improve inner ear circulation  Contraindicated for peptic ulcer / asthma Surgical: Intratympanic gentamicin injection (medical labyrinthectomy) Less commonly performed: o Endolymphatic sac decompression o Labyrinthectomy o Vestibular neurectomy

Answer 7

Cause: Post-viral infection, swelling of vestibular nerve S/S:  Sudden severe vertigo  Nausea, vomiting  Gait instability  Hearing usually spared  Poor caloric response in the involved ear  Positive head thrust test@ in the direction of the involved side Tx: self-limiting in days, unsteadiness for 3 months max vestibular sedative, stemetil (antiemetic) for acute phase

Answer 8

Causes:  Cholesteatoma  Trauma (including barotrauma)  Iatrogenic (e.g. stapedectomy)  Idiopathic Pathogenesis: Violation of barrier between middle and inner ear (most commonly round window/ oval window) S/S:  Vertigo onset after trauma  Episodic vertigo attacks – worse on straining  Fluctuating hearing loss Tx: Urgent surgical repair of fistula

Answer 9

Cause: Direct invasion of the inner ear by bacteria S/S:  Severe vertigo  Hearing loss  Ear discharge Tx:  Hospitalization  Hydration  Vestibular suppressants (stemetil)  IV antibiotics  Early surgical treatment of underlying CSOM/ cholesteatoma

Answer 10

Causes:  Acute/chronic otitis media; or  Early bacterial meningitis Toxins penetrate the round window/ IAC/ cochlear aqueduct S/S:  Mild vestibular dysfunction  Mild high-frequency hearing loss Tx: Abx

Answer 11

Cause: Reactivation of varicella zoster S/S: Ramsay Hunt syndrome:  Vesicles on pinnae/ external auditory canal  Facial weakness/ paralysis  Sensorineural hearing loss Diagnosis:  Clinical presentation  Culture of vesicular fluid (HSV) Tx:  Antiviral therapy (acyclovir)  Steroids  Analgesics

Answer 12

Type: nonspecific lightheadedness, presyncope, postural imbalance, spinning vertigo Time course - Episodic attack/ sustained acute/ sustained chronic Triggering factors e. g. social situation, bright light, URTI..etc Associated symptoms e. g. Meniere’s triad, photophobia, cerebellar signs

Answer 13

Supine/ sleep on specific side: BPPV Bright light (photophobia): Migrainous vertigo URTI (viral infection): Vestibular neuritis/neuronitis Head injury, Post-concussion, fractured temporal bone  perilymph fistula, BPPV Loud sound/ ear pressure  Perilymph fistula  Superior canal dehiscence Ototoxic drugs (antibiotics, chemotherapeutics, e.g. cisplatin) Vestibulopathy

Answer 14

Neurological exam for vision, proprioception Vestibular causes: * Otoscopy: r/o middle ear infection, cholesteatoma…etc * Pure tone audiogram (Definite Meniere’s) * Dix-Hallpike (BPPV) * Fistula test (perilymph fistula, superior canal dehiscence) * Central causes: Cerebellar signs * CN exams: Wallenberg/ Lateral medullary * Gait exam * HINTS: Head-Impulse test, Nystagmus, Test of Skew * Motor: Romberg test

Answer 15

Rule out central causes of dizziness (untreated = high mortality) HINTS: 1) Head-impulse test 2) Nystagmus (test with Frenzel goggles to eliminate visual fixation) 3) Test of Skew (detect skew deviation of eye by alternating cover test)

Answer 16

Imaging/ radiological for central causes: o CT/MRI Brain & Brainstem o MRI brain and internal auditory canal (with contrast) - acoustic neroma Audiological tests if not sure peripheral/ dx definite Meniere's o Pure tone audiometry o Electronystagmography (ENG) with caloric test or rotary chair o Posturography

Answer 17

Vision: wear glasses, treat cataracts… Proprioception: use walking stick, physiotherapy Vestibular: Vestibular sedatives for acute attack, Betahistine (meniere’s), Cawthorne-Cooksey exercises Central: Move slower Motor: Physiotherapy for motor training, TaiChi, yoga

Answer 18

Raised ICP Meningitis Temporal arteritis Subarachnoid hemorrhage Cervical spondylosis Others: Vascular: carotid/vertebral dissection, hypertensive crisis, vasculitis CSF: CSF hypotension, post-LP headache Other cranial structures: acute glaucoma, head trauma, neuralgia (post-herpetic, trigeminal, occipital)

Answer 19

* Bilateral, generalized, radiate forwards from occipital region * Band-like tightness lasting for hours to weeks, recur often * No associated symptoms, pt can carry on with activities * Time course: last for hours to days or even months → May be episodic or chronic (persist over years) Wax and wane, worse on touching scalp and worse in later part of day Can be associated with anxiety/depression/ stress

Answer 20

Unilateral severe and Pulsatile/ Throbbing pain for 4-72h 20% preceded by aura (99% visual, 31% sensory, 18% aphasic, 6% motor) Associated with photophobia, phonophobia, nausea/vomiting Debilitating (worsens by movement) → lies in a quiet, dark room

Answer 21

Severe, unilateral periorbital pain for 15-180 min Strikingly periodic – begin at same hour for consecutive days over weeks Associated with autonomic features eg. unilateral lacrimation, nasal congestion, conjunctival injection, Horner’s syndrome (~30-50%) highly agitated during attacks

Answer 22

Persistent unil/bil temporal headache in pt >50y/o Associated with temporal tenderness, jaw claudication, diplopia or amaurosis fugax Jaw claudication - pain in proximal jaw near TMJ after brief chewing of tough food

Answer 23

→ Bilateral (TTH, ↑ICP, …) vs unilateral (migraine, cluster, temporal arteritis, trigeminal) → Ocular: ocular diseases (eg. acute glaucoma), trigeminal autonomic cephalalgias (TACs), lesions at apex of orbit or cavernous sinus (rare) → Facial: trigeminal neuralgia, herpes zoster, post-herpetic neuralgia, dental/TMJ diseases, sinusitis

Answer 24

P/E: Full neurological exam + H&N exam (skull, C-spine, teeth, ENT, sinuses, eyes) + BP Investigations: for suspected serious secondary cause: CBC, L/RFT for systemic disease ESR Plain XR e.g. CXR CT/MRI brain (neurological deficits or seizures) Vascular imaging LP CSF analysis (infective or infiltrative) ENT evaluation

Answer 25

* Chronic migraine if ≥15d/mo for >3mo w/o medication overuse * Status migrainosus: debilitating migraine attack lasting for >72h * Persistent aura w/o infarction: if aura lasts for >1w * Migrainous infarction: aura symptoms lasting for >1h + ischaemic infarct on CT/MRI * Migraine-triggered seizure: epileptic seizure occur during or ≤1h of aura

Answer 26

→ Dietary: alcohol, chocolate, tyramine-containing (eg. dairy products), starvation, caffeine → Hormonal: often premenstrual or related to OCP (fluctuation in oestrogen) → Emotional: stress, anger, excitement → Others: change in sleep, irregular meals, certain drugs, smoking, fluorescent lights, weather

Answer 27

Indication: Severe migraine headache MoA: 5HT1 agonist → vasoconstriction, peripheral neuronal inhibition, ↓trigeminal neurotransmission S/E: dizziness, somnolence, asthenia, nausea C/I: IHD, stroke, CAD, uncontrolled HTN

Answer 28

Indication: Severe migraine headache MoA: 5HT1 agonist → vasoconstriction, ↓trigeminal neurotransmission S/E: vascular events (sustained generalized vasoconstriction), high risk of overuse syndrome and rebound headache C/I: IHD, thyrotoxic heart disease, PVD, uncontrolled HTN

Answer 29

□ Headache: new onset, bitemporal, intense throbbing headache □ Neurological S/S: Stroke, hearing loss, myelopathy, neuropathy Blindness due to acute ischaemic optic neuropathy (AION) □ Jaw claudication: pain when chewing or talking due to ischaemia of masseter □ Visual S/S: amaurosis fugax (transient), can progress into permanent blindness (sight-threatening) Due to arteritic acute ischaemic optic neuropathy (AAION) □ Systemic S/S: Fever, anorexia, malaise Polymyalgia rheumatica (50%): pain and stiffness over shoulder and pelvic girdle muscles

Answer 30

Diagnostic criteria: ≥3 criteria (1) Onset ≥50y (2) New headache (3) Abnormalities of temporal artery at PE: tender, thickened, non-pulsatile superficial temporal artery (4) ↑ESR (>50mm/h) (5) Abnormal findings on biopsy of temporal artery Tx: urgent prednisolone 60mg qd □ Urgent Tx prevents blindness and brainstem stroke and ↓headache □ Parenteral high dose if complications already occurred □ Gradual ↓dosage to maintenance level according to ESR level

Answer 31

Causes: □ Classical TN: → Vascular loop compression: most common, 80-90% → Idiopathic □ Other causes (secondary TN): → Multiple sclerosis, esp young and when bilateral → CPA masses: vestibular neuroma, meningioma, epidermoid cyst, AVM, angiomas… → Herpes zoster and post-herpetic neuralgia Treatment: Medical Tx: for classic TN Carbamazepine (first-line, most effective, 75% responsive) Surgical Tx: for refractory classic TN * Peripheral neurectomy, eg. alcohol ablation (temporary relief) * Microvascular decompression (separate vessels from trigeminal nerve root) * Percutaneous radiofrequency thermocoagulation rhizotomy (artificial lesion for trigger spot on Trigeminal nerve) * Treatment of underlying condition (eg. surgical decompression) for secondary TN