Diziness and Vertigo Flashcards
What are some examples of differentials for tinnitus?
- sensorineural HL
- conductive HL
- Vestibular schwannoma(acoustic neuroma)
- TMJ
- migraine
- meds
- stroke
- head injury
- thyroid
- depression/aniety
What are vertigo differential dx for the cochleovestibular system?
- Infection (otitis media,) syphilis, Herpes zoster, Lyme Disease
- degenerative- aging
- developmental- congenital anomalies of the inner ear
- Tumor- cholesteatoma, acoustic neuroma
- Vascular
- Ototoxins (aminoglycosides, alcohol)
- Disorders of bone metabolism (osteoperosis)
- Trauma
What are vertigo differential dx for the nervous system?
- vascular (hyperventilation)
- Tumor (meningioma)
- Developmental (malformations of base of the skull)
- Peripheral neuropathy (DM)
- Infection (meningitis)
- Seizure disorder (petit mal)
- Demyelinating disorders (MS)
- Degnerative (parkinsons)
What are vertigo differential dx for the cardiovascular system?
1.circulatory(orthostatic hypotension, anemia)
2. cardiac (arrythmias)
3. great vessels
Differential Dx chart
look at ppt
__________ is a subtype of dizziness. It is a cardinal symptom for vestibular disease
vertigo
Onset and progression of symptoms- slow and insidious (___________). or acute (__________). Does hearing fluctuate? (__________). Are there episodes associated with turning the head (____________) lying supine or sitting upright? Can the patient ambulate during an acute episode? (if not, think __________) Brainstem symptoms (________________)
CNS, vestibular
Meniere’s
BPPV
cerebellar
diplopia, dysarthria, facial paresthesia or extremity numbness or weakness
Vertigo with nose blowing (______________). Vertigo with pressure or noise (________________). Aura or warning before symptoms start(_____________) visual symptoms (____________)
fistula
superior canal dehiscience
migraine
scintillating scotoma
Vertigo with neck movement(___________) Symptoms preceded by an upper respiratory infection or fu like illness (______________)
cervical vertigo
vestibular neuronitis
Vestibular history key words
sudden onset
spinning
hearing loss
aural fullness
tinnitus
Not vestibular history keywords
gradual onset
Ill defined symptoms
passing out
cant ambulate
numbness/weakness
Surgery for cholesteatoma may result in ________ or acquired ______________.
iatrogennic
labyrinthine fistula
What may stapes surgery for otosclerosis or tympanosclerosis cause?
vestibular symptoms because of perilymphatic fistula, adhesions between the oval window and saccule, or an overly long prosthesis.
Balance or equilibrium is associated with which three systems?
visual, proprioceptive and vestibular
What is nystagmus?
involuntary, periodic, rhythmic ocular oscillation of the eyes.It can be unilateral or bilateral. It may also be spontaneous, gaze-induced or positional
Peripheral nystagmus is usually ____________-
rotary (torsional)
Pure _________ nystagmus usually is a sign of brainstem disease.
vertical
What are differentials for nystagmus?
- Congenital nystagmus-macular degen
- Acquired Nystagmus
-head trauma
-brain tumor
-stroke
-chiari malformation
-meniere’s, BPPV, labyrinthitis, vestibular neuronitis, MS, wernicke-korsakoff syndrome, thiamine deficiency - Toxic causes (alcohol, marijuana)
Gait test
check for staggering or learning to one side
normal gait: erect posture, moderately sized steps and walking in a straight line
Romberg test
stand heel to toe with one foot in front of the other with eyes closed
Tandem romberg
walk heel to toe with arms out for balance
What office test is used to identify BPPV?
dix-hallpike maneuver
How is the dix-hallpike maneuver performed and what is an abnormal finding?
performed by guiding patient rapidly from a sitting position with head turned to 45 degrees to one side to a supine position.
Abnormal: patient reports vertigo and has torsional (rotary) nystagmus that starts a few seconds after the pt lies back, lasts 40-60s, reverses when the patient sits up and fatigues with repetition
What is a fistula test?
it is designed to elicit symptoms of an abnormal connection (fistula) between the labyrinth and surrounding spaces.
Apply pressure to the pts ear canal (press on tragus) and observe eye movements)
What is a fukuda test and what is it helpful in diagnosing?
pt high steps in place for 20-30s. it is helpful to dx a weakness in inner ear. Which ever side that the patient turns to is the weaker side.
What are examples of vestibular tests?
electronystagmography testing (ENG)
1. saccadic test
2. gaze test
3. pursuit eyemovment test
4. optokinetic nystagmus test (OKN)
5. head shake nystagmus test
6. positional nystagmus test
7. positioning nytagmus test (dix hallpike)
8. bithermal caloric tests (warm + cold air blown in pts ear, good vestibular system=pt gets dizzy)
What are vestibular lab tests?
vestibular autorotation testing (VAT)
computerized platform posturography
electrochleography (Ecog)
auditory brainstem response (ABR)
vestibular evoked myogenic potentials (VEMP)
What are examples of diagnostic studies
- MRI of the brain and IAC (internal auditory canal) with and without gadolinium
- CT of brain or temporal bones
- Lab tests- arent helpful
Vestibular medical management
- antihistamines- vestibular suppressants
-antivert (meclizine) cannot take everyday bc wont heal - Benzodiazepines- depress CNS
-valium (diazepam) - Phenothiazine-treat emesis
-promethazine (phenergan) - oral steroids
- vestibular rehab (PT)
- At home excercises: cawthorne Cooksey/Brandt Daroff
What is peripheral vertigo?
labyrinthitis
meniere’s
positional vertigo (BPPV)
vestibular neuronitis
sudden onset
nystagmus is usually rotary
What is central vertigo?
acoustic neuroma (vestibular schwannoma)
brainstem vascular disease
arteriovenous malformations
tumors of the brainstem or cerebellum
MS
vertiginous migraine
slower onset
pure vertical nystagmus usually is a sign of brainstem disease
I get dizzy and off balance when i stand up
I get up and start to walk and feel like i am going to fall over
when i get up quickly, i feel like i could faint
orthostatic HTN
I felt like my heart was pounding out of my chest
i felt like i was standing outside my body
i felt like i was dying
i couldnt breathe
panic attack
I have episodes of spinning and nausea that comes without warning but had no ear symptoms
It felt like someone suddenly pulled the rug out from under me
I felt a sudden wave come over me
I cant stand any type of motion. It never bothered me when I was a kid
Bright light and sounds make me feel worse
migraine
I have had several episodes of severe vertigo with nausea,lasting for hours at a time
it didnt matter if i moved or not
i feel so much pressure in my head (ear)
my ear was roaring
after an episode, i need to sleep for several hours
menier’s
I had constant spinning and nausea for about 3 days
I was in the hospital for about 3 days and they couldnt find anything wrong with me
After the worst of it, (vertigo and nausea) I was ok if i didnt move. If i moved I was off balanced and would get nauseous if i moved too much
vestibular neuritis (no hearing)
I woke up and the bed was spinning
I bent over (rolled over, turned quickly, laid down, sat up from bed, etc) and everything started spinning around
Every time i tried to get up i fell back into the bed
BPPV
What is peripheral vertigo?
labyrinthitis, meniere’s, positional vertigo (BPPV), vestibular neuronitis
-sudden onset
-nystagmus is usually rotary
What is central vertigo?
acoustic neuroma (vestibular schwannoma), brainstem vascular disease, arteriovenous malformations, tumors of the brainstem or cerebellum, MS, vertiginous migraine
-slower onset
-pure vertical nystagmus usually is a sign of brainstem disease
What is benign paroxysmal positional vertigo (BPPV) caused by?
otolith debris (canalith) floating in the semicircular canals (canalithiasis) or adhering to the cupula (cupulolithiasis)
What are the possible causes of BPPV?
(can occur spontaneously)
vestibular neuronitis, Meniere’s head trauma, which dislodges particles (otoconia)
What is the most common type of BPPV?
posterior canalithiasis (90%) of the time
cupulolithiasis tend to be worse
What are the symptoms of BPPV?
acute vertigo with episodes lasting <1 minute that occurs with changing head/body position.
Residual sensation of disequilibrium between episodes
may spontaneously resolve
no meds
How do you diagnose BPPV?
by doing the dix hallpike test to look for rotary nystagmus
How do you treat BPPV?
- Epley manuever- canalith repositioning technique- the particles are shifted out of the semicircular canal
- Vestibular rehab
What is vestibular neuronitis?
-severe vertigo that begins acutely after an URI
-lasts 24-48 hours and gradually subsides with pts complaining of unsteadiness for weeks
-HEARING IS NOT AFFECTED
-patients cannot perform home or work activities
What are the treatment options for patients with vestibular neuronitis?
- meds- antiemetics, vestibular suppressants, corticosteroids
- vestibular rehab
1/3 of patients with vestibular neuronitis develop_______________
BPPV
_____________ + ___________ = labryinthitis
vestibular neuronitis + hearing loss
What is labyrinthitis?
it is the acute onset of continuous, severe vertigo lasting several days to weeks accompanied by sudden HEARING LOSS and tinnitus
hearing loss can be permanent
can be unilateral/bilateral
What can cause inflammation of the labyrinth?
bacteria/viruses
What is the treatment option for labyrinthitis?
meds: antiemetic meds, vestibular suppressant (meclizine), steroids
What are the 4 characteristics of Meniere’s disease (endolymphatic hydrops)?
- fluctuating, low frequency hearing loss in affected ear
- Tinnutus in affected ear
- Aural fullness in affected ear
- Episodes of vertigo that lasts for hours at a time
What is the patho of meniere’s disease?
overproduction or underabsorption of endolymph causing distension on the endolymphatic sac
What disease do you want to rule out if you suspect that a patient has Meniere’s?
syphilis; refer to ENT if negative
-vestibular testing (VNG, electrocochleography and or VEMP)
If Meniere’s disease (endolymphatic hydrops) goes untreated which type of hearing loss can it lead to ?
permanent unilateral sensorineural HL
What are the treatment options for Meniere’s disease?
- 80% respond to salt restriction (alcohol and caffeine restriction- less than 2 grams per day)
- Prednisone for acute attacks
- Diuretics (Dyazide)
- Vestibular rehab
- Antiemetics and short term use of vestibular suppressants
- surgery
What is a perilymphatic fistula?
abnormal connection due to a tear between the perilymph-filled inner ear and the middle ear.
What can cause a perilymphatic fistula?
may be trauma induced (surgical, head trauma, barotrauma, weight lifting, child birth) or idiopathic
What are diagnostic tools used for the evaluation of perilymphatic fistula?
exploratory surgery, CT/MRI, vestibular testing, audiogram, fistula test
What are the symptoms associated with a perilymphatic fistula?
symptoms get worse with pressure changes, noise-induced dizziness (tullio phenomenon). can cause diziness, tinnitus and hearing loss that can be treated surgically
What is superior semicircular canal dehiscience (SSCD)
The absence of bone overlying the superior semicircular canal facing towards the dura of the middle cranial fossa
What are the symptoms of superior semicircular canal dehiscience (SSCD) ?
tulio phenomenon (noise induced vertigo)
pressure induced vertigo
aural fullness
autophony (hearing internal noises)
CHL
fluctuating or progressive sensorineural HL
What are the causes of superior semicircular canal dehiscience (SSCD)
congenital, head trauma, barotrauma
What diagnostic tests are ordered for the evaluation of superior semicircular canal dehiscience (SSCD)
audiogram, vestibular testing, noncontrast CT temporal bone, MRI?
What is the treatment of superior semicircular canal dehiscience (SSCD)
Surgery
What is central vertigo?
vertigo due to a disease originating from the central nervous system (CNS) usually the brain stem or cerebellum
What are the causes of central vertigo?
CNS tumors (acoustic neuroma), migraines, MS, hemorrhagic or ischemic insults to the cerebellum, TIA’s, infection, trauma, drugs (anticonvulsants, aspirin, alcohol), seizures, psychiatric disorders, cerebrovascular disorders related to the vertebrobasilar circulation
What is acoustic neuroma?
vestibular shwannoma- CN8 tumor. It is a benign tumor in the CPA (cerebropontine angle)
What are the symptoms associated with acoustic neuroma?
unilateral SNHL, unilateral tinnitus, and or vertigo (which is a late symptom)
What imaging is used to diagnose acoustic neuroma?
MRI of the brain and internal auditory canal (IAC) with and without gadolinium
What is the treatment for acoustic neuroma?
refer for observation vs gamma knife treatment vs surgical excision
What is a vestibular migraine?
episodic vertigo lasting 5 min to 72 hours (spinning, rocking, swaying, disequilibrium)
+/- HA
sensitivity to light/sound with nausea/vomiting
no other vestibular explanation
What type of treatment does a vestibular migraine respond to?
migraine medication
Which demographic does vestibular migraine mostly affect?
younger patient with a history of a migraine
What is cervical vertigo?
vertigo or dizziness from the cervical spine and occurs with moving the head/neck
DIZZINESS LASTS MINUTES TO HOURS
What kinds of patients are affected by cervical vertigo?
patients with closed-head or whiplash injuries
What are the other causes of cervical vertigo?
migraine, cervical arterial issues, surgery
Post traumatic vertigo refers to dizziness that follows a _________ or ___________ injury
head, neck
What are the diagnoses associated with traumatic vertigo?
- brainstem concussion
- labyrinthine concussion
- BPPV
- post traumatic meniere disease
- perilymphatic fistula
- cervical vertigo
