Dizziness

Question 1

Case history:

• lady mid-30s
• intermittent episodes of dizziness
• last 1 day at a time
• had it for past 6 months
• recently started experiencing ringing and increased pressure in ears
• presented with husband, he’s not sure if it’s relevant that she has turned up the sound on the TV => experiencing hearing loss
• went to GP
• did MRI for head and turned out normal
• the worst symptom is the dizziness

What is her complaint?

Answer 1

• Ménière’s disease

Question 2

Case history:

• a lady in mid-40s (or man)
• dizziness + nausea for past 3 weeks
• everything is spinning
• lasts a few seconds, occurs several times a day
• worse when moves head and bends forwards
• occasionally dizziness so severe she can vomit, but not all the time
• does not have tinitus, pain in ears, hearing loss or high blood pressure

Answer 2

• benign paroxysmal postitional vertigo (BPPV)

Question 3

Case history:

• tennis player (athlete)
• once had a viral infection, runny nose, high temperature and sneezing lasting for 2 weeks
• recovered
• a copule of weeks later she developed vertigo
• induced every time she goes on the court to play tennis
• when she plays tennis she feels dizzy
• sometimes vomits, sometimes doesn’t
• feels comfortable hugging a bucket to throw up
• no tinitus, high blood pressure or ear pain, no hearing loss, is cognitive (talking well)
• sometimes has HAs

Answer 3

• vestibular neuronitis

Question 4

What is the definition of vertigo?

Answer 4

• illusion of movement of subject or surroundings, typically rotatory
• can be accompanied by vomiting
• feel of getting off a roundabout
• made worse by head movements
• patients prefer to stay still
• nystagmus (flickering eyes) principal sign

Question 5

What will happen during neurological testing of vertigo patients?

Answer 5

• testing will be normal

Question 6

When will nystagmus occur?

Answer 6

• only during an incident of vertigo

Question 7

If vertigo is seconds - minutes, which diagnosis is most likely?

Answer 7

• benign paroxysmal position vertigo

Question 8

If vertigo lasts minutes to hours, which diagnosis is most likely?

Answer 8

• Meniere’s disease

Question 9

If vertigo lasts hours to days, which diagnosis is most likely?

Answer 9

• labyrinthine or central pathology (something with brain)

Question 10

What are the causes of dizziness in patients?

Answer 10

• vertigo
• presyncopal (fainting) sensations due to transient cerebral hypo perfusion
• unsteadiness (cerebellum or postural stability disorders)
• nonspecific dizziness (anxiety, medication or hyperventilation => breathing shallowly for too long)
• peripheral (vestibular system) => deafness, otalgia (ear pain) + tinnitus
• central (brain stem + connections => accompanying symptoms => diplopia (double vision), weakness, cerebellum signs or cranial nerve palsy. Continuous true vertigo with nystagmus

Question 11

What questions should you ask patients with dizziness? What should you observe?

Answer 11

• attack duration => intermittent or sustained
• frequency
• trigger factors (head positions)
• problem with hearing
• medication (anticonvulsants, aminoglycosides cause irreversible vestibular damage)
• nystagmus without vertigo => CNS
• signs of CNS involvement e.g. ataxia (lack of coordination), dysarthria (speech disorder), sensory + motor signs in limbs => intracranial problem

Question 12

Name vestibular disorder with vertigo

Answer 12

• benign paroxysmal positional vertigo
• vestibular neuronitis
• Ménière’s disease
• migrainous vertigo (when they have a migraine)
• trauma (head trauma)

Question 13

What are the central causes of vertigo?

Answer 13

• can be brain stem pathology => more typically one comptent of a complex pathology with other symptoms + examination findings
• infarcts involving vestibular nuclei in medulla e.g. stroke
• demyelination involving brain stem e.g. MS, b12, vitamin D, encephalitis
• posterior fossa mass lesions (tumour, haemorrhage, vascular malformation)
• migraine
• tumours compressing vestibular nerve
• drugs (anticonvulsants, alcohol => fluidity of Aquarius humour in cochlear affected)

Question 14

What are the signs and symptoms of vestibular neuronitis?

Answer 14

• acute attack of isolated vertigo
• with nystagmus + often vomiting
• can follow viral infections e.g. labrynthitis
• lasts days/weeks
• sometimes followed by BPV
• self limiting and rarely recurs

Question 15

What differential diagnosis are there for vestibular neuronitis?

Answer 15

• MS
• brain stem vascular lesions

Question 16

What are the signs and symptoms of benign paroxysmal positional vertigo?

Answer 16

• rotatory vertigo (sign it’s coming form the ear)
• cause => loose otoliths in posterior semi-circular canal
• precipitated by head movements to particular position => when turning in bed or sitting up
• sudden and distressing onset
• last seconds or minutes
• becomes less severe when repeated (fatigue phenomenon)
• can follow vestibular neuronitis, head injury or ear infection

Question 17

What are the signs and symptoms of Ménière’s disease?

Answer 17

• recurring episodic rotatory vertigo
• unpredicatable, sever and disabling attacks
• lasts 30 minutes => a few hours
• attacks recurr over months/years
• comes with low frequency hearing loss, feeling of fullness in ear, loss of balance, tinnitus, vomiting

Question 18

What are the signs and symptoms of tinnitus?

Answer 18

• sensation of sound when theres no auditory stimulus
• due to heightened awareness of neural activity in auditory pathways
• hissing/ringing in ears, causing distress
• causes: vascular malformation, aneurysms, vascular tumours

Question 19

What a patient says ‘dizzy’, what might this mean?

Answer 19

• feeling of spinning of self or environment (vertigo/peripheral or central vestibular disorder)
• feeling of lightheaded News and impending fainting (Pre syncope)
• feeling of altered awareness and impaired consciousness (altered consciousness/complex partial seizures, a sense of attacks)
• unsteadiness with a clear head (ataxia/cerebellum or proprioception)