Dizziness

Question 1

What is vertigo?

Answer 1

A sensation of movement, usually spinning

Question 2

Not all dizziness is otogenic- how can pathology in the following organs lead to dizziness?

a) the eye
b) the brain
c) the CV system

Answer 2

a) Cataracts- impair vision. Diabetes mellitus retinopathy
b) Stress, migraine, space occupying lesion, MS
c) Cardiac arrhythmia, postural hypotension

Question 3

What is the purpose of the vestibule-ocular reflex?

Answer 3

Allows reflex eye movements to compensate for head movements in order to keep a steady image on the retina

Question 4

What is the role of the abducens nerve?

Answer 4

Controls movement of the lateral rectus muscle

Question 5

The medial rectus muscle is controlled by which nerve?

Answer 5

Oculomotor

Question 6

What is the clinical significance of the vestibular-ocular reflex?

Answer 6

Nystagmus will be seen in vestibular pathologies; most non-vestibular pathologies will not cause nystagmus

Question 7

Which questions should be asked in a dizziness history?

Answer 7

Triggers
Time course/onset
Associated symptoms especially deafness, tinnitus, vomiting
Alleviating factors
Any current medication

Question 8

What are common causes of dizziness (non-otogenic)?

Answer 8

Postural (Hb, Sodium, BP lying/standing)
Side effect of medication (history)
Psychogenic and interaction with imbalance

Question 9

What are the core symptoms of Meniere’s disease?

Answer 9

Vertigo, tinnitus, aural fullness, sensorineural hearing loss

Question 10

What is the hallmark of Meniere’s disease?

Answer 10

Fluctuating and episodic pattern of disease

Question 11

How can audiometry help diagnose Meniere’s disease?

Answer 11

Show sensorineural hearing loss

Question 12

What ENT diseases should be considered in a differential diagnoses of vertigo?

Answer 12

Meniere’s disease, benign positional paroxysmal vertigo, acute vestibular neuronitis

Question 13

What should be excluded in any patient with unilateral deafness, tinnitus and/or facial nerve palsy? How would this be achieved?

Answer 13

Acoustic neuroma (vestibular Schwannoma). MRI brain scan

Question 14

How is Meniere’s disease managed non-surgically?

Answer 14

Supportive measures- lifestyle advice: occupation, diet (avoid salt, caffeine, alcohol), stress
Therapy for tinnitus
Hearing aids

Question 15

What drug might be trialled in Meniere’s disease prophylaxis?

Answer 15

Betahistine (anti-vertigo drug)

Question 16

What more invasive treatments can be tried for Meniere’s disease?

Answer 16

Grommet insertion (micropressure therapy)
Intratympanic gentamicin (may cause a degree of sensorineural hearing loss)
Intratympanic steroids
Surgery

Question 17

What is the most common cause of vertigo on looking up?

Answer 17

Benign positional paroxysmal vertigo

Question 18

What is BPPV?

Answer 18

Attacks of vertigo triggered by head movements (such as looking up, turning in bed, getting out of bed, bending forward, moving head quickly). May be more noticeable in certain directions

Question 19

What is the underlying cause of BPPV?

Answer 19

Displacement of otoliths from the utricle into the semicircular canal (usually the posterior canal) causing abnormal fluid displacement which continues even when movement has stopped

Question 20

Which test is used to clinically confirm posterior canal BPPV?

Answer 20

Dix-Hallpike test. Patient sits on couch so that head will be off the end if they lie down, ask patient to turn head to 45 and warn not to close eyes if dizzy, lie the patient back as quickly as possible, hold in position and observe

Question 21

What constitutes a positive Dix-Hallpike test?

Answer 21

Nystagmus- usually a delay of around 30 seconds

Question 22

How does vestibular neuronitis present?

Answer 22

Prolonged vertigo (days) with no associated tinnitus or hearing loss

Question 23

How does labyrinthitis differ from vestibular neuronitis?

Answer 23

There may be associated tinnitus or hearing loss

Question 24

How are vestibular neuronitis and labyrinthitis treated?

Answer 24

Supportive with vestibular sedatives
Usually self limiting so if prolonged may require further investigation
In prolonged cases rehabilitation exercises may help

Question 25

What proportion of migraine patients experience vertigo?

Answer 25

Around 25%

Question 26

What disease may BPPV be confused with? What other symptoms need to present for this diagnosis to be made?

Answer 26

Vertebrobasilar insufficiency

Need other central neurological symptoms + vertigo, e.g. visual disturbance, weakness, numbness

Question 27

Why is it uncommon for brainstem causes of vertigo to present as vertigo alone?

Answer 27

Brainstem nuclei and tracts are confined within a small space

Question 28

Presentation of vestibular schwannoma? (4)

Answer 28

Vertigo
Unilateral deafness and tinnitus
Unilateral facial palsy
Unilateral loss of corneal reflex

Question 29

Minimum bedside assessment of a patient with vertigo/dizziness? (6)

Answer 29

Eye movements checking for nystagmus, internuclear opthalmoplegia
Assessment of hearing, otoscopy
Head impulse test- test the vestibulo-ocular reflex
Hallpike manouevre
Cranial nerve examination
Cerebellar examination

Question 30

How is the head impulse test performed and how should it be interpreted?

Answer 30

Ask patient to fix on distant object
Examiner turns patients head rapidly 15 degrees

If saccades (voluntary movement) of eyes towards target then there is a unilateral vestibulopathy on the side being tested