Dizziness and balance

Question 1

What neurological symptoms should you inquire about?

Answer 1

Sensory - numbness and tingling, visual, eye pain
Motor - weakness, difficulty with ADLs
Speech and swallow
Headaches
Seizures and blackouts
Constitutional - Weight loss, appetite, fever, night sweats

Question 2

What PMH should you specifically inquire about?

Answer 2

Strokes
Infections
Trauma

Question 3

What are the typical features in the history of ACUTE LABYRINTHITIS?

Answer 3

SUDDEN ONSET, ACUTE

Can be SEVERE

NAUSEA AND VOMITING

NO deafness or tinitus (sudden deafness = emergency)

VIRAL or VASCULAR in ORIGIN

Question 4

What are the typical features in the history of MENIERE’S DISEASE?

Answer 4

VERTIGO (at least 2 spontaneous attacks lasting at least 20 minutes within a single attack)

TINNITUS
AURAL FULLNESS

PRECIPITATED by SALTY food, ALCOHOL, COFFEE

(sensorineural hearing loss on Rinne’s or Webber’s, peripheral vestibular nystagmus present during attacks)

Question 5

What are the typical features in a history of thiamine deficiency?

Answer 5

Chronic alcoholism
Anorexia nervosa
Prolonged, severe, excessive vomiting
GI surgery or malabsorption

Imbalance, ataxic gait
Nystagmus
Abnormal ocular motility

COGNITIVE IMPAIRMENT

Question 6

What are the typical features in alcohol-related cerebellar degeneration?

Answer 6

Chronic history of alcohol abuse (>10 years)
Gradual onset of symptoms

IMBALANCE
GAIT ATAXIA
TREMOR
DYSARTHRIA

Question 7

What are the typical features in PARKINSONS that may be present on examination?

Answer 7

Top to toe

Myerson’s sign
Hypometric saccades
Hypophonic voice
Masked facies

Stooped posture
Decreased arm sing
Cogwheel rigidity
Pill rolling tremor
Slow finger movements

Bradykinesia
Slow shuffling gait
Postural instability

Question 8

What are the typical features on examination of PERIPHERAL NEUROPATHY?

Answer 8

Loss of PROPRIOCEPTION and SENSATION in LOWER EXTREMITIES

SENSORY ATAXIA

LOWER EXTREMITY WEAKNESS

GAIT difficulties

POSITIVE rhombergs sign

Question 9

What are the key features in the history of peripheral neuropathy?

Answer 9

Numbness in LOWER EXTREMITIES

PARAESTHESIA

LOWER EXTREMITY WEAKNESS

Difficulty with GAIT

FALLS!

Question 10

What are the key features in the history of Acoustic Neuroma / Vestibular Schwannoma?

Answer 10

UNILATERAL Hearing loss
DIZZINESS
BALANCE difficulty

With larger tumours

• Focal Neurological Deficit: facial NUMBNESS / WEAKNESS
• Symptoms of RAISED ICP

Question 11

What are the key features in the history of OTOTOXICITY?

Answer 11

DEAFNESS and TINITUS

Use of ototoxic drugs; streptomycin, vancomycin, gentamicin, chloroquines, chemotherapy

Question 12

What are the key features of RAMSAY HUNT SYNDROME?

Answer 12

EXTREMELY PAINFUL BLISTERED EXTERNAL MEATUS

Accompanied by

• Unilateral facial weakness
• Deafness, Tinnitus and Vertigo

Question 13

What is the management of BPPV?

Answer 13

Epley manoeuvre

Question 14

What is the management of acute labyrinthitis?

Answer 14

Bed rest

Antiemetics

Question 15

What is the management of Menier’s disease?

Answer 15

LOW SALT DIET
AVOID alcohol, caffeine and tobacco

PROPHYLACTIC BETAHISTINE may help
ANTIEMETICS for acute ATTACKS
HEARING AIDS

Question 16

What is the management of acoustic neuroma?

Answer 16

WATCH and WAIT

If GROWING, consider SURGERY or RADIOTHERAPY

Question 17

What is the management of Herpes Zoster Oticus (aka Ramsay Hunt Syndrome)?

Answer 17

Analgesia

Acyclovir within 72 hours of rash onset