Dizziness/Hearing Flashcards
A 54-year-old female presents with a complaint of dizziness. Two days ago, while riding in a friend’s car and trying to read a book, she experienced sudden extreme nausea and a “spinning” feeling that lasted for 20 minutes. She also had a headache that mainly felt like a fullness in the area around her left ear. Since then she has had only mild dizziness when she moves her head too quickly. She recalls experiencing these symptoms on two other occasions but cannot remember the circumstances, although she thinks one episode may have been related to having had too much caffeine.
A review of systems is positive for a humming in her ears over the last few years. On examination both ears appear normal. Mild horizontal nystagmus can be seen on movement of the head to the left. Audiograms are normal in the right ear, with a low-frequency hearing loss on the left.
Which one of the following is the most likely diagnosis? (check one)
Motion sickness
Meniere’s disease
Vestibular migraine
Benign positional vertigo
Meniere’s disease
This patient’s symptoms are compatible with Meniere’s disease, which is characterized by multiple episodes of vertigo lasting for 20–120 minutes, accompanied by a fluctuating hearing loss, tinnitus, and a sense of aural fullness. Audiograms will reveal a low-frequency hearing loss with an upsloping curve, which can become flattened over the years. Most patients develop unilateral symptoms, and many patients will develop bilateral disease many years after the onset of the unilateral symptoms. Multiple studies have reported the rate of bilateral Meniere’s disease to be as high as 50% many years after the initial diagnosis.
Motion sickness is a common cause of nausea, but the nausea usually does not come on suddenly and is not as pronounced as with Meniere’s disease. A vestibular migraine can present like a sudden Meniere’s disease attack but in this patient the audiograms, tinnitus, and aural fullness suggest Meniere’s disease. Benign positional vertigo is very common, and hearing loss could be an incidental finding. However, the most common form of age-related hearing loss is seen at the higher frequencies. Positional vertigo like this patient has is common between attacks of Meniere’s disease.
There is often a family history of Meniere’s disease, and there is frequently an association with allergies. The condition can also get worse with caffeine use. Even though the diagnosis is clinical, MRI and blood tests are recommended to rule out other conditions that may be putting pressure on the endolymphatic system and thus causing the symptoms.
A 54-year-old male presents with hearing loss associated with tinnitus. Which one of the
following additional characteristics would be an indication for MRI of the brain to assess for an
intracranial tumor? (check one)
A rapid onset of symptoms
Unilateral symptoms
Association with pain and otorrhea in the affected ear
Exposure to loud noise shortly before the symptoms began
Unilateral symptoms
Hearing loss and tinnitus are both common and typically benign complaints in primary care. If both are
present in only one ear, the diagnosis of acoustic neuroma, also known as vestibular schwannoma, should
be considered. Acoustic neuroma is a slow-growing benign tumor of the Schwann cells surrounding the
vestibular cochlear (8th cranial) nerve. Hearing loss associated with acoustic neuroma is typically slow in
onset. The presence of vertigo on the affected side is another symptom of abnormal function of the
vestibular cochlear nerve and should further raise suspicion of acoustic neuroma or another process
affecting that nerve. MRI is the preferred imaging study for diagnosing acoustic neuroma (SOR A).
Bilateral hearing loss is more common and is less likely to be caused by an intracranial mass. Exposure
to loud sounds can cause hearing loss unrelated to an intracranial mass. Pain and otorrhea suggest infection
rather than an intracranial tumor.
A 52-year-old male presents to your office because of increasing difficulty hearing conversations in social settings over the past 6 months. On examination the finger rub test is positive on the left ear. A Rinne test is positive on the left ear and negative on the right ear. A Weber test lateralizes to the left ear.
Which one of the following is the most likely etiology of this patient’s hearing loss? (check one)
Conductive hearing loss
Sensorineural hearing loss
Meniere disease
Ototoxic medication
Presbycusis
Conductive hearing loss
This patient notes progressive hearing loss and has a positive finger rub test on the left, which indicates the left ear is affected. The Rinne test measures bone conduction compared to air conduction in which air conduction should be greater than bone conduction. A positive test indicates that bone conduction is greater and is indicative of conductive hearing loss. When the Weber test lateralizes to the bad ear, this indicates conductive hearing loss. If the Weber test lateralizes to the good ear, then this indicates sensorineural hearing loss. This patient has conductive hearing loss, not sensorineural hearing loss. Both Meniere disease and ototoxic medications cause a sensorineural hearing loss. Presbycusis is age-related hearing loss that is typically bilateral and sensorineural.
Dizziness is most likely to have a serious etiology when it (check one)
is associated with diplopia
is associated with intense nausea and vomiting
occurs when the patient rolls over in bed
occurs when the patient first arises in the morning
occurs after 2 minutes of hyperventilation
is associated with diplopia
Diplopia, along with other neurologic symptoms such as weakness or difficulty with speech, suggests a central cause of vertigo and requires a complete workup. Dizziness on first arising, dizziness with rolling over in bed, and dizziness with nausea and vomiting are consistent with peripheral causes of vertigo, such as benign positional vertigo. Dizziness that occurs after a couple of minutes of hyperventilation suggests a psychogenic cause.
Which one of the following historical or audiographic findings in an elderly person would indicate that hearing loss is due to something other than presbycusis? (check one)
Conductive hearing loss
Bilateral hearing loss
Symmetric hearing loss
Gradual hearing loss
High-frequency hearing loss
Conductive hearing loss
Presbycusis, the hearing loss associated with aging, is gradual in onset, bilateral, symmetric, and sensorineural.
A 43-year-old male who works in a warehouse sees you because of dizziness. He first noticed mild dizziness when he rolled over and got out of bed this morning. He had several more severe episodes that were accompanied by nausea, and on one occasion vomiting occurred after he tilted his head upward to look for items on the higher shelves at work. You suspect benign paroxysmal positional vertigo, so you perform the Dix-Hallpike maneuver as part of the examination.
Which one of the following findings during the examination would confirm the diagnosis?
(check one)
Nystagmus when vertigo is elicited
Vertigo that occurs immediately following the test-related head movement
Persistence of vertigo for 5 minutes following the test-related head movement
A drop in systolic blood pressure of >10 mm Hg when supine
Nystagmus when vertigo is elicited
Benign paroxysmal positional vertigo (BPPV) originates in the posterior semicircular canal in the majority of patients (85%–95% range reported). The Dix-Hallpike maneuver, which involves moving the patient from an upright to a supine position with the head turned 45° to one side and the neck extended 20° with the affected ear down, will elicit a specific series of responses in these patients. Following a latency period that typically lasts 5–20 seconds but sometimes as long as 60 seconds, the patient will experience the onset of rotational vertigo. The objective finding of a torsional, upbeating nystagmus will be associated with the vertigo. The vertigo and nystagmus typically increase in intensity and then resolve within 1 minute from onset.
An otherwise healthy 57-year-old female presents with a sudden onset of hearing loss. She awoke this morning unable to hear out of her left ear. There was no preceding illness and she currently feels well otherwise. She does not have ear pain, headache, runny nose, congestion, or fever, and she does not take any daily medications.
On examination you note normal vital signs and find a normal ear, with no obstructing cerumen and with normal tympanic membrane motion on pneumatic otoscopy. You perform a Weber test by placing a tuning fork over her central forehead. She finds that the sound lateralizes to her right ear. The Rinne test shows sounds are heard better with bone conduction on the left and with air conduction on the right.
You refer her to an otolaryngologist for further evaluation including audiometry. You should also consider initiating which one of the following medications at this visit in order to optimize the likelihood of recovery?
(check one)
Acyclovir (Zovirax)
Amoxicillin/clavulanate (Augmentin)
Aspirin
Nifedipine (Procardia)
Prednisone
Prednisone
This patient has sudden sensorineural hearing loss (SSNHL) of the left ear without any accompanying features to suggest a clear underlying cause. An appropriate evaluation will fail to identify a cause in 85%–90% of cases. Idiopathic SSNHL can be diagnosed if a patient is found to have a 30-dB hearing loss at three consecutive frequencies and an underlying condition is not identified by the history and physical examination.
The most recent guideline from the American Academy of Otolaryngology–Head and Neck Surgery recommends that oral corticosteroids be considered as first-line therapy for patients who do not have a contraindication. While there is equivocal evidence of benefit, for most patients the risk of a short-term course of corticosteroids is thought to be outweighed by the potential benefit, especially when considering the serious consequences of long-term profound hearing loss. Because the greatest improvement in hearing tends to occur in the first 2 weeks, corticosteroid treatment should be started immediately. The recommended dosage is 1 mg/kg/day with a maximum dosage of 60 mg daily for 10–14 days.
Antiviral medications, antiplatelet agents, and vasodilators such as nifedipine have no evidence of benefit. Antibiotics also have no evidence of benefit in the absence of signs of infection.
A 67-year-old female reports hearing a ringing sound when she is in a quiet room. The ringing is not bothersome to her, but she wonders what is causing it. She has not noticed any hearing loss.
According to the American Academy of Otolaryngology—Head and Neck Surgery, neurologic imaging (such as contrast-enhanced MRI of the brain) would be indicated if
(check one)
the patient requests imaging
the tinnitus is nonpulsatile
the tinnitus is unilateral
treatment with an antidepressant such as fluoxetine (Prozac) fails
audiology testing identifies symmetric, mild, high-frequency hearing loss
the tinnitus is unilateral
Tinnitus that is bilateral and not bothersome can be treated conservatively with cognitive-behavioral therapy, sound therapy, and, if appropriate, hearing aids. Antidepressants are not recommended. Pulsatile tinnitus, unilateral tinnitus, or tinnitus associated with asymmetric hearing loss is more likely to be associated with a pathologic cause. Symmetric, mild, high-frequency hearing loss is common in elderly patients. Imaging should not be part of the routine management of tinnitus that does not have warning signs, and patients should be counseled on conservative measures as described.
The most effective therapy to improve quality of life in patients with tinnitus is: (check one)
a benzodiazepine
an SSRI
transcutaneous electrical nerve stimulation (TENS)
acupuncture
cognitive behavioral therapy
cognitive behavioral therapy
Tinnitus is the sensation of hearing an abnormal sound, such as a ringing, buzzing, or clicking, that is perceived in the ear or head in the absence of an internal or external source. Cognitive behavioral therapy is the only treatment that has been shown to improve quality of life in patients with tinnitus. Treatments that should be avoided include benzodiazepines, transcutaneous electrical nerve stimulation (TENS), and acupuncture. An SSRI could be considered for the management of tinnitus-associated anxiety, but is not considered the most effective therapy for tinnitus.
In addition to a thorough history and physical examination, the routine evaluation of patients presenting with syncope should include (check one)
a CBC, comprehensive metabolic panel, TSH level, and urinalysis
orthostatic blood pressure measurements and an EKG
cardiac stress testing
echocardiography and Doppler ultrasonography of the carotid arteries
CT or MRI of the brain
orthostatic blood pressure measurements and an EKG
Orthostatic blood pressure measurement and an EKG are indicated in the routine evaluation of patients with
syncope. All other testing should be directed by findings obtained in the history and on the physical
examination.
