Dizziness/Vertigo

Question 1

Benign Paroxysmal Positional Vertigo (BPPV)

Answer 1

• definition:
  
  • peripheral vertigo d/t displaced otolith particles within the semicircular canals of the inner ear (Canalithiasis)
• Etiology:
  
  • idiopathic, post-traumatic, viral
• Most common cause of peripheral vertigo. Frequently recurrent.
• S/sxs:
  
  • *Recurrent Episodes
  • -Sudden, episodic peripheral vertigo: lasting for less than 1 minute, provoked with specific head movements
• PE:
  
  • Dix Hallpike: produces fatigable rotary nystagmus, dependent ear is the culprit
  • NO HEARING LOSS or tinnitus
• Dx:
  
  • clinical dx
• Tx:
  
  • Self-Limiting. Medical therapy not usually needed
  • -Epley maneuver: canalith repositioning procedure, mainstay of tx
  • -Vestibular rehab therapy
  • -surgery: Singular neurectomy, posterior semicircular canal occlusion

Question 2

Superior Canal Dehiscence Syndrome

Answer 2

• Definition:
  
  • dehiscence (opening) in the temporal bone overlying the superior semicircular canal of the inner ear → 3rd window phenomenon
• Etiology:
  
  • slow erosion of bone, trauma, congenital (rare)
• S/sxs:
  
  • Transient vertigo induced by recumbency, valsalva, loud sound, or change in middle ear pressure
  • -Chronic Disequilibrium
  • -may develop sensorineural hearing loss
• PE:
  
  • Eye movement with loud noises, fistula test (blowing air into the ear canal), or tragal compression
• Dx:
  
  • can be a clinical dx
  • CT temporal bone: thinning or loss of bone over semicircular canal
• Tx:
  
  • Often sxs are mild enough that patients can live normally with them
  • -Superior semicircular canal ablation
  • -Superior Semicircular canal resurfacing

Question 3

Meniere’s Disease

Answer 3

• Definition:
  
  • idiopathic distention of the endolymphatic compartment of the inner ear d/t excess fluids
• Etiology:
  
  • unknown; overproduction of endolymph, under resorption of endolymph, autoimmunity, viral injury, genetic defect
• S/sxs:
  
  • *Usually unilateral
  • -Episodic peripheral vertigo
  • -Fluctuating sensorineural hearing loss
  • -Fluctuating low pitch tinnitus
  • -Fluctuating aural pressure
  • **THEME: all symptoms occur together & fluctuate
• PE:
  
  • Otoscopy: usually normal
  • -Hennebert’s sign: may elicit dizziness
  • -Tullio’s phenomenon: may elicit dizziness
  • -Full neuro exam
• Dx:
  
  • Clinical Dx
  • Audiogram: mild chronic low frequency sensorineural hearing loss, can track fluctuations
  • -MRI with gadolinium: r/o acoustic neuroma
  • -Labs: TPPA, ESR, ANA, CMP, CBC, tSH; r/o autoimmune disorders
  • -ENG/VNG: if suspect bilateral Meniere’s
• Tx:
  
  • 1st line management:
  • -low salt diet (<2000mg/day): mainstay of treatment
  • -Diuretics: thiazides, potassium sparing
  • -Vestibular supplements: meclizine → short term only; valium

Question 4

Labyrinthine Injury

Answer 4

• Vestibular neuritis:
  
  • inflammation of the vestibular portion of CN VIII: Proceeded by URI
• Labrinthitis:
  
  • inflammation of the vestibular & cochlear portion of CN VIII. Proceeded by URI.
• Vascular Injury:
  
  • cerebellar stroke or vestibular basilar ischemia
• Labyrinthine Concussion:
  
  • cerebellar stroke or vestibular basilar ischemia
• S/sxs:
  
  • *Severe acute onset of sxs
  • -Continuous spinning vertigo
  • -N/V
  • -Blurred vision
  • -Oscillopsia: unable to fixate on object
  • -Unilateral hearing loss
• PE:
  
  • -Normal neurologic exam: focus on eye & neurologic exam
• Dx:
  
  • -Audiogram
  • -MRI
  • -Labs
• Tx:
  
  • Gradual resolution of sxs over days to weeks
  • -Symptomatic relief: vestibular suppressants, antiemetics
  • -Vestibular rehabilitation: if delay in recover after a few weeks

Question 5

Vestibular Migraine

Answer 5

• General Info:
  
  • Underrecognized. 27% of migraine patients experience vertigo. Second most common cause of vertigo.
• S/sxs:
  
  • -Dizziness: lasting several minutes to hours, often independent of headache
  • -Motion intolerance
  • -Visual disturbances: diminished eye focus, photosensitivity
  • -Spatial disorientation
  • -Sound sensitivity, tinnitus
  • -Ear fullness
  • -”Brain fog”
• PE:
  
  • Ask pt to keep a log of their diet & activity to find trigger
• Ddx:
  
  • Mimics Meniere’s: vestibular migraine does NOT have hearing loss or a temporal relationship
• Tx:
  
  • Antimigraine meds unlikely to help
  • -Migraine prophylaxis
    
    • -Beta-blockers, anticonvulsants, CCB, TCA
  • -Vestibular rehab
  • -Diet: avoidance of caffeine, chocolate, nuts, alcohol, aged cheese, processed meats
  • *Best management is trigger avoidance

Question 6

Acoustic Neuroma (Vestibular Schwannoma)

Answer 6

• Definition:
  
  • benign tumor involving Schwann cells which produce myelin sheath
• Pathophys:
  
  • compresses the vestibular system nerve
• S/sxs:
  
  • -Unilateralsensorineural hearing loss
  • -Tinnitus
  • -+/- dizziness
• Dx:
  
  • MRI with gadolinium
• Tx:
  
  • Surgery or radiation therapy