Dizzy patient Flashcards
What is dizziness?
Non-specific term which can cover vertigo, pre-syncope, disequilibrium and others
What is vertigo?
Sensation of movement (usually spinning)
What are the end organs of the inner ear?
Saccule, urticle, three ampulla (cupula) of the semicircular canals
What is the structure of the inner ear called?
Labyrinth
Name the two parts of the labyrinth
Bony and membranous labyrinth
What type of movement do the semicircular canals sense?
Rotational
What type of movement do the urticle and saccule sense?
Linear acceleration
What are the components of the balance system?
Inner ear Eyes Joints (proprioception) Brain Heart
List the pathologies affecting the inner ear which may affect the balance system
BPPV
Menieres
Vestibular neuronitis
List the pathologies affecting the eye which may affect the balance system
Any pathology which causes visual loss (e.g diabetic retinopathy, cataracts)
Sight is important as horizontal and verticals will be used by the brain to correct balance. T/F
True buddy
List the pathologies affecting the joints which may affect the balance system
Diabetes neuropathy
Arthritis
Neurological conditions
List the pathologies affecting the heart which may affect the balance system
Arrhythmia
Postural hypotension
(heart causes pre-syncope not vertigo)
List the pathologies affecting the brain which may affect the balance system
Stress
Migraine
Space occupying lesion
Multiple sclerosis
Explain the vestibulo-ocular reflex
Horizontal movement of the head causes excitation at one side of the cupula and inhibition at the other side allowing fixed focus of the eyes despite movement (the image therefore remains in the centre of the visual fields thus stabilising vision)
(head moves to right -> right side of cupula excited ; left side of cupula inhibited)
What, apart from head movement, can stimulate the vestibulo-ocular reflex? This can be used to elicit clinical signs
Cold water/air
Why is the vestibulo-ocular reflex important clinically?
In vestibular, and some central, pathologies nystagmus will be observed (direction dependent on exact site of pathology)
What is important to test with regard to vestibular function?
Test for nystagmus
How common is dizziness?
Extremely common, particularly in the elderly
List possible causes of dizziness
CVS Haematological Metabolic Anxiety Trauma (fracture) Otological Neurological Drug side effects Migraine
Which medications are particularly implicated in dizziness?
Benzodiazapines
Anti-psychotics
Anti-depressants
Which examinations are important to perform on a patient with dizziness?
Otoscope Neurological Sitting and standing blood pressure Balance (Rombergs test) Audiometry
What is Rombergs test?
Standing patient is asked to close their eyes (positive if there is a loss of balance)
What are the most common causes of dizziness?
Postural hypotension
Medication side effect
Psychogenic
What is the typical history of someone with postural hypotension?
Dizziness comes on when rising from sitting/lying down
What are the causes of vertigo?
Menieres BPPV Vestibular neuronitis Labrynthitis Migranous vertigo
How common is benign positional paroxysmal vertigo?
Very common
When does BPPV typically occur?
Upon looking upwards (or on movement in a specific direction e.g turning over in bed)
What are the causes of BPPV?
Head trauma
Ear surgery
Idiopathic
How does BPPV occur?
Otolith material from urticle gets displaced into the semicircular canals
(commonly posterior SCC hence problem on looking up)
How long does episodes of vertigo with BPPV last?
Seconds (at most a minute)
What sign will be seen in BPPV?
Nystagmus
What condition can BPPV be confused with?
Vertebrobasilar insufficiency
How does vertebrobasilar insufficiency present?
Vertigo associated with:
- visual disturbance
- weakness
- numbness
What is vertebrobasilar insufficiency?
Impaired circulation to the posterior brain (pinching of arteries)
How does BPPV present?
Vertigo induced by:
- looking up
- turning over in bed
- laying down
- getting up in the morning
- bending forward
- rising from bending
- moving head quickly in one direction
Brief episodes (possibly with slight delay in symptom onset)
NO associated tinnitus, hearing loss or aural fullness
What can be done clinically to test for and treat BPPV?
Diagnosis
- Hallpike test
Treatment
- Epley manoeuvre
- Semont manoeuvre
- Brant-daroff exercises
How is the hallpike test performed?
Sit patient down so that upon lying back their head will be off the end of the bed >
Turn head 45 degrees to one side >
Warn patient not to close their eyes if dizzy >
Lie back as quickly as is comfortable with neck in extension >
Hold in position and observe for nystagmus (may be bilateral)
May be delay of up to 30 seconds
What needs to be noted about the hallpike test?
It fatigues - reduced or absent response on immediate repetition
How is the epley manoeuvre performed?
Sit the patient down so that upon lying back their head will be off the end of the bed >
Turn head 45 degrees to the side of nystagmus >
Lie back as quickly as is comfortable with neck in extension >
Remain in this position for at least 30 seconds >
Rotate the patients head 90 degrees in the opposite direction >
Remain in this position for at least 30 seconds >
Roll patient onto their shoulder and rotate head a further 90 degrees (looking downwards at 45 degrees) >
Remain in position for at least 30 seconds >
Slowly bring patient up to sitting position with head in same direction >
Hold for 30 seconds
Repeat as needed
After treating BPPV what is it important to tell patients not to do?
Lie flat for the first couple of nights after treatment
Which manoeuvre to treat BPPV can be carried out by the patient themselves?
Brant-daroff exercise
How can resistant BPPV be treated in the last instance?
Surgery to block the semi-circular canals
How does vestibular neuronitis present?
Prolonged vertigo (days)
Cold-like symptoms
NO associated tinnitus or hearing loss
What causes vestibular neuronitis?
Virus causing inflammation of vestibular nerve
How common is vestibular neuronitis?
Common
How does labyrinthitis present?
Prolonged vertigo (days)
Cold-like symptoms
May be associated tinnitus and/or hearing loss
What causes labyrinthitis?
Virus
How can vestibular neuronitis and labyrinthitis be managed?
Supportive Vestibular sedatives (prochlorperazine)
(self-limiting)
When should vestibular neuronitis or labyrinthitis be investigated?
When episodes are unusually prolonged and/or atypical
When might rehabilitation exercises be useful in the management of vestibular neuronitis or labyrinthitis?
When cases are prolonged
What complications can sometimes result from labyrinthitis? What is the course of these complication?
Permanent hearing loss
Permanent balance loss
Balance loss is usually compensated for over time (+/- rehabilitation exercises)
What causes meniere’s disease?
Dunno
What is endolymphatic hydrops?
A condition of enlarged endolymphatic space which is thought to occur in conjunction with meniere’s
(however not all people with EH have menieres!)
How does menieres disease present?
Recurrent, spontaneous and rotational vertigo where at least two of the episodes last >20 mins (hours)
Worsening tinnitus on affected side
Aural fullness on affected side
SNHL on at least one occasion
Meniere’s is a disease of exclusion. T/F
True - mostly anyway
How is hearing affected in meniere’s?
Each episode causes progressively worse hearing loss and can cause deafness
Is meniere’s bilateral?
Not usually but it happens
How should meniere’s be investigated?
Audiometry MRI (MUST exclude schwannoma)
Which frequency is typically lost in meniere’s?
Low
How is meniere’s managed?
Supportive during episodes Tinnitus therapy Hearing aids Grommet insertion + meniette Intratympanic gentamicin/steroids (kill nerve) Surgery
What MAY help with the prevention of episodes in meniere’s disease?
Salt restriction
Betahistamine (reduces frequency of attacks)
How may a migraine present?
Headache Vertigo Ataxia Phonophobia Fluctuating hearing loss (rare) Acute permanent hearing loss (very rare) Motion sickness
How common is menieres?
Uncommon!
