Dizzy Patient

Question 1

Define dizziness?

Answer 1

Non-specific term that covers vertigo, pre-syncope, disequilibrium, etc

Question 2

Define vertigo?

Answer 2

Sensation of movement, usually SPINNING; this can be a feeling of the room spinning or of themselves spinning

Question 3

Structure of the inner ear?

Answer 3

Labyrinth is a complex structure with bony and membranous structures; membrane separates perilymph from endolymph

Question 4

What are the 5 vestibular end-organs?

Answer 4

• Ampullae of superior, posterior and lateral semi-circular canals
• Maculae of the utricle and saccule

Question 5

Central pathways of hearing and balance?

Answer 5

Vestibulospinal tract

Medial longitudinal fasciculus and ocular muscles (vestibulo-ocular reflex)

Medial lemniscus, thalamus and cerebellum

Cerebellum (via inferior cerebellar peduncle)

Question 6

Systems involved with the balance systems?

Answer 6

Vestibular, ocular and joints - influence the brain and heart

Question 7

3 diseases that influence the vestibular system and cause dizziness?

Answer 7

• BPPV
• Ménière’s disease
• Vestibular neuronitis

Question 8

2 examples of diseases that influence the eyes and can cause dizziness?

Answer 8

• Cataracts

* Diabetes Mellitus

Question 9

3 examples of diseases that influence the joints and can cause loss of proprioception (potential dizziness)?

Answer 9

• Diabetes mellitus
• Arthritis
• Neurology

Question 10

2 examples of diseases/processes that arise from the CV system to cause dizziness?

Answer 10

• Arrhythmias

* Postural hypotension

Question 11

4 examples of diseases that affect the brain and can cause dizziness?

Answer 11

• Stress
• Migraine
• SOL (space-occupying lesion)
• MS (multiple sclerosis)

Question 12

Describe how the vestibulo-ocular reflex occurs

Answer 12

Eyes should be able to fix on an object (due to a compensatory eye movement) when turning one’s head

Due to excitation of extra-ocular muscles on 1 side and inhibition on the other side

Question 13

Effect of vestibular pathologies on the vestibulo-ocular reflex?

Answer 13

Can cause NYSTAGMUS, the direction of which depends on the inv. structures

Question 14

How can nystagmus be used to narrow the DD?

Answer 14

Most non-vestibular pathologies do not cause nystagmus, e.g: hyperventilation or anaemia

If nystagmus if accompanied by some of the 7 Ds, it is more likely to have an otological cause

Question 15

Potential causal areas in dizziness?

Answer 15

CV, haematological and metabolic issues

Neurological conditions

Otological conditions

Anxiety

Drug (anti-hypertensives) side effects/interactions

Migraine

Trauma

Question 16

Hx questions to consider with dizziness?

Answer 16

Triggers, e.g: certain movements

Time course

Assoc. symptoms, e.g: 7 Ds

Precipitating and alleviating factors

DH

Question 17

Examination of the dizzy patient should include?

Answer 17

Otoscopy and audiometry

Neurological system

BP (on lying and standing)

Balance system

Question 18

How to perform Hallpike’s test for BPPV?

Answer 18

Sit on couch so that head is off the end when they lie back; turn the head 45 degrees to the right

WARN PATIENT NOT TO CLOSE EYES IF THEY ARE DIZZY (test often does not work well when being repeated)

Lie back as quickly as possible and hold in position and observe

Question 19

Cautions with Hallpike’s test?

Answer 19

Usually, there is a delay of ~30 seconds before the nystagmus is seen

Condition MAY be bilateral

Question 20

How to confirm BPPV with Hallpike’s test?

Answer 20

If the test is done for a 2nd time/with repetition, response should be reduced/absent

Question 21

How to perform the Epley Manoeuvre?

Answer 21

……….

Question 22

How to perform Brandt-Daroff exercise?

Answer 22

……….

Question 23

Why is intratympanic gentamicin/steroids given for Ménière’s disease?

Answer 23

For severe attacks; by this point, it is likely the patient has severe hearing impairment

Toxic to middle ear and so they deaden the vestibular apparatus

Question 24

Examples of surgeries used in Ménière’s disease?

Answer 24

Rare as they have a high rate of complications, esp. when compared to intratympanic gentamicin injection

E.g: labyrinthectomy or vestibular nerve section

Question 25

Differences between:
• BPPV
• Ménière's 
• Labyrinthitis
• Vestibular neuronitis

Answer 25

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