ENT - Vertigo Flashcards
What is vertigo?
Sensation that there is movement between the patient and their environment
May feel they are moving or the room is spinning
Often horizontal spinning sensation
What are common symptoms associated with vertigo?
Nausea
Vomiting
Sweating
Feeling generally unwell
What sensory inputs are responsible for maintaining balance and posture?
- Vision
- Proprioception
- Signals from the vestibular system
Mismatch can lead to vertigo
Where is the vestibular apparatus located?
Inner ear
Consists of semicircular canals filled with endolymph
What is the role of stereocilia in the vestibular system?
Detects fluid shifts in the semicircular canals
Fluid causes the stereocilia to bend and generate action potentials which are relayed by the vestibular nerve to detective movement
Outline how balance works
Endolymph in the semicircular canals moves this causes the stereocilia to bend and generate action potentials
Vestibular apparatus transmits APs to vestibular nerve > Vestibular nucleus in the brainstem and cerebellum
Vestibular nucleus then sends signals to oculomotor, trochlear and abduces nuclei to control eye movements and the thalamus, spinal cord and cerebellum
What is the cerebellum responsible for?
Coordinating movement throughout the body
What are the two main causes of vertigo?
- Peripheral problems - vestibular system
- Central problems - brainstem or cerebellum
What are the main causes of peripheral vertigo?
Benign paroxysmal positional vertigo
Ménière’s disease
Vestibular neuronitis
Labyrinthitis
Less common :
Trauma to vestibular nerve
Vestibular nerve tumours
Otosclerosis
Hyperviscosity syndromes
Varicella zoster infection
What is Benign Paroxysmal Positional Vertigo (BPPV)?
Peripheral cause of vertigo
Calcium carbonate crystals otoconia become displaced into semicircular canals
Can be displaced by viral infection, trauma, ageing or idiopathic
Symptoms are positional as movement required to move crystals and bend stereocilia
Therefore veritgo triggered movement
Lasts around a minute before settling
What manoeuvres are used for BPPV?
Watch video
Dix Hallpike
Diagnosis
Moves endolymph through sermicircular canals and triggers vertigo
Check for neck pain or pathology
Triggers rotational nystagmus and vertigo
Eye will have rotational beats of nystagmus towards affected ear - clockwsie with left ear and anti-clockwise with right
Epley
Treatment
Move crystals in the semicircular canal into a position that does not disruput endolymph flow
What exercises can be used for BPPV?
Brandt-Daroff exercises
Repeated several times a day until symptoms improve
What is Ménière’s disease characterized by?
- Excessive buildup of endolymph - causes higher than normal pressure
- Attacks of hearing loss
- Tinnitus
- Vertigo
- Sensation of fullness in the ear
- Spontaneous nystagmus
Not positional symptoms
Outline AVN and Labyrinthitis
Acute vestibular neuronitis
Inflammation of vestibular nerve
Due to viral infection
Acute onset vertigo that improves over a few weeks
Labyrinthitis
Inflammation of inner ear structures
Due to viral infection
Acute onset of vertigo that improves
Hearing loss
What distinguishes acute vestibular neuronitis from labyrinthitis?
Labyrinthitis can cause hearing loss; vestibular neuronitis does not
What are some common causes of central vertigo?
Posterior circulation infarction
- Sudden onset
- Can have associated symptoms, ataxia, diplopia, cranial nerve defects or limb symptoms
Tumour
Cerebellum or brainstem
Gradual onset with associated features
MS
Relapsing and remitting symptoms
Other features of MS e.g. optic neuritis or transverse myelitis
Vestibular migraine
Symptoms lasting minutes to hours
Visual aura and headache
Can be triggered by :
- Stress
- Bright lights
- Strong smells
- Certain foods
- Dehydration
- Menstruation
- Abnormal sleep patterns
What symptoms are associated with central causes of vertigo?
Sustained, non-positional vertigo
Complete the table
What do each of these key features alongside vertigo suggest?
Recent viral illness
Headache
Typical triggers
Ear symptoms, pain or discharge
Acute onset neurological symptoms
Recent viral illness - labyrinthitis or vestibular neuronitis
Headache - vestibular migraine, cerebrovascular accident or brain tumour
Typical triggers - vestibular migraine
Ear symptoms - infection
Acute onset neurological smyptoms - stroke
What must you examine in patients presenting with vertigo?
Ear
Neurological
Cardiovascular
Cerebellar
HINTS
Romberg’s
Dix-Hallpike
What does the HINTS examination stand for?
Look up video for this
- Head Impulse
- Nystagmus
- Test of Skew
Used to distinguish between central and peripheral vertigo
What does the head impulse test assess?
The function of the vestibular system during head movements
Normally functioning vestibular system, patient can keep eyes on examiners nose
Abnormal vestibular system - eyes saccade as they fix back on examiner
Can diagnose a peripheral cause of vertigo, normal if patient has no current symptoms or central cause
What do different types of nystagmus suggest?
Unilateral horizontal - peripheral cause
Bilateral or vertical - central cause
What indicates a central cause in the test of skew?
Vertical correction when an eye is uncovered
What are short-term management options for peripheral vertigo?
- Prochlorperazine
- Antihistamines (e.g., cyclizine, cinnarizine, promethazine)
Central needs further investigation - CT or MRI head
What can be used to help reduce attacks in Meniere’s?
Betahistine
What lifestyle changes can help manage vestibular migraine?
- Avoiding triggers
- Getting enough sleep
- Staying hydrated
Triptans for acute symptoms
Propranolol, topiarmate or amitriptyline to prevent attacks
What is the DVLA guideline for patients with episodes of disabling dizziness?
Patients must not drive and must inform the DVLA
