ENT - Vertigo

Question 1

A 26yo man presents to the GP with a 12hr Hx of sudden onset severe vertigo. He has been unable to go to work because of this, and has felt nauseous and vomiting x4. He denies any hearing loss or tinnitus. Neuro exam: unidirectional horizontal nystagmus, nil else.

What is the likely diagnosis? How would you manage?

Answer 1

Vestibular neuritis

Mx:

• reassurance (usually self-limiting within 3-7/7) + encourage activity to hasten vestibular compensation
• safety net r/e neuro signs
• if symptomatic relief required: CYCLIZINE or PROCHLORPERAZINE (vestibular sedative, D2 R antagonist)

Question 2

A 65yo woman presents to GP complaining of brief episodes of dizziness lasting about 30 secs multiple times a day. Worse in mornings with head movement. Denies any hearing loss or tinnitus. Neuro exam: NAD.

What is the likely diagnosis and how would you confirm this? How would you manage?

Answer 2

BPPV

Confirm with Dix-Hallpike test: vertigo + rotatory nystagmus induced on affected side

Mx:

1. conservative
2. Epley’s manoeuvre
3. Brandt-Daroff exercises

Question 3

A 46yo man presents with a progressive hearing loss in his left ear over the last couple of years (noticed when trying to speak on phone on that side). In the last few months he has noticed increasing dizzy episodes and vague left sided facial numbness.

What is the likely diagnosis and how would you confirm this? How would you manage?

Answer 3

Acoustic neuroma

Ix: audiogram (sensorineural hearing loss) + brain MRI

Mx:

• if small + non-progressive: observe
• focused RT or surgery

Question 4

An 18yo male presents with 1 day Hx of sudden onset severe vertigo, N+V, hearing loss + tinnitus. Unidirectional nystagmus is noticed on examination. He reports a mild URTI 3/7 ago.

What is the likely diagnosis and how would you assess this? How would you manage?

Answer 4

Labyrinthitis

Ix: audiogram: sensorineural hearing loss (document extent)

Mx:

• reassurance (self-limiting over 3-7/7) + encourage activity to hasten vestibular compensation
• safety net r/e neuro Sx
• short term CYCLIZINE or PROCHLORPERAZINE for symptomatic relief
• PREDNISOLONE 20mg PO TDS 10-14/7 with 5/7 taper due to acute hearing loss

Question 5

A 40yo woman presents with a 1yr Hx of recurrent episodes of vertigo lasting 20mins-2hrs, associated with nausea. Also reports right sided tinnitus + hearing loss more pronounced at times of vertigo attacks. O/E she is unable to maintain position during Romber’s test and is unable to tandem walk (turns towards right side).

What is the likely diagnosis and how would you assess this? How would you manage acute attacks? Long term?

Answer 5

Meniere’s disease

Ix: serial audiograms +/- brain MRI

Acute Mx

• PROCHLORPERAZINE
• if sudden hearing loss: PREDNISOLONE 20mg TDS PO for 14/7 then taper
• white noise generators for tinnitus
• vestibular + balance rehab

Long term Mx

• notify DVLA
• hearing aid
• low sodium diet +/- THIAZIDE DIURETICS or ACETAZOLAMIDE: to prevent fluid accumulation in endolymphatic system
• BETAHISTINE: labyrinth vasodilator
• 2nd line: endolymphatic sac decompression, intratympanic steroid injection, intratympanic gentamicin injection (vestibular destruction), surgical labyrinthectomy

Question 6

You are assessing a patient presenting with constant vertigo over last 3 days. O/E: nystagmus but no other neuro signs.

How would you differentiate a peripheral vs central cause?

Answer 6

HINTS exam:

• Head impulse test: if +ve (corrective saccade) indicates peripheral cause
• Nystagmus: if unidiretional = peripheral, if vertical/bidirectional = central (cerebellum stroke)
• Test of Skew: abnormal movement + vertical diplopia = central