HEENT vertigo Flashcards
some differential diagnosis from the cochleovestibular system for vertigo
infection: serous otitis media, vestibular neuronitis, syphilis,
degenerative: aging
developmental: arnold-chiari malformation
tumor: cholesteaoma, acustic neuroma, glomus tumors,
vascular: infarction of labyrinthine artery, intralabyrinthine hemorrhage
ototoxins: aminoglycosides: loop diuretics
disorders of bone metabolisums
menieres disease
trauma: perilymph (labyrinthine) fistula, superior canal dehiscence
some differential diagnosis from the nervous system for vertigo
vascular: hyperventilation (anxiety) , migraine,
tumor: neoplasia, metastatic carinoma,
developmental: malformation of the base of the skull
peripheral neuropathy: DM, ethanol, B3/12 deficiency, Tabes dorsalis
infection: meningitis
seicure disorders: temporal lobe
dymyelinating disorders: MM sclerosis
some differential diagnosis from the cardiovascular system for vertigo
circulatory : hypovolemia, anemia, polycythemia, OTHORSTATIC HYPOTENSION
Great vessels: subclavian steal
cardiac: arrhythmias, valvular disease:
some differential diagnosis from the ocular system for vertigo
changes in fraction,
cataracts
glucoma
EMO neuropathy
some differential diagnosis from the allergy system for vertigo
inhalant
food
drug
some differential diagnosis from the autoimmune system for vertigo
autoimmune inner ear disease
collagen vascular disorder
old age syndrome (multisensory deficit) can cause vertigo… t/f
t
some differential diagnosis from the endocrine system for vertigo
DM
hypoglycemia
hyperlipidemia
hyperthyroidism
menstruations-pregnancy-menopause
can chronic anxiety and hysteria cause vertigo?
yes
what is a genetic cause for vertigo?
usher syndrome
if the duration of vertigo is seconds and you hear auditory symptoms, then it can be
perilymphatic fistula :
refers to a hole or tear in one of the membranes that separate your middle ear and inner ear
if the duration of vertigo is seconds and you CANT hear auditory symptoms, then it can be
BPPV
cervical vertigo
vertebrobasilar insufficiency
if the duration of vertigo is hours and you hear auditory symptoms, then it can be
endolymphatic hydrops (Meniere’s disease)
if the duration of vertigo is hours and you CANT hear auditory symptoms, then it can be
Recurrent vestibulopathy,
Vestibular migraine
if the duration of vertigo are DAYs and you CANT hear auditory symptoms, then it can be
vestibular neuronitis
if the duration of vertigo are days and you CAN hear auditory symptoms, then it can be
labyrinthitis,
labyrinthine concussion
if the duration of vertigo is months and you CANT hear auditory symptoms, then it can be
MS, cerebellar degeneration
if the duration of vertigo is months and you CAN hear auditory symptoms, then it can be
acoustic neuroma, ototoxicity
during the history, asking the pt. to describe their symptoms without using the word dizzy is important. t/f
T
during HPI, ask the pt if they feel or had
syncope
presyncope
light headedness
unsteadiness
disequilibrium
motion intolerance
floating sensation
drunk feeling
rocking on a boat
what is vertigo?
subtype of dizziness.
one will feel like they are moving or the environment is (cardinal symptom)
HPI : ask if onset and progression is slow or acute because …
slow = cns
acute = vestibular
HPI : ask if vertigo is continuous or ..
episodic
HPI : ask if their dizziness has other associated Sx. like
hearing loss
tinnitus
aural fullness
diaphoresis
nausea
emesis
(hearing fluctate: Meniere’s)
on HPI, ask if dizzy when turning their head (….), lying supine, or sitting upright
BPPV
asking the pt if they can ambulate during an acute episode of dizziness can help to see if it is
cerebellar problem if they cant move
what are some brainstem symptoms in a HPI for dizzy
diplopia
dyarthria (difficulty speaking)
facial paresthesia
extrem. numb / warm
asking a pt if they feel their vertigo duriing nose blowing can help rule in
fistula
asking a pt if they feel their vertigo with pressure or noise can help rule in
superior canal dehiscience (true vertigo)
asking a pt if they feel aura or warning signs before vertigo can help rule in
migraine
asking a pt if they have visual symptoms with their vertigo can help rule in
scintillating scotoma
asking a pt if they feel vertigo with neck movement can help rule in ?
cervical vertigo
asking a pt if they had head trauma that started their vertigo can help rule in
post traumatic hydrops
fistula
basilar skull fracture
labyrinthine concussion
asking a pt if they had an URI or flu-like illness prior to their vertigo can help rule in?
vestibular neuronitis
vestibular cause of vertigo will have the following history:
sudden onset
spinning
hearing loss
aural fullness
tinnitus
non vestibular cause of vertigo will have the following history:
gradual onset
ill defined symptoms
passing out
cant ambulate
numbness/ weakness
important past medical history you want to ask the pt who has vertigo is
headaches/ migraines
ear disease: chronic ear infections, cholesteatoma
anxiety/depression
diabetes
HTN
CV or cerebrovascular disease
Neurologic disease (MS)
ask the pt with vertigo if they had any ear surgery because surgery for cholesteatoma may result in …
iatrogenic
or
acquired labyrinthine fistula
ask the pt with vertigo if they had any ear surgery because surgery for otosclerosis or tympanosclerosis may result in …
vestibular symptoms bc of perilympathic fistula
what FHx should you ask a pt with vertigo?
CV, peripheral vascular disease, migraine, otosclerosis, Meniere’s disease
what Medication history should you ask a pt with vertigo?
new meds/ change in dose
OTC
herbal med
prescribed med
what 3 things play a role in equilibrium
visual system
vestibular system
proprioceptive system
what vital signs should you look at for someone with vertigo
orthostatic BP and pulse
for vertigo, you will do the following physical exam
vital signs
CV exam - hear heart and cervical vessels
neurologic exam - reflexes, EOM, CN
neck exam: ROM / flexibility
ENT exam: middle ear or external infection? retracted or perforated TM? test hearing
peripheral nystagmus is ….
pure vertical nystagmus is …
torsional (rotary)
sign of brainstem disease
acquired nystagmus is caused by
manières disease
BPPV
labyrinthitis
vesitbular neuronitis
which walking test will you do for vertigo pt
gait: watch out for staggering and leaning
romberg: standing heel to toe in front of each other w. eyes closed
tandem romberg: walk heal to toe with arms opened for balance
which test will ID BPPV ?
dix-Hallpike maneuver
have pt sitting with head 45 degrees to one side, rapidly lay them supine —> vertigo & torsional rotary nystagmus once they lay,,,, lay for 1 min, then bring them to sit = goes away
fistula test is
to see abnormal connection of the labyrinth and surrounding
apply pressure to pts ear canal (press the tragus) and observe eye movement
fukada test is
stepping in place with your eyes closed for 100 steps and then measuring how much you turned during the test.
peripheral vestibular dysfunction likely consistent with the side to which the patient has rotated
Saccadic test
Gaze test
Pursuit eye movement test
Optokinetic nystagmus test (OKN)
Head-shake nystagmus test
Positional nystagmus test
Positioning nystagmus test (Dix Hallpike)
Bithermal caloric tests
are all considered
electronystagmongraphy (ENG) testing
Vestibular autorotation testing (VAT)
Computerized platform posturography
Electrocochleography (Ecog)
Auditory brainstem response (ABR)
Vestibular evoked myogenic potentials (VEMP)
vestibular lab tests
what diagnostic study will you do for vertigo?
MRI of the brain IAC with contrast
-pts younger than 50 = 1%
ct brain and temproal bones
lab test
what home exercises can you give the pt to manage vertigo
cawthorne cooksey/ Brandt Daroff
antihistamine for vertigo are
vestibular suppressant (should not be longterm)
Antivert (meclizine)
dramamine
bezodiazephine for vertigo is
depresses CNS
Valium (diazepam)
Phenothiazine for vertigo
treats emesis
promethazine (phenergan)
prochlorperazine (compazine)
peripheral vertigo
DDx:
Onset:
Nystagmus:
labyrinthitis, menieres, BPPV, vestibular neuonitis
onset: slow
rotary
central vertigo
DDx:
Onset:
Nystagmus:
DDx: acoustic neuroma, brainstem vascular disease, arteriovenous malformation, tumors of the brain stem or cerebellum, MS, vertiginous migraine
Onset: slower
Nystagmus: pure vertical = sign of brainstem disease
benign paroxysmal positional vertigo (BPPV)
cause:
onset:
DDx:
cause: otolith debris floating in semicircular canals (canalithiasis) or to cupula (cupulolithiasis)
onset: spontaneous
DDx: vestibular neuronitis, manières disease/ head trauma (otoconia)
does posterior canalithiasis happen 90% of the time in BPPV?
yes
is canalithiasis worse than cupulolithiasis?
no, cupulolithiasis cause is worse in BPPV
acute vertigo with episodes less than 1 minute due to changing head and body
no medication to help
resolves alone
to diagnosis: dix-hallpike (rotary nystagus)
is
BPPV
how do you treat BPPV
epley manever: to reposition canalith out of semicircular canal
vestibular rehab
severe vertigo that begins acutely after an URI
can last 24-28 hrs - unsteadiness for weeks
hearing is not affected
pt cant perform work
1/3 of ppl develope BPPV
vestibular neuronitis
how do you treat vestibular neuronitis
medications, antiemetics, vestibular suppressants, corticosteroids
vestibular rehab
acute onset of continuous, severe vertigo lasting several days
sudden hearing loss and tinnitus
hearing loss can be permanent
one or both ears
caused by bacteria or virus = inflammation of the labyrinth
Labyrinthitis
how do you treat labyrinthitis
antimetic medications
vestibular supressant (meclizine/antivert)
steriods (oral/ intratympanic)
meniere’s disease (endolymphatic hydrops) has four s/s …
fluctate, low frequency hearing loss in affected ear
tinnitus and fullness in affected ear
epis. of vertigo that lasts hours at a time
RULE syphilis: refer to ENT if negative for vestibular testing VNG/VEMP/ Electrocochelography
cause of meniere’s disease and patho?
cause: unknown, head trauam
patho: over production or underabsorption of endolymph -> distention of the endolymphatic sac
if menieres disease (endolymphatic hydrops) is untreated, it can lead to
unilateral SNHL
treatment for menieres disease is
80% respond to salt restriction = less than 2 grams per day / ETHOL and Cafe
acute attacks = prednisone
diuretics (dyazide)
vestibular rehab
antiemetics and short term vestibular suppressants (meclinzine/antivert)
perilymphatic fistula, is an abnormal connection due to a tear between the perilymph filled inner ear and the middle ear.
caused
s/s
diagnosis;
trauma induced (child birth, barotruama, weight lifting), idiopathic
s/s worsen with pressure changes, dizzy, tinnitus, hearing loss (treated surgically)
explore surgery after CT/MRI, vestibular testing, audtiogram, fistula test
noise induced dizziness with perilympatic fistula is
tullio phenomenon
Superior semicircular canal dehiscence (SSCD)
is:
s/s
cause:
diagnosis
treatment
no bone overlying the superior semicircular canal facing towards the dura of the middle cranial fossa
tullio phenomeno (noise induced vertigo) , pessure induced vertigo, fullness, CHL, flucatuating SNHL
congenital, head trauma, barotruama
audiogram, vestibular testing, noncontrast CT temporal bone, MRI
Tx: surgical
central vertigo
is
cause
disease from CNS, brain stem/cerebellum
CNS tumor (acoustic neuroma)
migraines
MS
hemorrhaic or ischemic insults to cerebellum
tia
infection
drugs (anticonvulsants, aspirin, ETHOL)
seizures
psych disorder
vertebrobasilar circulation problems
acoustic neuroma (vestibular schwannoma)
is:
s/s:
diagnosis:
Tx:
CN8 tumor -benign in the CPA (cerebopontine angle)
unilateral SHL, tinnitus/ vertigo (late s/s)
MRI with IAC with or without contrast
observation, gamma knife tx, srgical excision
vestibular migraine
is:
affects:
s/s:
tx:
episodic vertigo lasting 5 min to 72 hrs
younger pt with hx of migraine
s: +/- headache, sensitivity to light/sound w. N/V
spinning, rocking, swaying, or disequilibirum
migraine medication
cervical vertigo
is:
cause
s/s
tx/tests/diagnosis
veritgo or dizziness from cervical spine … moving head/neck
cause: close head or whiplash injuries/ migraines, cervical arterial issues, surgery
dizziness mins to hours
no test or Tx
diagnosis of exclusion
