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(C) CM 1B: ID/EENT > Lecture 5: Vertigo and Tinnitus > Flashcards

Lecture 5: Vertigo and Tinnitus Flashcards

1
Q

What is vertigo?

A

Cardinal symptom of vestibular disease. It is a sensation of movement without any movement.
* Physiologic: sustained head rotation
* Pathologic: vestibular dysfunction

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2
Q

What is fainting due to usually?

A

Brain hypoperfusion

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3
Q

What is disequilibrium/imbalance?

A

Feeling off-balance, often due to either a CNS lesion or vestibular dysfunction.

Often the first sign of MS.

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4
Q

Clinical

Name whether each symptom is vertigo, lightheadedness, or disequilibrium.
* I felt like I was about to pass out.
* The room was spinning around me.
* I felt very unsteady when walking.
* My head felt like it was twirling around like a top.
* I thought I might just tip over at any moment.
* Everything started to go black; I had to lay down.

A
  • Lightheadedness
  • Vertigo
  • Disequilibrium
  • Vertigo
  • Disequilibrium
  • Lightheadedness
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5
Q

What is peripheral vertigo?

A
  • Sudden onset
  • Associated unilateral tinnitus
  • N/V
  • Possible horizontal nystagmus
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6
Q

What is central vertigo?

A
  • Gradual onset
  • No hearing symptoms
  • If tinnitus, usually bilateral
  • Vertical or any direction nystagmus.
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7
Q

What are the common etiologies for peripheral vertigo?

A
  • Vestibular neuritis
  • Labyrinthitis
  • Meniere’s
  • BPPV
  • Barotrauma
  • Perilymphatic fistulas
  • Semicircular canal dehiscence
  • Ethanol intoxication
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8
Q

What are the common etiologies for central/mixed vertigo?

A
  • Seizure
  • MS
  • Wernicke’s
  • Chiari malformation
  • Cerebellar ataxia syndromes
  • Migraine
  • Ischemia, infarct, hemorrhage, infection, or mass of brainstem/cerebellum.
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9
Q

What should we ask regarding dizziness in patient history?

A
  • Unilateral or bilateral
  • Acute or chronic
  • Progressive?
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10
Q

What etiologies could produce dizziness lasting months?

A
  • Acoustic neuroma
  • Ototoxicity
  • MS
  • Neurodegeneration
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11
Q

How long does a migraine generally produce dizziness?

A

Seconds to days.

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12
Q

If a patient’s dizziness is triggered by movement, what are the two more likely etiologies?

A
  • BPPV
  • Orthostasis
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13
Q

If a patient presents with unilateral tinnitus, what is the more likely vertigo type?

A

Peripheral

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14
Q

If a patient presents with aural fullness, what is the most likely etiology?

A

Meniere’s

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15
Q

What is pursuit movement? Saccade movement?

A
  • Pursuit eye movement is constant eye movement to track an object.
  • Saccade eye movement is a sudden eye movement, shifting from looking at one thing to another.
  • Abnormal suggests cerebellar pathologies.

Pursuit = H testing for EOM.

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16
Q

What is a head impulse test?

A
  • Patient stares straight ahead.
  • Patient’s head is rotated quickly one direction and back to the other; their focus should remain in front still.

Assesses for vestibulo-ocular reflex.

Positive test indicates peripheral vertigo.

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17
Q

What is a Dix-Hallpike maneuver?

A
  • Patient sits on a table, with legs stretched out in front of them.
  • Patient turns head to one side (45d) and lies down quickly with head NOT resting on table, 30 deg off the edge of the table.
  • If a patient suddenly gets vertigo AND NYSTAGMUS, they most likely have BPPV (Benign paroxysmal positional vertigo)
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18
Q

What are some specific diagnostic tests we can order to help determine vertigo etiology?

A
  • Audiometry
  • Caloric testing
  • CT/MRI
  • Electronystagmography (ENG) or Videonystagmography (VNG)
  • Vestibular evoked myogenic potentials (VEMPS)
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19
Q

Explain the process of caloric testing.

A
  1. cold/warm water irrigated into ear.
  2. Normal should induce nystagmus.
  3. Abnormal = NO nystagmus.
  4. Warm water mimics IPSILATERAL.
  5. Cold water mimics CONTRALATERAL
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20
Q

What indicates an abnormal caloric test? What could give a false reading?

A

Abnormal = no nygstagmus = vestibular system, nerve, or brain damage.

False positives can occur due to alcohol, antihistamines, or sedatives in the past 24hr.

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21
Q

What are the CIs to caloric testing?

A
  • Ear: OE, Middle ear effusion, TM perforation.
  • Medical: Epilepsy, psychosis, HTN, severe cardiac disease
  • Meds: 2nd generation antihistamines, anxiolytics, antidepressants in past 48hrs.

AKA discharge in ear or prone to seizures.

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22
Q

What is the mnemonic to remember the water temp for caloric testing?

A

COWS.
Cold opposite, Warm same.
Warm water causes nystagmus towards the same ear.
Cold water causes nygstagmus towards opposite ear.

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23
Q

When do we want to order a MRI for suspected vertigo?

A

When we suspect central etiology or an acoustic neuroma.

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24
Q

What is an ENG test?

A

Electrodes placed on patient, with tracing of eye movements.

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25
Q

What is a VNG test?

A

ENG with video imaging of the eyes as well.

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26
Q

When is an ENG/VNG test usually performed?

A

Alongside caloric testing or chair tilt/movement testing.

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27
Q

What is VEMP testing?

A
  • Electrodes placed on head/face.
  • Repetitive sound stimulus to one ear and measurement of muscle reaction to it.

Assess otolith function.

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28
Q

What are the two VEMPs measured? What muscle do they correspond to?

A
  • Cervical VEMP: saccule. Loud sound delivered to a single ear should trigger ipsilateral SCM.
  • Ocular VEMP: utricle. Records EOM potentials during head vibration.
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29
Q

What is the usual etiology of BPPV?

A

Canalithiasis: calcium deposits in the semicircular canal, usually due to free-floating otoconia in the posterior semicircular canal.

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30
Q

What are the risk factors for BPPV?

A
  • Age > 50
  • Female (esp in menopause)
  • Whiplash/trauma
  • Chronic OM
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31
Q

How does BPPV usually present?

A
  • Acute, recurrent BRIEF vertigo lasting < 1min.
  • Usually occurs a few seconds after head position changes.
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32
Q

What are the 3 types of BPPV that can be detected via a Dix-Hallpike maneuver?

A
  • Posterior Canal: Upward, torsional nystagmus
  • Superior/Anterior Canal: Vertical Nystagmus
  • Lateral/Horizontal Canal: Horizontal Nystagmus beating side to side
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33
Q

How do we treat BPPV?

A
  • Otolith repositioning: Epley maneuver
  • Deconditioning: Brandt-Daroff maneuver or Sermont Maneuver
34
Q

Describe an Epley maneuver.

A
  • Turn Head 45deg to one side. while laying down. (like starting Dix-Hallpike.)
  • After 30-60s, turn head to the other side at a 90deg angle QUICKLY.
  • Further turn the whole body so the head is turned diagonally (45deg) towards the floor. Body can be perpendicular to the table.

Indicated for POSTERIOR CANAL nygstamus on dix-hallpike.

https://www.youtube.com/watch?v=9SLm76jQg3g

35
Q

Describe a Brandt-daroff maneuver.

A
  • Patient sitting straight up turns their head 45deg.
  • Patient lies down on their side opposite head turn for about 30s AFTER vertigo subsides with head tilted.
  • Patient sits back up quickly.
  • Patient repeats on opposite side.

Deconditioning.

https://www.youtube.com/watch?v=0SVkxQGY9bY

36
Q

What is vestibular neuronitis vs labyrinthitis?

A
  • Vestibular neuronitis involves only the vestibular division of CN8.
  • Labyrinthitis involves both vestibular and cochlear division of CN8.
37
Q

What does vestibular inflammation usually occur due to?

A

Viral or post-viral inflammation.

38
Q

What is vestibular neuronitis/labyrinthitis?

A

Asymmetry of the labyrinthine inputs, simulating continuous head rotation.

39
Q

How does vestibular inflammation typically present?

A
  • Vertigo (sudden and continuous)
  • N/V
  • Gait instability (sways TOWARDS affected side)
  • Nystagmus (Horizontal, AWAY from affected side)
  • Labyrinthitis (unilateral hearing impairment/tinnitus)
40
Q

What can vestibular inflammation actually be sometimes? How do we rule out more emergent etiologies?

A

Acute cerebellar or brainstem infarct or hemorrhage.
A head impulse test will be normal in central lesion etiologies.

Evaluate for signs of diplopia, weakness, numbness, or dysarthria.

41
Q

What diagnostic study is most helpful in diagnosing vestibular inflammation?

A

None.
MRI may be used to r/o central etiologies.

42
Q

What is the treatment for the underlying cause of vestibular inflammation?

A
  • Corticosteroids (ideally within 3 days of onset)
  • Antimicrobials (antivirals or ABX depending on presentation)
43
Q

What is the symptomatic treatment for vestibular inflammation?

A
  • Antihistamines: meclizine
  • Benzos: diazepam/lorazepam (avoid after the first few days)
  • N/V: promethazine or ondansetron
44
Q

What is the non-pharmacological treatment for vestibular inflammation?

A

Vestibular rehabilitation therapy. (months-years)

45
Q

What is Meniere’s?

A

Endolymphatic hydrops thought to be due to excess endolymph in the inner ear.

46
Q

What are the suspected etiologies for Meniere’s? MC demographic?

A

Etiologies:
* Syphilis
* Head trauma
* Genetic?
* Blocked endolymph ducts

Women 20-40 are MC.

47
Q

What is the classic triad of Meniere’s?

A
  • Episodic vertigo (20mins-1hr)
  • Unilateral hearing impairment (sensorineural, low-freq)
  • Tinnitus (low-freq, “blowing”)
48
Q

How does Meniere’s typically present?

A
  • Unilateral aural fullness
  • Episodic N/V with vertigo
  • Hearing improves between episodes
  • Usually unilateral
  • Chronic, progressive.
49
Q

How do we diagnose Meniere’s?

A

Clinically:
* 2 vertigo episodes > 20 mins each.
* Unilateral sensorineural hearing loss.
* Tinnitis or aural fullness.

50
Q

What tests are used to help diagnose Meniere’s?

A
  • Audiometry
  • Caloric testing: reduced or absent nystagmus on AFFECTED side.
  • Brain Imaging: Central lesion suspicion
51
Q

What lifestyle modifications can we suggest to someone with Meniere’s?

A
  • Low salt
  • Restrict alcohol and caffeine
52
Q

What are the pharmacological treatment options for Meniere’s?

A
  • Vestibular suppressants: meclizine, diazepam, promethazine
  • Chronic: diuretics (Acetazolamide or HCTZ)
53
Q

For refractory Meniere’s, what non-destructive interventions can we do?

A
  • Intratympanic corticosteroid injections.
  • Positive pressure pulse generator into inner ear.
  • Endolymphatic shunt.
54
Q

For refractory Meniere’s, what destructive interventions can we do?

A
  • Intratympanic gentamicin injections.
  • Surgical labyrinthectomy.
  • Vestibular nerve resection.
55
Q

What is a perilymphatic fistula?

A

Leakage of perilymphatic fluid from inner ear into middle ear.

56
Q

What is semicircular canal dehiscence?

A

Abnormal thinning, or absence of bone above the superior semicircular canal.

57
Q

What are the common risk factors for a perilymphatic fistula or semicircular canal dehiscence?

A
  • Blunt head trauma/hand slap to ear
  • Scuba diving, flight
  • Weight lifting (valsalva)
58
Q

How do perilymphatic fistulas and semicircular canal dehiscence present?

A
  • Sensorineural hearing loss in fistula, conductive in dehiscence. (no bone = no conduction)
  • Recurrent, very brief vertigo (seconds)
  • Sneezing/coughing
  • Straining
  • Loud noises (tullio phenomenon, causing dizziness/vertigo from loud sounds.)
59
Q

How do we diagnose a perilymphatic fistula or semicircular canal dehiscence?

A

Usually clinically.
CT/MRI should show:
* Perilymphatic fistula: fluid accumulation in round window recess.
* Semicircular canal dehiscence: thin or absent bone above canal.

60
Q

How do we treat a perilymphatic fistula or semicircular canal dehiscence?

A
  • Bed Rest
  • Head elevation
  • Avoid straining
  • Symptomatic meds PRN.
  • Refractory: surgical patch
61
Q

What is barotrauma?

A

Buildup of pressure between the middle and inner ear, causing negative pressure in the middle ear.

62
Q

What are the risk factors for barotrauma?

A
  • Eustachian tube dysfunction (congenitally narrow, mucosal edema)
  • Barometric stressors (scuba diving, FLYING, rapid altitude changes)
63
Q

How does a eardrum shift with unequal air pressure?

A

A blocked eustachian tube will cause an INWARD bulge of the eardrum towards the inner ear.

64
Q

How does barotrauma typically present?

A
  • Ear pressure/pain
  • Vertigo
  • Hearing loss
  • Tinnitus
65
Q

How do we diagnose barotrauma?

A
  • Hx of flight or diving
  • Congruent S/S
  • ENT exam: may see hemorrhage behind TM or TM perforation.
66
Q

How do we treat barotrauma?

A
  • Analgesics symptomically
  • Surgery if refractory and not healing. (Myringotomy, tympanoplasty)
67
Q

What patient education can we provide to help prevent barotrauma?

A
  • Decongestants prior to event.
  • Diving slowly
  • Swallowing/yawning frequently
  • Chewing gum or pacifier in infants
68
Q

What is tinnitus?

A

Sensation of sound in the ABSENCE of exogenous sound source.

69
Q

How is tinnitus categorized?

A
  • Pulsatile or non-pulsatile
  • Continuous or non-continuous
70
Q

What are the common etiologies of pulsatile tinnitus?

A
  • Vascular: Carotid bruits, AVMs and AV fistulas, Paraganglioma, Venous hum (HTN)
  • Neuromuscular: Spasms of the tensory tympani or stapedius, chiari malformations, MS
  • Eustachian tube: patulous eustachian tube.

Pulsatile =. tends to occur with HR.

71
Q

What are the common etiologies of a NON-pulsatile tinnitus?

A
  • Sensorineural hearing loss
  • Otosclerosis
  • Vestibular schwannoma
  • Meniere’s
  • Barotrauma
  • TMJ
  • Intracranial tumors
72
Q

What is a paraganglioma/glomus tumor?

A
  • Benign vascular neuroendocrine tumor of the MIDDLE ear.
  • MC neoplasm of the middle ear, with high vascularity.
  • Treated via surgery.
73
Q

What is a patulous eustachian tube?

A
  • Open eustachian tube, often caused by significant weight loss.
  • Usually a “roaring tinnitus” when breathing.
  • Autophony (hearing one’s voice)
  • Treatment consists of either mucosal irritants like a premarin drop or surgeery.
74
Q

What is sensorineural hearing loss often characterized by? TX?

A
  • High-frequency hearing loss.
  • Pathologic hearing loss or presbycusis
  • Loss/dysfunction of hair cells in cochlea
  • TX: Hearing aid.
75
Q

How do we diagnose tinnitus?

A
  • PE: ENT, CV, CN
  • Audiometry: checking for associated hearing loss
  • MRI: r/o masses of vascular abnormality
76
Q

What are the main treatment goals for tinnitus?

A

Treating the underlying cause.
* Hearing loss: hearing aid
* Removing any masses.
* Controlling HTN
* Reviewing meds

77
Q

What can worsen tinnitus?

A
  • Depression
  • Insomnia: white noise
78
Q

What behavioral therapy is recommended for tinnitus treatment?

A
  • Tinnitus retraining therapy (TRT)
  • Stress reduction
  • CBT
79
Q

What is a tinnitus retraining program?

A
  • Noise inducing generators + counseling.
  • Essentially designed to habituate a patient to tinnitus.
80
Q

What are the non-behavioral treatment options for tinnitus?

A
  • Meds: BZDs, intra-TM steroid shots, misoprostol
  • Masking devices
  • TMS

(C) CM 1B: ID/EENT (27 decks)

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