Lecture 5: Vertigo and Tinnitus Flashcards
What is vertigo?
Cardinal symptom of vestibular disease. It is a sensation of movement without any movement.
* Physiologic: sustained head rotation
* Pathologic: vestibular dysfunction
What is fainting due to usually?
Brain hypoperfusion
What is disequilibrium/imbalance?
Feeling off-balance, often due to either a CNS lesion or vestibular dysfunction.
Often the first sign of MS.
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.
- Lightheadedness
- Vertigo
- Disequilibrium
- Vertigo
- Disequilibrium
- Lightheadedness
What is peripheral vertigo?
- Sudden onset
- Associated unilateral tinnitus
- N/V
- Possible horizontal nystagmus
What is central vertigo?
- Gradual onset
- No hearing symptoms
- If tinnitus, usually bilateral
- Vertical or any direction nystagmus.
What are the common etiologies for peripheral vertigo?
- Vestibular neuritis
- Labyrinthitis
- Meniere’s
- BPPV
- Barotrauma
- Perilymphatic fistulas
- Semicircular canal dehiscence
- Ethanol intoxication
What are the common etiologies for central/mixed vertigo?
- Seizure
- MS
- Wernicke’s
- Chiari malformation
- Cerebellar ataxia syndromes
- Migraine
- Ischemia, infarct, hemorrhage, infection, or mass of brainstem/cerebellum.
What should we ask regarding dizziness in patient history?
- Unilateral or bilateral
- Acute or chronic
- Progressive?
What etiologies could produce dizziness lasting months?
- Acoustic neuroma
- Ototoxicity
- MS
- Neurodegeneration
How long does a migraine generally produce dizziness?
Seconds to days.
If a patient’s dizziness is triggered by movement, what are the two more likely etiologies?
- BPPV
- Orthostasis
If a patient presents with unilateral tinnitus, what is the more likely vertigo type?
Peripheral
If a patient presents with aural fullness, what is the most likely etiology?
Meniere’s
What is pursuit movement? Saccade movement?
- 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.
What is a head impulse test?
- 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.
What is a Dix-Hallpike maneuver?
- 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)
What are some specific diagnostic tests we can order to help determine vertigo etiology?
- Audiometry
- Caloric testing
- CT/MRI
- Electronystagmography (ENG) or Videonystagmography (VNG)
- Vestibular evoked myogenic potentials (VEMPS)
Explain the process of caloric testing.
- cold/warm water irrigated into ear.
- Normal should induce nystagmus.
- Abnormal = NO nystagmus.
- Warm water mimics IPSILATERAL.
- Cold water mimics CONTRALATERAL
What indicates an abnormal caloric test? What could give a false reading?
Abnormal = no nygstagmus = vestibular system, nerve, or brain damage.
False positives can occur due to alcohol, antihistamines, or sedatives in the past 24hr.
What are the CIs to caloric testing?
- 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.
What is the mnemonic to remember the water temp for caloric testing?
COWS.
Cold opposite, Warm same.
Warm water causes nystagmus towards the same ear.
Cold water causes nygstagmus towards opposite ear.
When do we want to order a MRI for suspected vertigo?
When we suspect central etiology or an acoustic neuroma.
What is an ENG test?
Electrodes placed on patient, with tracing of eye movements.
What is a VNG test?
ENG with video imaging of the eyes as well.
When is an ENG/VNG test usually performed?
Alongside caloric testing or chair tilt/movement testing.
What is VEMP testing?
- Electrodes placed on head/face.
- Repetitive sound stimulus to one ear and measurement of muscle reaction to it.
Assess otolith function.
What are the two VEMPs measured? What muscle do they correspond to?
- Cervical VEMP: saccule. Loud sound delivered to a single ear should trigger ipsilateral SCM.
- Ocular VEMP: utricle. Records EOM potentials during head vibration.
What is the usual etiology of BPPV?
Canalithiasis: calcium deposits in the semicircular canal, usually due to free-floating otoconia in the posterior semicircular canal.
What are the risk factors for BPPV?
- Age > 50
- Female (esp in menopause)
- Whiplash/trauma
- Chronic OM
How does BPPV usually present?
- Acute, recurrent BRIEF vertigo lasting < 1min.
- Usually occurs a few seconds after head position changes.
What are the 3 types of BPPV that can be detected via a Dix-Hallpike maneuver?
- Posterior Canal: Upward, torsional nystagmus
- Superior/Anterior Canal: Vertical Nystagmus
- Lateral/Horizontal Canal: Horizontal Nystagmus beating side to side
How do we treat BPPV?
- Otolith repositioning: Epley maneuver
- Deconditioning: Brandt-Daroff maneuver or Sermont Maneuver
Describe an Epley maneuver.
- 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
Describe a Brandt-daroff maneuver.
- 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
What is vestibular neuronitis vs labyrinthitis?
- Vestibular neuronitis involves only the vestibular division of CN8.
- Labyrinthitis involves both vestibular and cochlear division of CN8.
What does vestibular inflammation usually occur due to?
Viral or post-viral inflammation.
What is vestibular neuronitis/labyrinthitis?
Asymmetry of the labyrinthine inputs, simulating continuous head rotation.
How does vestibular inflammation typically present?
- Vertigo (sudden and continuous)
- N/V
- Gait instability (sways TOWARDS affected side)
- Nystagmus (Horizontal, AWAY from affected side)
- Labyrinthitis (unilateral hearing impairment/tinnitus)
What can vestibular inflammation actually be sometimes? How do we rule out more emergent etiologies?
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.
What diagnostic study is most helpful in diagnosing vestibular inflammation?
None.
MRI may be used to r/o central etiologies.
What is the treatment for the underlying cause of vestibular inflammation?
- Corticosteroids (ideally within 3 days of onset)
- Antimicrobials (antivirals or ABX depending on presentation)
What is the symptomatic treatment for vestibular inflammation?
- Antihistamines: meclizine
- Benzos: diazepam/lorazepam (avoid after the first few days)
- N/V: promethazine or ondansetron
What is the non-pharmacological treatment for vestibular inflammation?
Vestibular rehabilitation therapy. (months-years)
What is Meniere’s?
Endolymphatic hydrops thought to be due to excess endolymph in the inner ear.
What are the suspected etiologies for Meniere’s? MC demographic?
Etiologies:
* Syphilis
* Head trauma
* Genetic?
* Blocked endolymph ducts
Women 20-40 are MC.
What is the classic triad of Meniere’s?
- Episodic vertigo (20mins-1hr)
- Unilateral hearing impairment (sensorineural, low-freq)
- Tinnitus (low-freq, “blowing”)
How does Meniere’s typically present?
- Unilateral aural fullness
- Episodic N/V with vertigo
- Hearing improves between episodes
- Usually unilateral
- Chronic, progressive.
How do we diagnose Meniere’s?
Clinically:
* 2 vertigo episodes > 20 mins each.
* Unilateral sensorineural hearing loss.
* Tinnitis or aural fullness.
What tests are used to help diagnose Meniere’s?
- Audiometry
- Caloric testing: reduced or absent nystagmus on AFFECTED side.
- Brain Imaging: Central lesion suspicion
What lifestyle modifications can we suggest to someone with Meniere’s?
- Low salt
- Restrict alcohol and caffeine
What are the pharmacological treatment options for Meniere’s?
- Vestibular suppressants: meclizine, diazepam, promethazine
- Chronic: diuretics (Acetazolamide or HCTZ)
For refractory Meniere’s, what non-destructive interventions can we do?
- Intratympanic corticosteroid injections.
- Positive pressure pulse generator into inner ear.
- Endolymphatic shunt.
For refractory Meniere’s, what destructive interventions can we do?
- Intratympanic gentamicin injections.
- Surgical labyrinthectomy.
- Vestibular nerve resection.
What is a perilymphatic fistula?
Leakage of perilymphatic fluid from inner ear into middle ear.
What is semicircular canal dehiscence?
Abnormal thinning, or absence of bone above the superior semicircular canal.
What are the common risk factors for a perilymphatic fistula or semicircular canal dehiscence?
- Blunt head trauma/hand slap to ear
- Scuba diving, flight
- Weight lifting (valsalva)
How do perilymphatic fistulas and semicircular canal dehiscence present?
- 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.)
How do we diagnose a perilymphatic fistula or semicircular canal dehiscence?
Usually clinically.
CT/MRI should show:
* Perilymphatic fistula: fluid accumulation in round window recess.
* Semicircular canal dehiscence: thin or absent bone above canal.
How do we treat a perilymphatic fistula or semicircular canal dehiscence?
- Bed Rest
- Head elevation
- Avoid straining
- Symptomatic meds PRN.
- Refractory: surgical patch
What is barotrauma?
Buildup of pressure between the middle and inner ear, causing negative pressure in the middle ear.
What are the risk factors for barotrauma?
- Eustachian tube dysfunction (congenitally narrow, mucosal edema)
- Barometric stressors (scuba diving, FLYING, rapid altitude changes)
How does a eardrum shift with unequal air pressure?
A blocked eustachian tube will cause an INWARD bulge of the eardrum towards the inner ear.
How does barotrauma typically present?
- Ear pressure/pain
- Vertigo
- Hearing loss
- Tinnitus
How do we diagnose barotrauma?
- Hx of flight or diving
- Congruent S/S
- ENT exam: may see hemorrhage behind TM or TM perforation.
How do we treat barotrauma?
- Analgesics symptomically
- Surgery if refractory and not healing. (Myringotomy, tympanoplasty)
What patient education can we provide to help prevent barotrauma?
- Decongestants prior to event.
- Diving slowly
- Swallowing/yawning frequently
- Chewing gum or pacifier in infants
What is tinnitus?
Sensation of sound in the ABSENCE of exogenous sound source.
How is tinnitus categorized?
- Pulsatile or non-pulsatile
- Continuous or non-continuous
What are the common etiologies of pulsatile tinnitus?
- 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.
What are the common etiologies of a NON-pulsatile tinnitus?
- Sensorineural hearing loss
- Otosclerosis
- Vestibular schwannoma
- Meniere’s
- Barotrauma
- TMJ
- Intracranial tumors
What is a paraganglioma/glomus tumor?
- Benign vascular neuroendocrine tumor of the MIDDLE ear.
- MC neoplasm of the middle ear, with high vascularity.
- Treated via surgery.
What is a patulous eustachian tube?
- 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.
What is sensorineural hearing loss often characterized by? TX?
- High-frequency hearing loss.
- Pathologic hearing loss or presbycusis
- Loss/dysfunction of hair cells in cochlea
- TX: Hearing aid.
How do we diagnose tinnitus?
- PE: ENT, CV, CN
- Audiometry: checking for associated hearing loss
- MRI: r/o masses of vascular abnormality
What are the main treatment goals for tinnitus?
Treating the underlying cause.
* Hearing loss: hearing aid
* Removing any masses.
* Controlling HTN
* Reviewing meds
What can worsen tinnitus?
- Depression
- Insomnia: white noise
What behavioral therapy is recommended for tinnitus treatment?
- Tinnitus retraining therapy (TRT)
- Stress reduction
- CBT
What is a tinnitus retraining program?
- Noise inducing generators + counseling.
- Essentially designed to habituate a patient to tinnitus.
What are the non-behavioral treatment options for tinnitus?
- Meds: BZDs, intra-TM steroid shots, misoprostol
- Masking devices
- TMS
