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Gwen - ENT > Otology - VERTIGO > Flashcards

Otology - VERTIGO Flashcards

1
Q

What is vertigo?

A

The erroneous impression of movement

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2
Q

What are the central causes of vertigo?

A

Cerebrovascular disease - inner ear stroke or TIA Migraine Multiple sclerosis Vertebrobasilar insufficiency/ischaemia Cervical vertigo (provoked by a particular neck posture no matter what the orientation of the head is to gravity) Drug induced

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3
Q

What are the peripheral causes of vertigo?

A

Common: Benign paroxysmal positional vertigo (BPPV) Menieres disease Vestibular neuritis Viral labyrinthitis Rare: Vestibular schwannoma Suppurative middle ear disease affecting the inner ear (eg cholesteatoma or acute suppurative otitis media)

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4
Q

What are the drug causes of vertigo?

A

Aspirin

Loop diuretics

Aminoglycosides

Alcohol

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5
Q

When taking a history, how can you dissociate true vertigo from dizziness?

A

Vertigo is often described as the room spinning. There must be a real sense of movement. In contrast, dizziness is often described as feeling light headed or having a funny turn.

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6
Q

What examination/investigations would you do in someone with vertigo?

A

Assess CNS + ears: tests CN’s, cerebellar function + reflexes

Assess nystagmus, gait + Romberg’s test

Provocation tests= Dix-Hallpike test

Ix= pure tone audiogram, tympanogram

IF UNILATERAL TINNITUS - MRI TO EXCLUDE ACOUSTIC NEUROMA

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7
Q

How might the length of time that vertigo last for help you narrow down your differential diagnoses?

A

If it lasts for seconds - likely to be BPPV If it lasts for minutes to hours - likely to be Menieres disease If it lasts for days to weeks - likely to be vestibular neuritis

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8
Q

What special tests should you perform in someone with vertigo?

A

Gait assessment Romberg’s test - vestibular lesions the patient will tend to fall to that side Unterberger’s test - Patient walks on the spot for 30 seconds with eyes closed. Rotation greater than 30 degrees suggests vestibular pathology. Dix-Hallpike test

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9
Q

What are the features of benign paroxysmal positional vertigo (BPPV)?

A

Momentary (10-20 seconds) vertiginous sensation associated with sudden changes in head position, typically rolling over in bed. Nausea

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10
Q

What is the pathophysiology of benign paroxysmal positional vertigo (BPPV)?

A

Thought to be due to debris in the inner ear.

Displacement of otoconia (calcium carbonate particles displaced from cells within endolymph) in semi-circular canals

Activation of CN VIII (vestibular part)

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11
Q

Risk factors for BPV

A

Idiopathic

Middle ear disease

Head injury

Otosclerosis

Spontaneous labyrinthine degeneration

Post viral illness

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12
Q

What age group are more commonly affected by benign paroxysmal positional vertigo (BPPV)?

A

Average age of onset is 55. Very rare to affect younger patients.

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13
Q

What is the special test used to diagnose benign paroxysmal positional vertigo (BPPV)?

A

Dix-Hallpike test - aims to replicate the symptoms by a rapid change in head movement.

If +ve patient experience vertigo and rotary nystagmys, after a latent period of 5-10sec

If -ve seek central cause

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14
Q

How do you treat benign paroxysmal positional vertigo (BPPV)?

A

Symptomatic relief:

Epley maneuver

Semont maneuver

Teach patient to do Brandt-Darroff exercises at home

BPPV will usually resolve spontaneously after a weeks or months

Reducing alcohol can help

Posterior SCC denervation or destruction is the last resort.

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15
Q

What is Meniere’s disease?

A

It is poorly understood but it appears to be due to recurrent increases in endolymph pressure within the vestibule with progressive dilation of the endolymphatic system (excess lfuid in the inner ear). This leads to bouts of otological and vestibular hyperstimulation.

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16
Q

What age group are most commonly affected by Meniere’s disease?

A

Middle aged adults but may be seen at any age

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17
Q

What are the symptoms of Meniere’s disease?

A

Triad of:

Vertigo (lasting hours and associated with vomiting and nausea) Tinnitus

Sensorineural hearing loss

Also sensation of aural fullness is a common feature

Episodes last minutes to hours

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18
Q

Are symptoms of Meniere’s disease such as tinnitus and sensorineural hearing loss typically unilateral or bilateral?

A

Unilateral but bilateral symptoms may develop after a number of years.

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19
Q

What are the clinical signs of Meniere’s disease?

A

Nystagmus

Positive Romberg’s tests

20
Q

How do we manage someone with vertigo, tinnitus and sensorineural hearing loss suggestive of Meniere’s disease?

A

ENT referral to confirm diagnosis

Treatment of acute attacks: prochlorperazine IM or buccal, admission is sometimes necessary,

Betahistine and bendrogluazide can be used - vestibular sedatives.

Salt restricted diet and diuretics are used to counteract the increased endolymphatic pressure

Patients should inform the DVLA. The current advice is to cease driving until satisfactory control of symptoms is achieved

21
Q

What prophylactic medication can be given to someone with Meniere’s disease?

A

Betahistine may be of benefit

22
Q

What is the natural history and prognosis of Meniere’s disease?

A

Symptoms resolve in the majority of patients within 5-10 years Most patients will be left with a degree of hearing loss

23
Q

Management of acute attacks of meniere’s

A

Intra-tympanic gentamicin - day case, usually avoids deafness

Vestibular nerve section - spares hearing

Labrythectomy

24
Q

What is vestibular neuritis?

A

Viral infection of the vestibular nerve. Follows a febrile illness.

Inflammatio of nerve connecting labrinth to brain.

25
Q

What is the difference between vestibular neuritis and viral labyrinthitis?

A

The aetiological difference is poorly understood. Labyrinthitis suggests an element of labyrinth involvement however the evidence is poor. Vestibular neuritis is nearly always viral whereas labyrinthitis can in rare occasions be bacterial from middle ear infections. The clinical distinction is made on whether or not there is associated hearing loss. Vestibular neuritis does not involve hearing loss whereas hearing may be affected in labyrinthitis.

26
Q

What are the features of vestibular neuritis?

A

Abrupt onset vertigo

Recurrent vertigo attacks lasting hours to days

Recent viral infection

Importantly no hearing loss

Nystagmus

27
Q

What are the features of acute labyrinthitis?

A

Sudden onset vertigo Recent viral infection Nausea and vomiting Hearing will often be affected May be features of middle ear infection in which case suspect bacterial aetiology

28
Q

What viruses most commonly cause vestibular neuritis and viral labyrinthitis?

A

Tends to be herpes viruses

29
Q

What investigations may be done in someone who presents with vertigo on the back of a recent viral illness suggestive of vestibular neuritis?

A

vHIT test - eliminates stroke as a cause

30
Q

What are the complications of vestibular neuritis or labyrinthitis?

A

Can lead to BPPV

31
Q

How do we manage someone with vestibular neuritis?

A

Management is supportive. Steroids can be useful short term.

Anti-emetics such as prochlorperazine are used.

They also have vestibular sedative effect.

However, they must only be used in the first few days as they interfere with the adaptive processes of the vestibular system.

The patient is encouraged to mobilise where possible to help with the adaptive process.

Longterm antihistamine eg cyclazine can be useful.

32
Q

What is the syndrome related to vestibular neuritis caused by varicella-zoster in the geniculate ganglion of seventh cranial nerve?

A

Ramsay-Hunt syndrome

33
Q

What are the clinical features of Ramsay-Hunt syndrome?

A

Auricular pain Facial nerve palsy Vesicular rash around the ear Vertigo Tinnitus

34
Q

How do we treat Ramsay-Hunt syndrome?

A

Oral aciclovir Corticosteroids

35
Q

What is the other name for vestibular schwannoma?

A

Acoustic neuroma

36
Q

What is a vestibular schwannoma?

A

A benign, slow growing tumour which originates from the Schwann cells surrounding the vestibular division of the 8th cranial nerve. The 7th and 5th cranial nerves can also be affected adding to the symptoms it causes.

37
Q

How common are vestibular schwannomas (acoustic neuromas) relative to other brain tumours?

A

They account for 5% of all intracranial tumours and 90% of all cerebellopontine angle tumours.

38
Q

What disease is associated with bilateral vestibular schwannoma?

A

Neurofibromatosis type 2

39
Q

What is the most common presenting complaint in someone with a vestibular schwannoma?

A

Although this is a vestibular nerve lesion, the ability of the vestibular system to accommodate, means that any balance problems are usually transient. Progressive sensorineural hearing loss accompanied by tinnitus is therefore the most common presenting complaint.

40
Q

What are the clinical features of a vestibular schwannoma (acoustic neuroma)?

A

8th nerve: Hearing Loss Vertigo Tinnitus 7th nerve: facial palsy 5th nerve: absent corneal reflex

41
Q

Where are the most common sites for a vestibular schwannoma to develop?

A

Just before the nerve exits the internal auditory meatus In the cerebellopontine angle

42
Q

How is a vestibular schwannoma diagnosed?

A

Gadolinum-enhanced MRI scan of the internal auditory meatus and cerebellopontine angle will reveal an enhancing lesion.

43
Q

How do you manage someone with a diagnosed vestibular schwannoma?

A

If it is slow growing, it might be more appropriate to watch and wait. If not the options are surgical removal or targeted radiotherapy.

44
Q

What is a sign that vertebrobasilar insufficiency/ischaemia could be the cause of vertigo?

A

Dizziness on extension of the neck

45
Q

What is unterberger’s test?

A

The Unterberger test, also Unterberger’s test and Unterberger’s stepping test, is a test used in otolaryngology to help assess whether a patient has a vestibular pathology.[1] It is not useful for detecting central (brain) disorders of balance.

Gwen - ENT (13 decks)

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