Presentations Flashcards
What is the first question you should ask if a pt tells you they are experiencing vertigo or dizziness?
What do you mean by dizzy/vertigo?
Tell me exactly what you experience.
How will true vertigo feel to the pt?
As if the room is spinning around them.
What will dizziness that isn’t vertigo be described as?
Light-headedness Shakiness (like with low blood sugar) Weakness Unsteadiness Feeling faint Visual disturbance Other funny turns
A pt describes recurrent episodes of dizziness. They describe it as the room appears to spin around them.
What are the main differentials you want to consider in this patient?
BPPV Vestibular migraine Labyrinthitis Vestibular neuronitis Ménière’s disease
May have a central cause
A pt describes recurrent episodes of dizziness. They describe it as a light-headed feeling, but no room spinning occurs.
What are the main differentials you want to consider in this patient?
Cardiovascular cause e.g. postural hypotension, arrhythmia, vertebrobasilar insufficiency etc.
Neurological cause e.g. head injury, epilepsy, peripheral neuropathy etc.
Metabolic cause e.g. hypoglycaemia, adrenal insufficiency, hypothyroidism.
Psychogenic e.g. anxiety
Iatrogenic (esp. in older polypharmacy pts)
What are the main neurological causes of vertigo?
MS
Posterior stroke
Migraine
Intracranial space occupying lesion
What is vertigo the result of?
Conflict between vestibular input and other sensory inputs of balance (vision and proprioception).
A pt describes recurrent episodes of dizziness. They describe it as the room appears to spin around them.
What would make you suspect BPPV over other otological causes of vertigo?
- Triggered by head movement e.g. getting out of bed, bending to pray etc.
- Last a few seconds, may not be immediate after movement (small latency).
- No other ear symptoms e.g. tinnitus, pain, fullness, hearing loss.
A pt describes recurrent episodes of dizziness. They describe it as the room appears to spin around them.
What would make you suspect Ménières disease over other otological causes of vertigo?
- Classic triad - severe paroxysmal vertigo, sensorineural hearing loss, and tinnitus.
- Unilateral symptoms, with remission between attacks
- Aural fullness in affected ear
- Lasts minutes to hours
A pt describes recurrent episodes of dizziness. They describe it as the room appears to spin around them.
What would make you suspect vestibular neuronitis over other otological causes of vertigo?
- Last for days
- Preceding URTI
- Incapacitating
- Associated N+V
What is tinnitus?
The perception of sound without an external auditory stimulus.
How might a patient describe tinnitus?
Intermittent or continuous sounds, such as ringing, buzzing, clicking, whistling, but with nothing making the noise in the environment.
What is primary tinnitus often associated with?
Sensorineural hearing loss
A pt presents with ringing ears.
What systems do you need to ask about to try and find a cause?
Ears Medications Metabolic conditions Neurological symptoms Psychological Vascular risk factors
What otological causes of tinnitus are there, and how can they be divided?
Conductive problems - cerumen impaction, otosclerosis, otitis media.
Sensorineural problems - presbycusis, Ménières disease, acoustic neuroma
What are the medications that can cause tinnitus?
NSAIDs Tetracyclines Quinine Sodium Valproate Chemotherapy
To help differentiate between the different causes of tinnitus, wht questions do we need to ask?
SQITARS it up!!
S - both ears or just one?
Q - what does it sound like? Is it always the same? Onset - sudden or gradual?
I - How much does it impact their life? Associated hearing loss?
T - how long does it last, when does it come on?
A - Any head trauma? Drugs hx? Stress?
R - If chronic, is it better in less stressful times?
S - Hearing loss? Pain? Focal neurology? Vertigo? Anything else?
What are the red flags that make tinnitus an otological emergency?
- Sudden onset, pulsatile tinnitus
- Significant neurological symptoms
- Severe vertigo
- Head trauma -> tinnitus
- Sudden hearing loss (unexplained)
When examining a pt with tinnitus, what should we look at?
Otoscopy
Audiometry
Cranial nerve examination
TMJ for focal neurology
What is otalgia?
Aching or pain in the ear
What are the 3 sources of otalgia?
External ear
Middle ear
Referred pain from local structures
What are the possible causes of otalgia relating to the external ear?
- Infection/Inflammation - otitis externa, bullous myringitis, herpes zoster, perichondritis
- Trauma or a foreign body
- Neoplasm
- Sjögren’s syndrome
What are the possible causes of otalgia relating to the middle ear?
- Infection/Inflammation - otitis externa, otitis media with effusion, acute mastoiditis
- Barotrauma
- Eustachian tube obstruction
- Trauma
- Neoplasm
Conditions in which local structures might cause referred otalgia?
- Nasopharynx
- Cranial nerves
- Salivary glands
- Teeth/jaw
- Oesophagus
- Thyroid
- Temporal ateritis
- Tongue
Are most cases of otalgia transient?
Yes
What are the important factors to elicit from a HPC of otalgia?
The usual, SQITARS! Most importantly:
- Onset
- Precipitating factors
- Duration
- Discharge
- Fever
- Swallowing
- Dental history
When might auroscopy not visualise a problem causing otalgia?
If the otalgia is due to referred pain.
Which cranial nerves might otalgia be referred from in particular?
Cranial nerves V, IX, and X.
What red flags would suggest a neoplastic cause of otalgia?
- Persistent otalgia
- Weight loss
- Voice change
- Lymphadenopathy
- Dysphagia
