The Dizzy Patient

Question 1

which systems does the balance system rely on inputs from

Answer 1

inner ear

eyes

joints

heart brain

Question 2

which cardiac problems can cause dizziness

Answer 2

arrhythmias and postural hypotension

Question 3

how can DM cause dizziness

Answer 3

hypoglycaemia

Question 4

how can arthritis cause dizziness

Answer 4

in the neck can occlude the vertebral arteries, resulting in dizziness

Question 5

nystagmus

Answer 5

Eyes make repetitive, uncontrolled movements

These often result in reduced vision and depth perception and can affect balance and coordination.

Question 6

vestibular nystagmus

Answer 6

VOR: activation of the vestibular system causes eye movement

This reflex functions to stabilise images on the retinas during head movement by producing eye movements in the opposite direction to head movement

impairement can cause vestibular nystagmus

Note: VOR is important for stabilising vision all the time, it may be hard to read small print

Question 7

what are important things to elicit from the history of a dizzy patient

Answer 7

• Triggers – movement, standing up
• Time course
• Associated symptoms
• Precipitators
• Alleviating factors
• Medication

Question 8

examination of a dizzy patient

Answer 8

• Otoscopy
• Neurological
• BP - lying and standing
• Balance system
• Audiometry

Question 9

what can cause postural dizziness

Answer 9

low Sodium, low blood pressure, anaemia (check Hb)

Question 10

can stress cause dizziness

Answer 10

yes, also through hyperventilation

Question 11

benign positional paroxysmal vertigo

Answer 11

very common

attacks of sudden rotational vertigo lasting >30 seconds that are provoked by head turning

Question 12

symptoms of BPPV

Answer 12

usually just vertigo

rare to have other ontological symptoms eg hearing loss, aural fullness or tinnitus

Question 13

aetiology of BPPV

Answer 13

• Common after head injury
• Ear surgery
• Idiopathic
• Middle ear disease
• Otosclerosis

Question 14

pathogenesis of BPPV

Answer 14

displacement of otoconias in urticle into semicircular canals

Question 15

why is BPPV the most common cause of vertigo looking up

Answer 15

otoconia are most commonly displaced into posterior SCC, this causes vertigo on looking up

Question 16

what may BPPV be confused with

Answer 16

vertebrobasilar insufficiency - poor blood supply in basilar and vertebral arteries due to atherosclerosis

Question 17

how would BPPV be differentiated from vertebrobasilar insufficiency

Answer 17

diagnosis of vertebrobasilar insufficiency requires symptoms of impaired circulation in the posterior brain due in association with vertigo

eg bilateral visual disturbance, weakness and numbness, nausea and vomiting, slurred speech, loss of coordination etc.

Question 18

when is vertigo particularly experienced in BPPV

Answer 18

• Looking up
• Turning in bed, often worse on one side
• First lying down in bed at night
• On first getting out of bed in the morning
• Bending forward
• Rising from bending
• Moving head quickly, often only in one direction

Question 19

what negatives are important to establish in the diagnosis of BPPV

Answer 19

• No persistent vertigo
• No speech, visual, motor or sensory problems
• No tinnitus, headache, facial numbness or dysphagia
• No vertical nystagmus

Question 20

what test is used in the diagnosis of BPPV

Answer 20

Hallpike’s test: this rotates the posterior semicircular canal in the plane of gravity

The patient’s eyes must be open and they must look straight ahead. While supine, the head is held and turned 40 degrees to one side, then rapidly lowered to below couch level. Ask the patient if they feel dizzy and look for nystagmus.

This lasts for under a minute due to adaption and reoccurs on sitting. If any of these features are absent (or persisting nystagmus), seek a central cause. The test fatigues so can only be performed accurately once.

Question 21

name 2 important points about the Hallpike test

Answer 21

test fatigues - must be right first time

patient must not close eyes

Question 22

Epley manoeuvre

Answer 22

BPPV diagnosis - allows displaced otoconia to be relocated back into the urticle using gravity

Question 23

what exercise can be performed if patient cannot tolerate Epley or Hallpike

Answer 23

Brandt-Daroff Exercise

Question 24

treatment of BPPV

Answer 24

it is usually self-limiting in months

alcohol intake may help

drugs: vestibular sedatives and histamine analogues

Question 25

name a vestibular sedative used for the treatment of vertigo

Answer 25

prochloperazine

Question 26

name a histamine analogue

Answer 26

betahistine

Question 27

Vestibular Neuronitis

Answer 27

prolonged vertigo (days-weeks) with no associated tinnitus or hearing loss

tends to be worst on the first day and then improve

Question 28

cause of Vestibular Neuronitis

Answer 28

possible viral aetiology - preceded by viral prodromal symptoms (URT)

can also be caused by bacterial infection (meningitis, middle ear infection)

Question 29

labrynthitis

Answer 29

prolonged vertigo (days-weeks) that may have associated tinnitus or hearing loss

Question 30

aetiology of labrynthitis

Answer 30

It has a possible viral aetiology and is often preceded by viral prodromal symptoms.

Less commonly caused by systemic infections e.g. measles, mumps, infectious mononucleosis.

Rarely caused by bacterial infection.

Question 31

management of vestibular neuronitis and labrynthitis

Answer 31

usually self-limiting (days-weeks)

mainly managed supportively with vestibular sedatives (eg prochloperazine)

if prolonged/atypical may require further investigation

Question 32

Ménière’s Disease

Answer 32

Excess endolymph causes dilatation of the endolymphatic spaces of the membranous labyrinth causes vertigo for around 12 hours with prostration, nausea/vomiting ± a feeling of fullness in the ear.

There is associated uni or bi lateral tinnitus ± sensorineural deafness.

Question 33

describe the pattern of attacks in Ménière’s disease

Answer 33

occur in clusters (<20 a month)

tinnitus can appear/get louder as a warning sign to attack

Question 34

cause of Ménière’s disease

Answer 34

unknown

Question 35

audiogram of Ménière’s disease

Answer 35

uni or bi lateral sensorineural hearing loss

Question 36

treatment of Ménière’s disease

Answer 36

supportive treatment during episodes

tinnitus therapy eg prochloperazine and betahistine

Grommet insertion/Meniette

intratympanic Gentamicin/steroids

Question 37

Grommets and Meniette

Answer 37

• Meniette gives out low pressure ear pulses that influence the fluid system and displace the excess endolymphatic fluid
• In order to use this, the patient must have a Grommet inserted in their ear

Question 38

prevention of Ménière’s disease

Answer 38

salt restriction, betahistine

roles of caffeine, alcohol, stress have controversion preventative action

Question 39

ototoxic effects of Gentamicin

Answer 39

damages the vestibular system and can cause complete hearing loss, vertigo, dizziness, tinnitus

however, it can be used as a last resort therapy in Ménière’s disease to purposefully damage the inner ear to stop attacks

Question 40

migraine and vertigo

Answer 40

it is estimated that a quarter of migraine sufferers have spontaneous attacks of vertigo and ataxia

Question 41

describe the auditory symptoms of migraine

Answer 41

phonophobia

fluctuating hearing loss and acute permanent hearing loss

motion sensitivity with bouts of motion sickness

Question 42

criteria for definite migrainous vertigo

Answer 42

• Episodic vestibular symptoms of at least moderate severity (interfere with but don’t impede daily activities)
• Migraine according to International Headache Society criteria
• At least 1 of the following during at least 2 attacks: migrainous symptoms during vertigo, migraine-specific precipitants of vertigo, response to anti-migrainous drugs
• Other causes must be ruled out

Question 43

criteria for probable migrainous vertigo

Answer 43

• Episodic vestibular symptoms of at least moderate severity (interfere with but don’t impede daily activities)
• At least 1 of: migrainous headache, photophobia, phonophobia, visual or other aura

Question 44

compare the use of prochlorperazine and betahistine

Answer 44

prochlorperazine is used for more severe cases than betahistine