The dizzy patient Flashcards
What can cause dizziness?
CV system Haematological and metabolic Anxiety Neurological conditions Drug side-effects/ interactions Migraine Otological Trauma
What is dizziness?
A non-specific term which covers vertigo, presyncope, disequilibrium etc
What is vertigo?
A sensation of movement, usually spinning or falling
What vestibular problems can cause dizziness?
BPPV
Meniere’s
Vestibular neuronitis
What visual problems can cause dizziness?
Cataracts
DM
What proprioceptive problems can cause dizziness?
DM
Arthritis
Neurology
What cardiovascular problems can cause dizziness?
Arrhythmias
Postural hypotension
What central pathways can cause dizziness?
Stress
Migraine
SOL - space occupying lesion
MS
What would point to a cardiac cause of dizziness in the history?
Lightheadedness
Syncope
Palpitations
What would point to a neurological cause of dizziness in the history?
Blackouts Visual disturbance Paraesthesia Weakness Speech and swallow problems
Why is the duration of vertigo cruital in history taking for a diagnosis?
Seconds - benign positional paroxysmal vertigo
Minutes/hours - meniere’s
Days - vestibular neuritis
Variable - migraine associated vertigo
What are common signs of meniere’s disease?
Vertigo for mins/hours
Hearing loss
Tinnitus
Aural pressure - inner ear problem causing SNHL
What would point to a migraine cause of vertigo?
Smell or vision triggers
Closing eyes makes it better
Photophobia
What are good questions to ask in a dizzy history?
Do you get dizzy rolling over in bed? BPPV
Was your first attack severe, lasting hours with assoc N+V? Vestibular neuritis
Are you light-sensitive during the spells? Vestibular migraine
Do you feel one ear full or do you get hearing loss before or during the spell? Meniere’s
What should be included in an examination of a dizzy patient?
Otoscopy Neurological BP lying and standing Balance system Audiometry
What would stem an urgent referral to an ENT surgeon upon examination of the ears of a dizzy patient?
Acute otitis media
Cholesteatoma
What does the fast phase of a nystagmus tell you?
The affected ear - the fast phase is away from the affected ear
What is bi-directional nystagmus pathognomonic of?
Central MS plaque
What does a vertical nystagmus tell you?
Central lesion - commonly a stroke
What can cause BPPV and what is the pathophysiology of it?
Causes: head trauma, ear surgery, idiopathic
Pathophysiology: otolith material from utricle displaced into the posterior semicircular canal
What other condition can benign positional paroxysmal vertigo be confused with?
Vertebrobasilar insufficiency
For a diagnosis of VBI, need other symptoms of impaired circulation in the posterior brain such as visual disturbance, weakness and numbness
What commonly triggers vertigo in BPPV?
Looking up
Turning in bed
Upon first lying down at night and on first getting out of bed in the morning
Bending forwards
Rising from bending
Moving head quickly - often only in one direction
How can BPPV be diagnosed?
Sit up with eyes open
Lie down rather quickly
Look for a short delay and then symptoms of vertigo and vertical nystagmus with twisting
Feel dizzy and sick
How can BPPV be treated?
Epley manoeuvre
Semont manoeuvre
Brandt-daroff exercises
What is vestibular neuronitis?
Prolonged vertigo for days
No assoc tinnitus or hearing loss
Viral aetiology
What is labyrinthitis?
Prolonged vertigo for days
Associated tinnitus or SNHL
Viral aetiology
How is vestibular neuronitis/ labyrinthitis treated?
Supportive with vestibular sedatives
Self-limiting
If prolonged requires further investigation
Can be helped with rehab exercies
What is the rule of 3 associated with vestibular neuronitis?
In bed for 3 days
Off work for 3 weeks
Off balance for 3 months
What should be suspected with chronic vestibular neuronitis?
Vestibular schwanomma
What is the pathophysiology behind meniere’s disease?
Endolymphatic hydrops - high pressure causing a rupture
This results mixing of endolymph and perilymph
What is the criteria for diagnosing meniere’s disease?
Recurrent, spontaneous rotational vertigo with at least 2 episodes lasting more than 20 mins
Occurence of or worsening of tinnitus on affected side
Occurence of aural fullness on affected side
Documented SNHL on at least one occasion
What are of hearing will be affected in meniere’s disease?
Low frequency reduced in bone and air conduction in one side
Bone conduction and air conduction on unaffected side normal
How is meniere’s disease treated?
Supportive treatment during episodes Tinnitus therapy Hearing aids Salt restriction Caffeine and alcohol limitations Grommet insertion Intratympanic steroids or gentamicin Surgery - vestibular nerve section
What is the most common auditory symptom in migraines?
Phonophobia - dislike of loud noises during attack
Fluctuating hearing loss occur in a small proportion of patients
What vertigo conditions are associated with hearing loss or tinnitus?
Meniere’s disease
Labryinthitis
What vertigo condition is associated with aural fullness?
Meniere’s disease
What vertigo condition is associated with a clear positional trigger?
BPPV
What is a vestibular schwannoma?
Benign tumour of the VIIIth nerve sheath at the cerebellopontine angle
Progressive imbalance and hearing loss
Space occupying disease of IMA so can have facial nerve dysfunction
