Tinnitus and vertigo

Question 1

What is tinnitus?

Answer 1

The perception of sound typically in the absence of sound

Question 2

What are the different characters of tinnitus and what do they suggest?

Answer 2

Ringing, hissing or buzzing suggests an inner ear or central cause
popping or clicking suggests problems in the external or middle ear
Pulsatile can suggest increased awareness of the ears bloodflow

Question 3

What are the two main types of tinnitus?

Answer 3

Objective - heard by examiner - rare - vascular disorders, high output carotid states
Subjective - associated commonly with SNHL - ototoxic drugs can cause bilateral hearing loss with subjective tinnitus

Question 4

What is the pathophysiology of tinnitus?

Answer 4

It is poorly dnerstood, possible mechanisms include spontaneous otoacoustic emissions or increased activity in the acoustic nerve

Question 5

What tests should be done for tinnitus?

Answer 5

Audiometry and tympanogram

MRI for unilateral tinnitus to exclude acoustic neuroma

Question 6

What is the treatment for tinnitus?

Answer 6

Take time to explain tinnitus, it usually starts to resolve itself over time by habituation
Treatment is aimed at reducing symptoms:
-hearing aids to improve perception of background noise
-psychological support - sound therapy
-Cognitive behavioural therapy

Question 7

What is an acoustic neuroma?

Answer 7

A benign vestibular schwanoma that causes problems through compression

Question 8

What are the symptoms of an acoustic neuroma?

Answer 8

Ipsilateral tinnitus with or without SNHL
Large tumours can give ipsilateral cerebellar signs
Can also compress nearby CNs (V, VI, VII)

Question 9

What tests should be done for a suspected acoustic neuroma?

Answer 9

MRI

Question 10

What is the treatment for acoustic neuroma?

Answer 10

Difficult surgery

Not usually required in elderly, radiosurgery is increasingly popular

Question 11

What is true vertigo?

Answer 11

The sensation that the world around you is moving or spinning

Question 12

How can you determine in a history if ‘Dizziness’ is vestibular?

Answer 12

Ask whether things seemed to spin around the patient. Which way did they spin? The patient does not usually hesitate to answer this if it is true vertigo

Question 13

What do the different lengths of time of vertigo suggest in terms of diagnosis?

Answer 13

seconds to minutes = BPPV
30min to 30 hr = Meniere’s or migraine
30hr to a week = acute vestibular failure

Question 14

What does the examination for vertigo involve?

Answer 14

Assess cranial nerves and ears
Test cerrebellar function and reflexes
Assess nystagmus, gait, Romberg’s test
Provocation tests (head thrust, Hallpike test

Question 15

What are the clinical features and pathogenesis of BPPV?

Answer 15

This is vertigo brought on by head turning and lasts more than 30 seconds. It is caused by displacement of otoconia that irritate the semicircular canals

Question 16

How is BPPV diagnosed?

Answer 16

By ruling out - persistent vertigo, Speech visual and sensory problems, tinnitus, headache, nystagmus
Hallpike test is positive

Question 17

How is BPPV treated?

Answer 17

Usually self limiting, epley manouvre 70-80% effective
Home repositing manouvres can help
Vasibular supressant medication does not stop the vertigo but can help

Question 18

What is the pathogenesis of menieres disease?

Answer 18

This is dilation of the endolymphatic spaces in the membranous labyrinth causes sudden vertigo

Question 19

What are the clinical features of menieres disease?

Answer 19

Sudden vertigo that always comes with nystagmus, lasts 2-4 hrs commonly, often becomes bilateral

Question 20

What is the treatment of menieres disease?

Answer 20

prochlorperazine is a short term vestibular sedative
Prophylaxis is with betahistine
Labyrinthectomy (cochlear and semi circular canals) is 95% effective but causes ipsilateral deafness

Question 21

What is acute vestibular failure? what are the clinical features?

Answer 21

This is labyrinthitis - causes sudden attacts of unilateral vertigo and vomiting
Lasts 1-2 days
Nystagmus away from the affected side

Question 22

What is the treatment for acute vestibular failure?

Answer 22

Vestibular supressants e.g. prochlorperazine or cyclizine

Question 23

How do you perform the hallpike test?

Answer 23

Get the patient to sit up and look forwards
Then turn their head 45 degrees towards the test ear
Then quickly lie them back with their head 30 degrees below horizontal
This causes maximum stimulation and will cause dizziness or nystagmus if positive

Question 24

How many episodes of tonsillitis should occur a year to elicit a tonsilectomy?

Answer 24

Should be more than 5

Question 25

What is sialadenitis?

Answer 25

This is inflammation of a salivary gland likely secondary to obstruction by a stone impacted in the duct

Question 26

How do you differentiate vestibular neuronitis and labyrinthitis?

Answer 26

Vestibular neuronitis usually has preserved hearing whereas labyrinthitis you can get tinnitus and hearing loss

Question 27

How long should vestibular sedatives e.g. cyclizine be used in acute vestibular failure?

Answer 27

Should be used for the acute phase 24-72 hours but then stopped after this as this is the period of compensation. During this time they should be stopped to allow optimal compensation and patients should be encouraged to return to normal activity