Tinnitus and Vertigo

Question 1

What is tinnitus?

Answer 1

Perception of ringing in the ear without auditory stimulation but sometimes with auditory stimulation. Often causes by an underlying abnormality. Commonly associated with sensori-neural hearing loss. Pathophysiology is poorly understood – possibly spontaneous acoustic emissions, altered or increasing activity in nerve VIII, inappropriate feedback etc.

Unilateral or bilateral
Pulsatile or non-pulsatile

Question 2

How does tinnitus caused by pathology in the inner ear differ in presentation from external

Answer 2

Ringing, hissing or buzzing – inner ear or central cause

Popping or clicking – problems in the external or middle ear

Question 3

How do you classify tinnitus?

Answer 3

Objective – audible to the examiner, rare and usually due to vascular disorders. Can also by myoclonus of palatal or stapedius/tensor tympani muscles resulting in an audible click. Also Patulous Eustachian tube – prolonged opening causing abnormal sound transmission.

Subjective – audible only to the patient. Most commonly associated with other disorders causing SNHL. Conductive hearing loss causes are less commonly associated. Ototoxic drugs (aminoglycosides, aspirin, loop diuretics and quinine), otitis media + effusion, otosclerosis, thyroid issues, diabetes, MS and acoustic neuroma.

Question 4

How should tinnitus be investigated?

Answer 4

MRI if unilateral to exclude acoustic neuroma

Audiometry

Question 5

How should tinnitus be managed?

Answer 5

Treat any underlying cause
Stop ototoxic drugs if possible
Address underlying concerns and explain what it is
Positive attitude – most improve with habituation
CBT and psychological support can help
Hearing aids if loss > 35dB

Question 6

What is vertigo?

Answer 6

Symptom – sensation that you or the world is spinning (note important difference). If the patient doesn’t know it may be pertinent to pursue other causes e.g. light headedness.

Question 7

How is vertigo classified?

Answer 7

Vestibular (peripheral) which is often severe and can be accompanied by loss of balance, nausea, vomiting, HL, tinnitus nystagmus (horizontal usually) and diaphoresis

Central which is often less severe and can be accompanied by nystagmus which may be horizontal or vertical.

Question 8

What causes peripheral vertigo?

Answer 8

Meniere’s disease
Benign paroxysmal positional vertigo (BPPV)
Vestibular neuronitis and labyrinthitis
Superior semi-circular canal dehiscence

Question 9

What causes central vertigo?

Answer 9

Acoustic Neuroma or other neoplasms
MS 
Head injury 
Migraine associated dizziness or vestibular migraines 
Drugs
Stroke

Question 10

How should vertigo be investigated?

Answer 10

Examine Cranial nerves and ears
Test cerebellar function reflexes
Gait, nystagmus and Romberg’s test particularly important
Provocation tests – Head thrust test and hall pike test
HiNTS (Head impulse, Nystagmus Test of Skew)

Audiometry
MRI

Question 11

What is benign paroxysmal positional vertigo?

Answer 11

Most common cause of vestibular vertigo. This occurs when displacement of otoconia (the otoliths or crystals) stimulate the semi-circular canal hair cells. The cause is usually head injury or idiopathic. Most common at 55yrs and rare in young patients.

Question 12

What are the clinical features of BPPV?

Answer 12

Sudden attacks of rotational (i.e. triggered by change in head position) vertigo lasting 10-20 seconds provoked by head turning.
May have nausea
Rarely have other otological symptoms

To diagnose must confirm:
No persistent vertigo
No speech, visual, motor or sensory problems
No tinnitus, headaches, ataxia, facial numbness or dysphagia
No vertical nystagmus
Dix-Hallpike test is positive

Question 13

How is BPPV managed?

Answer 13

Usually self-limiting, if persistent try Epley manoeuvre (70-80% effective). Home repositioning (modified Epley manoeuvre and the Bradt-Daroff exercises).
Medication – Betahistine but of limited value
Last resort is surgical blockage of the canals to stop the crystals moving.
Often there is recurrence of symptoms within 3-5 years

Question 14

What is meniere’s disease?

Answer 14

Dilation of the endolymphatic spaces of the membranous labyrinth

Question 15

What are the clinical features of meinere’s disease?

Answer 15

Sudden attack of vertigo lasting 2-4 hours with associated N+V
Nystagmus (always)
Positive Romberg’s test
Increasing fullness in the ears
Tinnitus sometimes precedes the vertigo
Symptoms often become bilateral and there may be fluctuating SNHL that becomes permanent.

Question 16

How is meniere’s disease investigated?

Answer 16

Diagnosis with electrocochleography of the posterior fossa

MRI

Question 17

How is meniere’s managed (excluding surgical)?

Answer 17

Resolves spontaneously over 5-10 years
Acute with prochlorperazine (Buccastem)
To prevent recurrent attacked treat with betahistine. Also encourage low salt diet and thiazide diuretics long term.

Question 18

How is meniere’s managed surgically?

Answer 18

Insertion of a grommet
Dexamethasone middle ear injection
Endolymphatic sac decompression
Vestibular destruction using middle ear injection of gentamicin
Labyrinthectomy treats vertigo in 90% of cases but causes complete ipsilateral deafness. Vestibular neurectomy – 90% effective but 5% risk of hearing loss.

Question 19

Can patients drive with a diagnosis of meniere’s?

Answer 19

Notifiable to DVLA – must stop driving until controlled

Question 20

What is vestibular neuronitis?

Answer 20

(Acute vestibular failure)
Presents with sudden attacks of unilateral vertigo and vomiting in a previously well patient following an URTI. This usually lasts hours to days and improves over a week. Horizontal nystagmus will be seen away from affected side. Will not have hearing loss or tinnitus.

Question 21

Are there any long term effects of vestibular neuronitis?

Answer 21

Usually an associated long-term deficit after the acute attack for a number of weeks.

Question 22

Are any investigations warranted in suspected vestibular neuronitis?

Answer 22

Audiogram should be done if there is hearing loss

Question 23

How should acute vestibular failure be managed?

Answer 23

Acute treatment – Buccastem (if severe) or Cyclizine
After the attacks no vestibular suppressants should be taken but vestibular physiotherapy should be prescribed and recommended.

Question 24

What is viral labyrinthitis?

Answer 24

Labyrinthitis is an inflammatory disorder of the membranous labyrinth, affecting both the vestibular and cochlear end organs. Labyrinthitis can be viral, bacterial or associated with systemic diseases. Viral labyrinthitis is the most common form of labyrinthitis.

Question 25

How is viral labyrinthitis differentiated from vestibular neuronitis?

Answer 25

Labyrinthitis should be distinguished from vestibular neuritis as there are important differences: vestibular neuritis there is only the vestibular involvement, hence there is no hearing impairment. The average age of presentation is 40-70 years

Question 26

What are the clinical features of viral labyrinthitis?

Answer 26

Vertigo not triggered by movement but exacerbated by movement
Nausea and vomiting
Sensorineural Hearing loss: may be unilateral or bilateral, with varying severity
Tinnitus
Preceding or concurrent symptoms of upper respiratory tract infection

Question 27

What specific clinical signs are seen in viral labyrinthitis?

Answer 27

Spontaneous unidirectional horizontal nystagmus towards the unaffected side
Abnormal head impulse test signifies an impaired vestibulo-ocular reflex
Gait disturbance: the patient may fall towards the affected side
Normal skew test
Abnormality on inspection of the external ear canal and the tympanic membrane e.g. vesicles in herpes simplex infection

Question 28

How common is vestibular migraine?

Answer 28

A common cause of vertigo and the most common cause of spontaneous episodic vertigo. It affects approximately 10% of patients with migraine.

Question 29

What are the features of a vestibular migraine

Answer 29

Spontaneous and positional vertigo
Head motion vertigo/dizziness and ataxia
Variable duration, ranging from seconds to days,
Independent of migraine associated headache
Photophobia, phonophobia, or aura may be diagnostic symptoms.

Question 30

How is vestibular migraine managed?

Answer 30

Management is similar to the recommended treatment of migraine headaches, and includes dietary and lifestyle modifications, and prophylactic therapies (beta blockers, calcium channel blockers, and tricyclic antidepressants).

Question 31

What is HINTS?

Answer 31

This is a test designed to differentiate between central and peripheral vertigo. It consists of the head impulse test, evaluation of nystagmus and a test of skew.

Question 32

Describe a Head impulse test and what the findings mean

Answer 32

Head impulse test
This must be done on patient who are currently symptomatic, and you must ask if they have any head and neck trauma or cervical spine osteoarthritis.
1. Gently move the patient’s head side to side, making sure the neck muscles are relaxed.
2. Then ask the patient to keep looking at your nose whilst you turn their head left and right.
3. Turn the patient’s head 10-20° to each side rapidly and then back to the midpoint.

Positive test = eyes move with the head and then attempt to move back to the doctor’s nose and the patient will find it difficult to fixate on the clinician’s nose. This indicates disruption in the vestibulo-ocular reflex and is indicative of peripheral vertigo.

Question 33

Describe a nystagmus test and what the results mean?

Answer 33

Assess by observing patient primary gaze whilst looking straight ahead. Then ask the patient to look left and then right without moving their head and without focusing on any objects.

Unidirectional nystagmus indicates peripheral vertigo
If the nystagmus changes direction or is vertical it is more likely to be central
Bidirectional nystagmus is highly suggestive of stroke

Question 34

Describe a test of skew and what the results mean?

Answer 34

Test of Skew

1. Ask the patient to look at your nose and subsequently cover one of their eyes.
2. Then, quickly move your hand to cover the patient’s other eye. During this process, observe the uncovered eye for any vertical and/or diagonal corrective movement.
3. Repeat this manoeuvre on the other eye.

Any abnormal movement observed here, often associated with vertical diplopia, is highly specific for a central cause of vertigo.