Vertigo Flashcards
Vertigo: sensation of motion with respect to gravity when there is no motion (spinning, linear, rocking, tilting, shifting)
- Positional: head movement to which side (suggests ___)
- Postural (suggests __)
- Weather/atmospheric pressure (suggest ___ migr__aine)
- Pressure-induced: bending down, heavy lifting, coughing, sneezing) (suggests __, __)
- Sounded-induced: aka the Tullio phenomenon (suggests __<PLF)
- Motion stimuli (suggest __, __, __ __ ___, __)
- Light stimuli (suggests __ migraine, __)
NOTE: SCDS: superior semicircular canal dehiscence PLF: perilymphatic fistula
Vertigo: sensation of motion with respect to gravity when there is no motion (spinning, linear, rocking, tilting, shifting)
- Positional: head movement to which side (suggests BPPV)
- Postural (suggests cardiovascular)
- Weather/atmospheric pressure (suggest vestibular migraine)
- Pressure-induced: bending down, heavy lifting, coughing, sneezing) (suggests SCDS, PLF)
- Sounded-induced: aka the Tullio phenomenon (suggests SCDC<PLF)
- Motion stimuli (suggest VN, BPPV, vestibular syndrome migraine, PPPD)
- Light stimuli (suggests vestibular migraine, PPPD)
Sensory Input from the Peripheral Vestibular System
Linear Acceleration: from the otolithic organs (saccule and utricle)
saccule→ vertical linear acceleration and changes in gravity
Utricle → horizontal linear acceleration
Angular Acceleration: rotational acceleration from SCCs
Posterior : IVN via singular nerve
superior/anterior: SVN
lateral/horizontal: SVN
Oscillopsia
visual illusion of to and fro environmental motion, and blurred vision whenever the head is in motion (ex/ shaking of vision)
Lightheadedness/presyncope/brain fog.
Do you get dizzy rolling over in bed? → ______
Are you sensitive to light during a spell? → ___
Does one ear feel full immediately after or before your dizzy attack? →______
Does a loud sound make you dizzy or make your world jiggle? → _____, ____(PLF)
Was your first attack severe vertigo lasting hours and causing nausea and vomiting? → ____ (VN), ____, __.
Are you light headed when rising from a chair? → __ __
Do you pass out completely with your dizziness? → __
Do you get dizzy rolling over in bed? → Benign paroxysmal positional vertigo
Are you sensitive to light during a spell? → vestibular migraine
Does one ear feel full immediately after or before your dizzy attack? → meniere disease
Does a loud sound make you dizzy or make your world jiggle? → superior semicircular canal dehiscence syndrome, perilymphatic fistula (PLF)
Was your first attack severe vertigo lasting hours and causing nausea and vomiting? → vestibular neuritis (VN), labyrinthitis, stroke.
Are you light headed when rising from a chair? → orthostatic hypotension
Do you pass out completely with your dizziness? → cardiovascular
Benign paroxysmal Positional Vertigo causes, diagnosis and treatment
Causes: Vertigo induced by changes in head position (positional vertigo)
- Rolling over in bed, sitting up/lying down in bed
- Looking up at a cabinet/shelf
- Looking at a blind spot while driving
- Head trauma, viral labyrinthitis, otitis media, meniere diseases, recent surgery.
Treatment: often spontaneous onset and spontaneous resolution. May benefit from Epley Maneuver
Characteristics of Nystagmus: latent onset, short duration (<60 s), reversibility, fatigability, directionality.
Diagnosis: Dix-Hallpike Test for posterior and superior SCC
Unilateral Vestibular Loss (Vestibular Neuritis) is caused by inflammation of the ____ ___ (cranial nerve ___), sometimes spreceted by a ____ invfection.
- symptoms include severe vertigo ________, wose with eyes ___, nausea, vomiting, imbalance lasting days.
- obbious ____ is noted; spontaenous horizontal beating away from affected side. Accentuated with gaze ___ from the affected side.
- NO HEARING LOSS
Second most common cause of peripheral vertigo
Inflammation of the vestibular nerve (CNVIII)
Causes: may have history of viral infection.
Symptoms: SEVERE vertigo all the time, worse with eyes closed, nausea, vomiting, imbalance lasting DAYS.
Obvious nystagmus; spontaneous horizontal beating away from affected side. Accentuated with gaze away from affected side.
No headache, hearing loss or cranial nerve palsies.
differentiate between vestibular neuritis and acute labryrinthitis
both are unilateral vestibular losses that present with severe vertigo all the time, worse with eyes close, nausea and vomiting nad nystagmus.
- ACUTE LABYRINTHITIS is an emergency!!! It is often due to bacterial or viral inner ear infection +/- pus. AL HAS CONCURRENT SENSORINEURAL HEARING LOSS AND HEADACHE, where as vestibular neuritis does not have a headache or hearing loss.
Treatment for AL is steroids, plus gravol and ativan.
Generally, for unilateral vestibular loss, there will be specific nystagmus characteristics: Nystagmus is an involuntary rhythmic side-to-side, up and down or circular motion of the eyes that occurs with a variety of conditions.
Horizontal nystagmus with slow and fast components/phase
Nystagmust more obvious when patient looks _____ direction of fast phase (_____ from the disease/weakened side).
Alexander’s Law: suggestive of peripheral disorder.
Generally, for unilateral vestibular loss, there will be specific nystagmus characteristics: Nystagmus is an involuntary rhythmic side-to-side, up and down or circular motion of the eyes that occurs with a variety of conditions.
Horizontal nystagmus with slow and fast components/phase
Nystagmust more obvious when patient looks toward direction of fast phase (away from the disease/weakened side).
Alexander’s Law: suggestive of peripheral disorder.
General Treatment of Unilateral Vestibular Loss
Symptom management
Rehydration if a lot of vomiting
Control nausea and vomiting with antiemetics like gravol.
Steroids for SNHL acute labyrinthitis
Rule out other causes (posterior fossa stroke via HINTS examination and MRI)
When vomiting settles, encourage movement and exercises with eye and head movements as early as possible.
- Central compensation via vestibular rehabilitation (physiotherapy)
Loss of the VOR bilaterally (rare)
Leads to oscillopsia: jumbling of the panorama– blurry vision with head/body movements
Significant imbalance with bilateral vestibular dysfunction
May occur with other neurologic dysfunction
Can be seen in ototoxicity, systemic disease, autoimmune disease, stroke, etc
Bilateral Vestibular Loss
Menirers Disease is a diagnosis f ____.
Symptoms?
Treatment?
DIAGNOSIS OF EXCLUSION
Symptoms: episodes of severe vertigo lasting hour, preceded by or simultaneous aural fullness/pressure, roaring non pulsatile tinnitus, fluctuating hearing loss, progressive hearing loss
Natural history:
unpredictable time course with remissions and recurrences. Median duration of meniere disease is 9 years.
Bilateral meniere disease: consideration for ablative treatments
Audiometric monitoring: hearing aid while hearing continues to be serviceable/aidable.
Treatment: treatment depends on frequency and severity of attacks
First line: life style changes → strict low-salt diet (<1.6 g sodium/day), reduced caffeine, stress control, better sleep
Acute episodes: antiemetics +/- vestibular suppressants
Chronic therapy: betahistine (do not prescribe to just any patient with dizziness), diuretics (hydrochlorothiazide, acetazolamide, amiloride)
Surgery:
Non ablative (intratympanic steroid injections)
Ablative (intratympanic gentamycin injections– chemical labyrinthectomy), surgical labryinthectomy. Surgical vestibular nerve section.
