Vertigo

Question 1

What is meniere; History/PE, Dx; Tx

Answer 1

A cause of recurrent vertigo with unilateral auditory symptoms. More common among women. This disorder of the inner ear is characterized by ↑ volume of endolymph (cochlea-hydrops).

History/PE

• ■ Presents with recurrent episodes of severe vertigo (usually vertigo episode lasts for several hours never more than 24, often less than 4 hrs), hearing loss, tinnitus, and ear fullness
  . Nausea and vomiting are typical. Patients progressively lose low-frequency hearing over years and may
  become deaf on the affected side.
  ■ Rule out cerebellopontine angle tumors by MRI.

Diagnosis
The diagnosis is made clinically and is based on a thorough history and physical exam. Two episodes lasting ≥ 20 minutes with remission of symptoms between episodes, hearing loss documented at least once with audiometry, and tinnitus or aural fullness are
vertigo (Usually vertigo episode lasts for several
hours never more than 24, often less than 4 hrs),
hearing loss, tinnitus, and ear fullness
needed to make the diagnosis once other causes (eg, TIA, otosyphilis) have been ruled out.

Treatment
■ Acute: Meclizine or benzodiazepines to control spinning sensation during acute attacks; antiemetics for nausea/vomiting.
■ Chronic: Dietary changes that limit salt intake to avoid fluid retention; diuretics.
■ For severe unilateral cases, intratympanic injection of gentamicin into the middle ear (absorbed by the inner ear) has been shown to reduce the frequency and severity of vertigo attack.

Question 2

Describe the clinical presentation of vestibular neuritis

Answer 2

patient complains of vertigo & vomiting for 1 wk after having been diagnosed with a viral infection, think acute vestibular neuritis

Question 3

Describe the history/ PE of acute peripheral vestibulopathy (Labyrinthitis or Vestibular neuritis)

Answer 3

■ Presents with acute onset of severe vertigo, head motion intolerance, and gait unsteadiness accompanied by nausea, vomiting, and nystagmus.

Question 4

Describe Symptoms of Labyrinthitis

Answer 4

■ Labyrinthitis: Auditory or aural symptoms (tinnitus, ear fullness, or hearing loss). Lateral pontine/cerebellar stroke (anterior inferior cerebellar artery territory) may
present with similar symptoms, but may have additional occipital headache, ataxia, nystagmus.
– Serous (Secondary to otitis media or meningitis)
– Acute suppurative (Secondary to otitis media or meningitis/ Severe hearing loss and vertigo EMERGENCY !!! )
– Toxic (Aminoglycosides, salicylate, iki tarafta da olursa baş dönmesi yok fakat yürürken ufku sabitleyemez)
– Chronic (in to mid fistula due to cholesteatome)

Question 5

Describe the symptoms of vestibular neuritis

Answer 5

■ Vestibular neuritis: Lacks auditory or aural symptoms. Lateral medullary/cerebellar stroke (posterior inferior cerebellar artery territory) can present with similar symptoms.
Generally viral : VZV RAMSAY HUNT S. : -Deafness
-Vertigo
-Facial Nerve Palsy -EAC Vesicles

Question 6

Describe how acute peripheral vestibulo pathy is diagnosed/ treated

Answer 6

Diagnosis
■ A diagnosis of exclusion once the more serious causes of vertigo (eg, cerebellar/brain stem stroke) have been ruled out.
■ Acute peripheral vestibulopathy demonstrates the following:
■ An abnormal vestibulo-ocular reflex as determined by a bedside head impulse test (ie, rapid head rotation from lateral to center while staring at the examiner‘s nose).
■ A predominantly horizontal nystagmus that always beats in one direction, opposite the lesion.
■ No vertical eye misalignment by alternate cover testing.
■ If patients are ―high risk‖ (ie, if they have atypical eye findings or neurologic symptoms or signs, cannot stand independently, have head or neck pain, are > 50 years of age, or have one or more stroke risk factors), MRI with diffusion-weighted imaging is indicated.
Treatment
Acute treatment consists of corticosteroids given < 72 hours after symptom onset and antivertigo agents (eg, meclizine). The condition usually subsides
spontaneously within weeks to months. If suppurative admit and give Abx.

Question 7

Describe what BPPV is; History/PE, Dx, Tx

Answer 7

BPPV
An extremely common cause of recurrent peripheral vertigo resulting from displacement of an otolith (―earstone‖) that leads to disturbances in the semicircular canals.

History/PE
Patients present with transient, episodic vertigo (lasting < 1 minute) and nystagmus triggered by changes in head position (eg, while turning in bed, getting in and out of bed, or reaching overhead). Patients may complain of vertiginous or nonvertiginous dizziness or lightheadedness.
* Horizontorotary nystagmus with crescendo- decrescendo pattern after slight latency period (Less pronounced with repeated stimuli)
* Usually a single position that elicits vertigo
* No hearing loss or tinnitus

Diagnosis
■ Dix-Hallpike maneuver: Have the patient turn his or her head 45 degrees right or left and go from a sitting to a supine position. If vertigo and the typical nystagmus (fast phase toward the affected side) are reproduced, benign paroxysmal positional vertigo is the likely diagnosis.
■ Nystagmus that persists for > 1 minute, gait disturbance, or vomiting should raise concern for a central lesion.

Treatment
■ Epley maneuver (an extended version of the Dix Hallpike maneuver used as treatment) resolves 80% of cases.
■ The condition usually subsides spontaneously in weeks to months, but 30% recur within 1 year. Long- term use of antivertigo medications (eg,meclizine) are generally contraindicated, as they have limited efficacy, they are sedating, and they inhibit vestibular compensation, which may lead to chronic unsteadiness

Question 8

Describe how to differentiate central and peripheral vertigo

Answer 8

CENTRAL
* Vertical nystagmus is characteristic of a (superior colliculus) brain stem lesion!

• Vertebro Basilar Migraine
• should be considered in any elderly patient with new-onset vertigo without an obvious etiology
• vertigo, dysarthria, ataxia, visual changes, paresthesias generally followed by headache
• Family history of migraine
• No residual neurologic signs
• Wallenberg S. (PICA occlusion)
• Loss of pain and temperature sensation on ipsilateral face and contralateral body Ipsilateral bulbar weakness
• Ipsilateral Horner syndrome
• Vertigo, nystagmus

Before discussing conditions that cause vertigo, it is worth defining vertigo and differentiating it from lightheadedness. ―Dizziness‖ is often used to describe vertigo and lightheadedness. Vertigo feels as if one or one’s surroundings are moving when there is no actual movement. Lightheadedness feels as if one is about to faint or ―pass out.‖ Conscious sensation of vertigo occurs in the cerebral cortex as a result of an error signal of observed over expected from the lower centers.

Periferik vertigolara

• Labyrinthine Disorders
  – Most common cause of true vertigo – Five entities
• Benignparoxysmalpositionalvertigo (BPPV)
• Labyrinthitis
• Ménière disease
• Vestibular neuronitis
• Acoustic Neuroma

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