Vertigo Flashcards
Central vs peripheral vertigo
Causes of peripheral vertigo
BPPV,
Meniere Disease,
vestibular neuritis
Causes of central vertigo
Stroke, migraine, multiple sclerosis
nystagmus differences in peripheral vs central vertigo
peripheral vertigo: nystagmus is never purely vertical, inhibited by fixation of gaze, fatigable (<1 min duration), lantency period is 2-40 seconds)
Central vertigo: may have any trajectory, not inhibited by fixation of gaze, not fatigable >1 min duration, no latency period
Other neurological signs associated with peripheral vertigo
Hearing loss/tinnitus
walking is preserved
no other CNS signs
Central vertigo other neuro signs
hearing loss/ tinnitus absent
severe postural instability
other CNS symptoms
(headache, diplopia, dysarthria, weakness/numbness of face and limbs often present)
What test should always be ordered when someone presents with new neurological symptom?
POC glucose if <50 it can neuro symptoms
When to treat with meclizine?
Treament of BPPV
what is the Epley’s maneuver?
Treats BPPV and moves the otolith to the proper position in the semicircular canals
how to diagnosis BPPV
Dixhall pike maneuver - have pt lie back to supine position and slightly extend and rotate head 45% towards side with dizziness and look for latent vertical nystagmus.
should exhaust after 30 seconds and recurrs in opposite direction with sitting up.
DO NOT confuse the Dixhall pike maneuver (diagnosis) and Epley maneuver (treatment)
recurrent episodes of vertigo lasting 20 minutes to several hours
sensorneural hearing loss
may have tinnitus or feeling fullness in the ear (aural fullness)
Meniere’s disease
brief episodes of vertigo triggered by head movement
confirmed with dix hallpike maneuver that causes nystagmus
BPPV
acute single episode that can last days.
often follows a viral syndrome
abnormal head thrust test
vestibular neuritis
vertigo associated with headache and other migraionous phenomenon (visual aura) and symptoms resolve completely between episodes
migraine headache
sudden onset persistent vertigo, usually other neurological symptoms
brainstem/cerebellar stroke
what causes Meniere’s dx
inner ear disorder that we see increased volume and pressure of endolymph (endolymphatic hydrops). This results in distention of the endolymphatic system and damages the vestibular and cochlear components of the ear
Diagnosis of Meniere’s dx
based on clinical findings.
Audiometry is helpful for fully characterizing hearing loss and following its course over time.
Initial management of Meniere’s disease is
restriction of sodium, caffeine, nicotine, and alcohol.
Benzos, antihistamines, and antiemetics can relieve acute symptoms. Diuretics can be done if dietary changes are insufficient.
Treatment of BPPV
Epley maneuver to help reposition canalith.
treatment of acute vestibular neuritis (which follows after viral infection)
treatment with oral glucocorticoids like methylprednisolone
If ther’s hearing loss then it’s labyrinthitis.
Do we use steroids to treat Meniere’s dx?
not a routine recommended treatment.
can be used but no good data to support its use
Time course of cerebellar infarction
Physical exam of cerebellar infarction
associated symptoms:
endolymphatic hydrops is also known as
Meniere’s disease - from either too much or too absorption of endolymph.
Will develop tinnitis in one ear associated with ear fullness and progressive sensorineural hearing loss and vertigo.
No papilledema.
Common causes of vertigo based on duration
acute sustained vertigo with bidirectional nystagmus is concerning for
cerebellar stroke.
Nystagmus can distinguish -
peripheral dx like vestibular neuritis or Meniere’s dx - will have a suppressible nystagmus that does not reverse direction but beats away from lesion.
Central dx like cerebellar stroke or MS - will have a nonsuppressible nystagmus that can reverse direction, bidirectional and beats towards the lesion.
limb ataxia, inability to ambulate and falling and nystagmus to side of lesion and symptoms persisting >72 hrs suggest:
Also will see dysmetria and dysdiadochokinesia and persistent hiccups
cerebellar infarct
For suspected cerebellar stroke what to do:
get brain imaging with MRI or MR angiography to detect for acute cerebellar infarction and posterior circulation occlusion
CT scan is less sensitive in detecting posterior fossa abnormalities and may be normal within hours of stroke
Epley maneuver is done
treatment of BPPV
Diagnosis is dix hallpike maneuver
Categories of dizzines
Treatment of disequilibrium:
disequilibrium could be due to:
decreased vision,
peripheral neuropathy,
deconditioning,
decreased peripheral vestibular function
early parkinsons.
medications
Treat with balance training exercise in addition to better physical conditioning, vision correction and improving hearing deficiencies and instruction in assistive devices and evaluation of pts living space for safety features.
Treatment of Meniere’s dx that is refractory to medical management:
Needs endolymphatic decompression
this is when salt restriction, anti histamine therapy and diuresis don’t work.
Failure of therapy occurs in 10% of pts and can significantly impair quality of life in pts.
what’s the difference between labyrinthitis and vestibular neuritis?
are they the same thing?
NO.
Labyrinthitis - inflammation of the both branches of the cranial nerve 8
Vestibular neuritis - peripheral vestibular condition caused by inflammation of the vestibular nerve- nerve in inner ear that sends messages to the brain. symptoms are sustained and rainges from days to weeks. No auditory symptoms are seen. Rather see vertigo and nystagmus no hearing loss.
both will have similar presenting symptoms but if hearing is affected then labyrinthitis is the cause. Inflammation of labyrinth affects hearing while inflammation of vestibular nerve does not. Vestibular neuritis has just nystagmus and vertigo.
labyrinthitis is
peripheral vertigo that is continuous and long lasting with sensorineural hearing loss. Affects both branches of vestibulocochlear nerve 8
followed a URI.
vestibular neuritis
peripheral neuronitis that is a result of inflammation from the vestibular branch of the CN8. See only vertigo and nystagmus but no hearing loss.
preceded by a nviral infection
symptoms of vertigo are sustained ranging from days to weeks.
