Vertigo

Question 1

Central vs peripheral vertigo

Answer 1

Question 2

Causes of peripheral vertigo

Answer 2

BPPV,

Meniere Disease,

vestibular neuritis

Question 3

Causes of central vertigo

Answer 3

Stroke, migraine, multiple sclerosis

Question 4

nystagmus differences in peripheral vs central vertigo

Answer 4

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

Question 5

Other neurological signs associated with peripheral vertigo

Answer 5

Hearing loss/tinnitus

walking is preserved

no other CNS signs

Question 6

Central vertigo other neuro signs

Answer 6

hearing loss/ tinnitus absent

severe postural instability

other CNS symptoms

(headache, diplopia, dysarthria, weakness/numbness of face and limbs often present)

Question 7

What test should always be ordered when someone presents with new neurological symptom?

Answer 7

POC glucose if <50 it can neuro symptoms

Question 8

When to treat with meclizine?

Answer 8

Treament of BPPV

Question 9

what is the Epley’s maneuver?

Answer 9

Treats BPPV and moves the otolith to the proper position in the semicircular canals

Question 10

how to diagnosis BPPV

Answer 10

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)

Question 11

recurrent episodes of vertigo lasting 20 minutes to several hours

sensorneural hearing loss

may have tinnitus or feeling fullness in the ear (aural fullness)

Answer 11

Meniere’s disease

Question 12

brief episodes of vertigo triggered by head movement

confirmed with dix hallpike maneuver that causes nystagmus

Answer 12

BPPV

Question 13

acute single episode that can last days.

often follows a viral syndrome

abnormal head thrust test

Answer 13

vestibular neuritis

Question 14

vertigo associated with headache and other migraionous phenomenon (visual aura) and symptoms resolve completely between episodes

Answer 14

migraine headache

Question 15

sudden onset persistent vertigo, usually other neurological symptoms

Answer 15

brainstem/cerebellar stroke

Question 16

what causes Meniere’s dx

Answer 16

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

Question 17

Diagnosis of Meniere’s dx

Answer 17

based on clinical findings.

Audiometry is helpful for fully characterizing hearing loss and following its course over time.

Question 18

Initial management of Meniere’s disease is

Answer 18

restriction of sodium, caffeine, nicotine, and alcohol.

Benzos, antihistamines, and antiemetics can relieve acute symptoms. Diuretics can be done if dietary changes are insufficient.

Question 19

Treatment of BPPV

Answer 19

Epley maneuver to help reposition canalith.

Question 20

treatment of acute vestibular neuritis (which follows after viral infection)

Answer 20

treatment with oral glucocorticoids like methylprednisolone

If ther’s hearing loss then it’s labyrinthitis.

Question 21

Do we use steroids to treat Meniere’s dx?

Answer 21

not a routine recommended treatment.

can be used but no good data to support its use

Question 22

Time course of cerebellar infarction

Physical exam of cerebellar infarction

associated symptoms:

Answer 22

Question 23

endolymphatic hydrops is also known as

Answer 23

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.

Question 24

Common causes of vertigo based on duration

Answer 24

Question 25

acute sustained vertigo with bidirectional nystagmus is concerning for

Answer 25

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.

Question 26

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

Answer 26

cerebellar infarct

Question 27

For suspected cerebellar stroke what to do:

Answer 27

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

Question 28

Epley maneuver is done

Answer 28

treatment of BPPV

Diagnosis is dix hallpike maneuver

Question 29

Categories of dizzines

Answer 29

Question 30

Treatment of disequilibrium:

Answer 30

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.

Question 31

Treatment of Meniere’s dx that is refractory to medical management:

Answer 31

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.

Question 32

what’s the difference between labyrinthitis and vestibular neuritis?

are they the same thing?

Answer 32

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.

Question 33

labyrinthitis is

Answer 33

peripheral vertigo that is continuous and long lasting with sensorineural hearing loss. Affects both branches of vestibulocochlear nerve 8

followed a URI.

Question 34

vestibular neuritis

Answer 34

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.