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X Clin Med III Final Exam > Vertigo and Syncope > Flashcards

Vertigo and Syncope Flashcards

1
Q

What is vertigo?

A

Sensation of movement when there is none or just abnormal movement, often spinning (tumbling, falling forward/back)
It is a symptom!
Associated with nystagmus and postural instability

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2
Q

What is disequilibrium?

A

Sense of imbalance (losing balance without sensation of movement)
-Imbalance and gait difficulties

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3
Q

What is presyncope?

A

Feeling of impending faint of LOC (no true syncope, generally associated with cardiac etiology)

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4
Q

Causes of vertigo

A

Peripheral (vestibular ex otologic lesion)

Central (central ex brainstem lesion)

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5
Q

Presentation of peripheral vertigo

A

Sudden, acute onset (may be severe)
Associated ear sxs (hearing loss, tinnitus)
Nystagmus can be horizontal and/or torsional (rotary)
Neuro sxs ABSENT

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6
Q

Presentation of central vertigo

A

May be gradual and progressive
Rare to have ear sxs
Nystagmus can occur in any direction, can be dissociated in 2 eyes (often vertical and nonfatigable)
Neuro sxs PRESENT (diplopia, ataxia, dysrthria)
May see HA or n/v

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7
Q

Lightheadedness

A

Vague, nonspecific “dizziness”

Can be associated with psych disorders (anxiety, depression, stress rxn) and hyperventilation

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8
Q

What to ask with the dizzy pt?

A

Duration of sxs and events
Relation to position (standing. head movement etc)
Possible triggers
Associated sxs (n/v, hearing loss, ear fullness, tinnitus, HA, vision, seizures, weakness)

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9
Q

What serious causes of vertigo MUST always be ruled out?

A

Cerebrovascular disease (vertebrobasilar insufficiency/stroke)
MS
Acoustic neuroma

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10
Q

Important parts of PE in vertigo

A

VS (orthostasis)
Ear (obstruction, fluid, perf)
Cardiac
Neuro (CNs, motor, cerebellar testing)

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11
Q

What is nystagmus?

A

Slow drift in one direction followed by fast response in the opposite direction

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12
Q

Categories of nystagmus

A

(direction of fast component)
Horizontal: peripheral or metabolic cause
Horizontal/torsional: peripheral or positional
Vertical: think CNS!!!

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13
Q

What is Dix-Hallpike maneuver most helpful for?

A

BPPV

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14
Q

What is electronystagmography or videonystagmography?

A

Assessment of vestibular function/ocular motility

-Record eye movements in response to visual, positional or rotational stimuli

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15
Q

What is caloric testing used for?

A

Vestibulo-ocular reflex

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16
Q

Normal response in caloric testing

A

COWS (Cold Opposite Warm Same)-direction of fast bearing nystagmus response
Cold water: eyes deviate ipsilateral and nystagmus beats away to opposite side
Warm water: eyes deviate contralateral and nystagmus beats to same side

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17
Q

What is vestibular paresis?

A

Seen in abnormal caloric testing

Impaired or absent thermally induced fast nystagmus (indicates pathology in labyrinth on irrigated side)

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18
Q

Most common cause of vertigo

A

Benign Paroxysmal Positional Vertigo

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19
Q

Presentation of BPPV

A

Transient (<1 min) episodes of vertigo associated with changes in head position
No hearing changes
Self limited but may last weeks or months

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20
Q

What is BPPV associated with?

A

Prolonged bed rest and head trauma

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21
Q

PE for BPPV

A

Normal
Dix-Hallpike can reproduce vertigo and horizontal nystagmus
Sxs fatigue with repetition

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22
Q

Management of BPPV

A

Reassurance that self-limited
Particle repositioning maneuvers
Vestibular rehab (OT or positional exercises)
Anti vertigo meds might help

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23
Q

First line vestibular suppressants

A

Anticholinergics (Scopolamine) or antihistamines (Meclizine or dimenhydrinate)

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24
Q

Other vestibular suppressants

A

Phenothiazines (prochlorperazine, promethazine)

Benzos

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25
Q

Etiology of vestibular neuritis

A

(vestibular neruonitis, labyrinthitis etc)
Young to middle age
Presumed viral or postviral inflammatory (affecting vestibular portion of CN VIII)

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26
Q

Presentation of vestibular neuritis

A

Single attack of severe vertigo (several days to a week)
Associated with viral URI
N/v and gait instability
No tinnitus or hearing loss (if hearing loss then labyrinthitis)
Fall to affected side

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27
Q

How to diagnose vestibular neuritis

A

Positive head thrust test
No CNS deficits
Audiograms normal
Caloric testing shows vestibular paresis on affected side

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28
Q

Management of vestibular neuritis

A 
Self-limited
Symptomatic tx (bed rest, vestibular suppressants, anti-emetics PRN, prednisone taper over 10 days)
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29
Q

Pathogenesis of Meniere’s

A

Secondary to endolympathic hydrops (syphilis and head trauma)-distortion of membranous endolymph containing portions of labyrinthine system

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30
Q

Rupture theory of Meniere’s

A

Swelling then rupture of membranous labyrinth causes paralysis of vestibular nerve fibers and degeneration of cochlear hair cells

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31
Q

Presentation of Meniere’s

A

Triad: episodic vertigo, tinnitus and fluctuating hearing loss
Sudden onset of attacks (20 min-24 hrs)
Fullness of ear, n/v

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32
Q

Progression of Meniere’s

A

Hearing loss gets worse and can eventually be irreversible
Audiogram will show sensorineural hearing loss
Lose low tones and then high tones

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33
Q

When do attacks of vertigo stop with Meniere’s?

A

When deafness is complete

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34
Q

Management of acute attack of Meniere’s

A

Bed rest

Symptomatic: anti-emetics or vestibular suppressants

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35
Q

Prophylactic management of Meniere’s

A

Low salt diets
Limit caffeine, nicotine, alcohol, MSG
Diuretics (HCTZ)

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36
Q

Surgical management for refractory Meniere’s

A 
Intratympanic corticosteroid injection
Endolymphatic sac decompression
Vestibular ablation (transtympanic gentamicin, vestibular nerve section, surgical labyrinthectomy)
37
Q

What is a perilymphatic fistula?

A

Abnormal connection between perilymph and middle ear (inner ear fluid can leak into middle ear)

38
Q

Presentation of perilymphatic fistula

A

Associated with sudden changes in pressure of middle ear (head trauma, weight lifting, erosion, congenital)
Hearing loss, tinnitus, vertigo

39
Q

How to confirm presence of perilymphatic fistula

A

Pneumatic otoscope (abnormal to see eye movements with changes in pressure but may see nystagmus)

40
Q

Management of perilymphatic fistula

A

Bedrest
Hydration
Symptomatic
Surgery

41
Q

Red flags with vertigo

A

Neuro deficit
Ipsilateral hearing loss
Gait abnormality
Direction changing nystagmus

42
Q

Sxs leading to a diagnosis of vertigo: aural fullness

A

Acoustic neuroma

Menieres

43
Q

Sxs leading to a diagnosis of vertigo: ear/mastoid pain

A

Acoustic neuroma

Acute middle ear disease (AOM, herpes zoster oticus)

44
Q

Sxs leading to a diagnosis of vertigo: facial weakness

A

Acoustic neuroma

Herpes zoster oticus

45
Q

Sxs leading to a diagnosis of vertigo: focal neuro findings

A

Cerebellar tumor
CVD
MS

46
Q

Sxs leading to a diagnosis of vertigo: HA

A

Acoustic neuroma

Migraine

47
Q

Sxs leading to a diagnosis of vertigo: hearing loss

A 
Menieres
Acoustic neuroma
Otosclerosis
Labyrinthitis
Herpes zoster
TIA
Cholesteatoma
Perilympathic fistula
48
Q

Sxs leading to a diagnosis of vertigo: imbalance

A 
Acute vestibular neuritis (moderate)
Cerebellar tumor (severe)
49
Q

Sxs leading to a diagnosis of vertigo: phono/photophobia

A

Migraine

50
Q

Sxs leading to a diagnosis of vertigo: rash

A

Herpes zoster oticus

51
Q

Sxs leading to a diagnosis of vertigo: tinnitus

A

Acute labyrinthitis
Acoustic neuroma
Menieres

52
Q

Provoking factors leading to a diagnosis of vertigo: changes in head position

A 
Acute labyrinthitis
BPPV
Cerebellar tumor
MS
Perilymphatic fistula
53
Q

Provoking factors leading to a diagnosis of vertigo: spontaneous with no provoking factors

A 
Vestibular neuritis
TIA/CVA
Menieres
Migraine
MS
54
Q

Provoking factors leading to a diagnosis of vertigo: recent URI

A

Vestibular neuritis

55
Q

Provoking factors leading to a diagnosis of vertigo: stress

A

Psychogenic

Migraine

56
Q

Provoking factors leading to a diagnosis of vertigo: immunosuppresion

A

Herpes zoster oticus

57
Q

Provoking factors leading to a diagnosis of vertigo: changes in ear pressure, trauma, noises

A

Perilymphatic fistula

58
Q

What is syncope?

A

Sudden, transient loss of consciousness with spontaneous recovery (loss of postural tone, due to diminished cerebral BF)

59
Q

Possible etiologies of syncope

A

Neurally mediated/neurocardiogenic-reflex syncope
Cardiac (higher risk of death)- obstruction, arrhythmias
Orthostatic/autonomic
Psych (GAD, panic attacks, somatic sx disorder)

60
Q

Prodrome associated with syncope

A

Uneasiness or apprehension
Lightheaded, facial pallor, diaphoresis, nausea
Visual blurring, CP, SOB, HA, neuro sxs

61
Q

What part of the prodrome is consistent with vasovagal syncope?

A

Lightheaded, facial pallor, diaphoresis, nausea

62
Q

BP positive for orthostasis

A

Drop in systolic >20 or diastolic >10

63
Q

Diagnostics for syncope

A 
EKC
Echo (when cardiac disease, abnormal PE or ECG)
Electrophysiologic testing
Exercise stress testing maybe
Carotid u/s
Neuroimaging MRI if abnormal PE
EEG r/o seizure
Labs
64
Q

When is tilt table indicated?

A

For recurrent episodes of unexplained syncope and no history of cardiac disease

65
Q

What is the tilt table?

A

Provocative test for vasovagal syncope
Pt is tilted upright by 60-90 degrees:
Normal is minimal drop in BP and increase HR
Abnormal is exaggerated drop in BP with or without drop in HR associated with dizzy or lightheaded

66
Q

When is carotid sinus massage indicated?

A

Recurrent episodes of syncope with negative work up or history of carotid sinus syncope

67
Q

What is the carotid sinus massage?

A

Massage it for 5-10 sec and monitor HR and BP
(palpate carotids and listen for bruit first!)
+ is sxs reproduced and period of asystole >3-5 sec or drop in BP (>50 mmHg)

68
Q

Contraindications for carotid sinus massage

A

Prior TIA or stroke within last 3 mos

Pts with carotid bruits

69
Q

Risk factors for cardiac syncope

A 
Abnormal EKG
History of ventricular arrhythmias
History of HF
Age >45
*poor prognosis so need to ID (palpitations associated suggest hypotension and mad arrhythmia)
70
Q

Bradyarrhythmia in cardiac syncope

A 
Sinus node dysfunction
AV block (Second degree type II or complete)
71
Q

Tacharrhythmias in cardiac syncope

A

SVT
Wolff Parkinson White
Ventricular tachycardia
Do ECG and Holter

72
Q

Most common outflow obstruction leading to cardiac syncope

A

Aortic stenosis

73
Q

Presentation of cardiac syncope from aortic stenosis

A

Exertion association and cannot compensate

74
Q

Cardiac syncope due to aortic dissection

A

Acute onset of tearing pain radiating to back

Unstable pt means high mortality

75
Q

How to distinguish HCM from cardiac syncope

A

See dyspnea and increased systolic heart murmur with standing or exertion

76
Q

How to distinguish PE from cardiac syncope

A

Acute dyspnea, pleuritic chest pain, hemopytysis and leg swelling

77
Q

How to distinguish cardiac tamponade from syncope

A

Muffled hearts sounds and increased neck veins

78
Q

What is reflex syncope?

A

Loss of sympathetic tone (or sudden increase in parasympathetic) leading to vasodilation and bradycardia and then hypotension and syncope
Vasovagal, carotid sinus, situational

79
Q

Vasovagal syncope

A

Seen in adolescents and YAs
Emotional lability and stress, usually a provoking stimulus
Prodrome of diaphoresis, nausea and pallor
No long term tx needed

80
Q

Who has carotid sinus syncope?

A

Middle age or elderly (probs male with atherosclerotic vascular disease)
Tight collars or shaving can precipitate

81
Q

Tx for carotid sinus syncope

A

Cardiac pacemaker

82
Q

What is micturition syncope?

A

Syncopal episode after emptying distended bladder
Seen after excess fluid ingestion, maybe alcohol
Secondary to vagal stimulation or orthostasis

83
Q

What is tussive syncope?

A

Seen in barrel chest/COPD/ kids with asthma

Severe coughing increases intrathoracic pressure and decreases CO

84
Q

Causes of orthostatic hypotension

A

Autonomic failure
Vol depletion
Aging
Meds (anti-hypertensives, TCAs)

85
Q

Associations of orthostatic hypotensions

A

Diabetic polyneuropathy, PD

Malnutrition, anemia, blood loss, adrenal insufficiency all worsen it

86
Q

Management of orthostatic hypotension

A

Avoid vol depletion
Med adjustment
Behavior (slow movements, doriflex feet or handgrip before standing, jobst stocking)

87
Q

What is subclavian steal syndrome?

A

Stenosis of subclavian artery near origin and flow reversal in ipsilateral vertebral artery causing decreased brain perfusion

88
Q

Sxs of subclavian steal syndrome

A

Diplopia, vertigo, syncope, dysrthria, ataxia
Look for sxs with arm exertion
look for different UE pulses

89
Q

Management of syncope

A

Treat underlying disorder

IF remains unexplained then probably benign with good prognosis

X Clin Med III Final Exam (6 decks)

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