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HEENT > Vertigo And Tinnitus > Flashcards

Vertigo And Tinnitus Flashcards

1
Q

Symptom of vertigo, lightheadedness/faintness, imbalance, combination

A

Dizziness

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2
Q

Cardinal symptom of vestibular disease, sensation of movement where there is no movement, asymmetry of vestibular inputs

A

Vertigo

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3
Q

Vertigo can be either ____ or ____

A

Physiologic (sustained head rotation), pathologic (vestibular dysfunction)

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4
Q

Feeling faint, about to lose consciousness Presyncopal sensation, typically related to brain hypoperfusion

A

Lightheadedness/faintness

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5
Q

Feeling off-balance

A

Disequilibrium/imbalance

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6
Q

What are causes of disequilibrium/imbalance

A

CNS lesion or vestibular dysfunction

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7
Q

Is this vertigo, lightheadedness, or disequilibrium: i felt like I was about to pass out

A

Lightheadedness

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8
Q

Is this vertigo, lightheadedness, or disequilibrium: the room was spinning around me

A

Vertigo

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9
Q

Is this vertigo, lightheadedness, or disequilibrium: i felt unsteady while I was walking?

A

Disequilibrium

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10
Q

Is this vertigo, lightheadedness, or disequilibrium: my head felt like it was whirling around like a top

A

Vertigo

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11
Q

Is this vertigo, disequilibrium, or lightheadedness: i thought i might just tip over at any minute

A

Disequilibrium

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12
Q

Is this vertigo, lightheadedness, or disequilibrium: everything started to go black- i had to lay down

A

Lightheadedness

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13
Q

What are the differences between peripheral and central vertigo?

A

Peripheral is sudden onset with associated tinnitus/hearing loss, may have nausea/vomiting, may have horizontal nystagmus

Central is gradual onset usually without hearing symptoms; if tinnitus, will likely be bilateral; may have vertical nystagmus

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14
Q

What do you need to differentiate with dizziness?

A

Type of dizziness? Danger? Is it vestibular? Peripheral or central?

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15
Q

Talking about history of symptom and duration

A
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16
Q

If movement/position change triggers the symptom, what would you think?

A

BPPV, orthostasis

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17
Q

If a patient presents with aural fullness, what should you suspect?

A

Meniere’s

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18
Q

If a patient presents with double vision, ataxia, and/or numbness, what should you think?

A

Brain stem or cerebellar lesion

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19
Q

What neurologic assessments can you do on hearing loss/tinnitus?

A

Gait
Romberg
Cranial nerves: EOM- pursuit/saccades: abnormal can indicate cerebellar pathology
Nystagmus: involuntary back and forth movement of the eyes
Head impulse test: assess vestíbulo-ocular reflex

Hearing evaluation: whisper test, Weber, Rinne

Dix-Hallpike maneuver

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20
Q

When would you perform audiometery and what does it measure?

A

If history or exam indicate comorbid hearing impairment

Hearing acuity, tones, pitches, and frequencies

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21
Q

Cold and/or warm water or air is irrigated into the ear. Warm water mimics a head turn to the ipsilateral side. Cold water mimics a head turn to the contralateral side

A

Caloric testing

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22
Q

Normally, adding cold and/or warm water or air to ear with cause what?

A

Warm- nystagmus towards ipsilateral ear
Cold-nystagmus towards contralateral ear

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23
Q

What is an abnormal finding on caloric testing?

A

Lack of nystagmus indicates damage to vestibular system, vestibular nerve, or brain

Alcohol, antihistamines, sedatives within 24 hours can cause false abnormal

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24
Q

Go back to contraindications for caloric testing

A
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25
Q

When would you perform brain imaging? What is the procedure of choice/backup?

A

If suspecting central etiology or acoustic neuroma
MRI/MRA, CT if not available

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26
Q

What is electronystagmography?

A

Electrodes placed and eye movements traced to record presence of nystagmus

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27
Q

VNG

A
28
Q

What test assesses saccule?

A

Cervical VEMP, should trigger reflex on ipsilateral SCM

29
Q

What test assesses utricle?

A

Ocular VEMP, records EOM potentials during head vibration

30
Q

What is the etiology of BPPV?

A

Canalithiasis (calcium deposits in semicircular canal)
Usually free-floating otoconia that have dislodged from utricle, most commonly in posterior semicircular canal (first place that is hit)

31
Q

What are risk factors for BPPV?

A

Age >50
Whiplash or trauma to head/ear
Chronic otitis media
Female gender (increased hormonal fluctuations in menopause)

32
Q

What is the presentation of BPPV?

A

Acute, brief episodes of vertigo (<1 minute) that occur after changes in head position ie rolling over in bed without other neurologic deficits

33
Q

What evaluations should be done when suspecting BPPV?

A

Dix-Hallpike maneuver- will elicit vertigo and nystagmus

Posterior canal BPPV will cause upward, rotary
Anterior canal BPPV will cause downward, rotary
Horizontal canal will cause nystagmus toward floor

34
Q

How is BPPV treated?

A

Repositioning otoliths: Epley maneuver is most effective treatment
Reconditioning exercises: Brandt-Daroff Maneuver- exposure therapy or Serumont Maneuver
Recurrence is common

35
Q

What is the etiology of vestibular Neuronitis/labyrinth it is

A

Thought to be viral or post viral inflammatory response
Vestibular neuronitis: only vestibular division of CN VIII
Labyrinthitis: vestibular and cochlear division of CN VIII
Asymmetry of labyrinth inputs, simulating continuous head rotation

36
Q

What is the presentation of vestibular neuronitis/labyrinthitis?

A

Sudden onset persistent vertigo, event when not moving
GI: nausea and vomiting
Gait instability toward affected side
Nystagmus beating away from affected side
Labyrinthitis will also have unilateral hearing impairment and/or tinnitus

Evaluate for central infarct

37
Q

How should vestibular inflammation be evaluated?

A

Clinical- no specific diagnostic studies
May need brain MRI/CT to rule out central etiology

38
Q

How is vestibular neuronitis/labyrinthitis treated?

A

Corticosteroids: methyl prednisone or prednisone 10 day to 3 week tapering dose
Antimicrobials: not consistently effective

Symptomatic: vertigo suppression with meclizine (antihistamine), benzodiazepines (Valium, Ativan), avoid after first few days
Nausea and vomiting: promethazine or ondansetron

Vestibular rehabilitation therapy: may require for months-years

39
Q

What is the etiology of Ménière’s disease?

A

Excess fluid in the inner ear with unclear etiology: related to syphilis and head trauma, genetic component, blocked endo lymphatic ducts, most often seen in women 20-40 y/o

40
Q

What is the presentation of Ménière’s disease?

A

Classic triad: episodic vertigo: 20 mins-several hours
Unilateral hearing impairment: sensorineural, usually low-frequency
Tinnitus-usually low-tone and blowing
Unilateral aural fullness, +/- pain
Episodic N/V with vertigo episodes
Hearing usually improves between attacks
Usually unilateral, can be bilateral
Usually chronic, progressive, remitting/relapsing course

41
Q

How is Ménière’s disease evaluated?

A

Clinical: 2 spontaneous episodes of vertigo lasting at least 20 minutes each
Unilateral sensorineural hearing loss
Tinnitus and/or aural fullness

Audiometry- will show hearing loss during acute attacks
Caloric testing- reduced or absent nystagmus on affected side
Brain imaging- if central lesion suspected

42
Q

What is treatment of Ménière’s disease?

A

Early ENT referral
Lifestyle modifications: low salt diet, restrict alcohol and caffeine
+ more (was looking at sub menu)

43
Q

What is the etiology of peri lymphatic fistula?

A

Fistula: leakage of peri lymphatic fluid from inner ear into middle ear
Dehiscence: abnormal thinning or absence of bone above the superior semicircular canal

44
Q

What are risk factors for peri lymphatic fistula?

A

Physical injury: blunt head trauma, hand slap to ear
Barotrauma: scuba diving, flight
Vigorous valsalva maneuvers: weight lifting

45
Q

What is the presentation of peri lymphatic fistula?

A

Sensorineural hearing loss, recurrent brief episodes of vertigo

specific triggers for symptoms: sneezing and coughing
straining- heavy lifting, constipation, valsalva
loud noises: dizziness or vertigo induced by sounds

46
Q

What is the evaluation/diagnosis of peril y photic fistula?

A

Often based on clinical presentation
CT or MRI of head: perilymphatic fistula will show fluid accumulation in round window recess
Semicircular canal dehiscence thin or absent bone above canal

47
Q

Treatment for perilymphatic fistula

A
48
Q

Etiology/risk factors for barotrauma

A
49
Q

What is the presentation of barotrauma?

A

Ear pressure —> pain
Vertigo
Hearing loss
Tinnitus

50
Q

What is evaluation/diagnosis of barotrauma?

A

History of recent flight or diving, congruent s/s
ENT exam: may see hemorrhage behind TM or TM perforation

51
Q

How is barotrauma treated?

A

Symptomatic- analgesics

Refractory- surgery: myringotomy, tympanoplasty

52
Q

What is patient education for barotrauma?

A

Decongestants several hours or 1 hour before anticipated event
Diving- change depths slowly and in stages
Swallow, yawn, auto inflate frequently, chewing gum or pacifier in infants

53
Q

What is tinnitus?

A

Sensation of sound in the absence of an exogenous sound source

Can be buzzing, ringing, roaring, hissing, clicking
Pulsatile or non-Pulsatile
Continuous or intermittent

And may accompany any form of hearing loss

54
Q

What is the epidemiology of tinnitus

A
55
Q

What are the most common causes of Pulsatile tinnitus (occurs with patients heart beat)?

A

Vascular
Neuromuscular
Eustachian tube: patulous Eustachian tube

56
Q

what are the common causes of non Pulsatile tinnitus?

A

Sensorineural hearing loss

….

57
Q

What is a paraganglioma, which can cause tinnitus?

A

Benign vascular Neuro endocrine tumor of middle ear that arises from paraganglia of middle ear

58
Q

What are presentations of tinnitus due to paraganglioma?

A

Reddish or bluish madd, may see bulging TM on exam, Pulsatile tinnitus, conductive hearing loss, vertigo

59
Q

What is treatment of paraganglioma?

A

Surgery

60
Q

What is a patulous Eustachian tube?

A

Tube stays open inappropriately MC after significant weight loss causing a roaring tinnitus that often accompanies breathing and autophony (hearing one’s own voice), symptoms improve when lowering head below heart

61
Q

What is treatment of patulous Eustachian tube?

A

Application of mucosal irritants such as Premarin drops, causes mucosal swelling
Surgery

62
Q

What is the presentation of sensorineural hearing loss causing tinnitus?

A
63
Q

What is treatment of sensorineural hearing loss?

A

Hearing aid

64
Q

How is tinnitus diagnosed?

A

Exam-ENT, cardiovascular, cranial nerves
Audiometry- evaluate for associated hearing loss
MRI/MRA- to rule out mass, vascular abnormality
ENT referral

65
Q

How is tinnitus treated?

A

Treatment of underlying disorder—>
Hearing loss- hearing aid
Removal of masses
Control of HTN
Review medications

Exacerbating factors: depression, insomnia-white noise

66
Q

What is treatment of tinnitus?

A

Behavior therapy: tinnitus retraining therapy- noise inducing generators PLUS counseling to habituate patient to tinnitus
Stress reduction programs, CBT

Meds- BZDs, intra-TM steroid shots, misoprostol
Masking devices
Transcranial magnetic stimulation

HEENT (2 decks)

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