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eent exam 2 > Vertigo and Tinnitus > Flashcards

Vertigo and Tinnitus Flashcards

1
Q

Dizziness is a _____

A

symptom, not a diagnosis

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2
Q

Dizziness is also considered ____ - unsteady or loss of balance

A

“Disequilibrium”

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3
Q

Benign and serious causes of Vertigo

A

Benign- BPPV, etc
Serious- Brainstem ischemia and Cerebellar stroke, Tumor, Multiple sclerosis, Intracranial hemorrhage, etc

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4
Q

Benign and Serious causes of Lightheadedness

A

Benign- Syncope or presyncope, Vasovagal, Medication, etc
Serious- MI, Shock, Arrhythmia, etc

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5
Q

Vertigo is further divided into ____

A

peripheral (at the ear level), or central vertigo ( at the CNS level)

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6
Q

Inner Ear- Two parts

A
  1. Vestibular apparatus
  2. Auditory apparatus
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7
Q

Vertigo

A

○ The sensation of motion in a
stationary environment
○ Dizziness that creates the false
sense that you or your surroundings are spinning or moving

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8
Q

Nystagmus

A

● Rhythmic beating of the eye, (like a muscle tremor elsewhere)
● Few beats at extreme lateral gaze are normal
● Can be seen at rest or provoked by certain maneuvers or tests
● Vertigo peripheral or central causes, drug toxicity, congenital

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9
Q

Peripheral Vertigo with nystagmus

A

Horizontal w/ a rotary component, but never vertical

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10
Q

Central Vertigo with nystagmus

A

Horizontal, rotary or vertical

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11
Q

PE of the ears with vertigo

A

○ Inspection, palpation, otoscopy with insufflation, audiometric testing
■ Insufflation of the TM of a patient with vertigo is referred to as a fistula test
● Positive if patient reports increasing symptoms and nystagmus is seen while positive
pressure is applied in the EAC
● Indicates the presence of a perilymph fistula that is leaking labyrinthine fluid

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12
Q

T/F all patients with vertigo get a full neuro exam

A

T

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13
Q

positive Dix-Hallpike Maneuver

A

● Positive if vertigo reported, characteristic nystagmus seen
● Get a bucket ready

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14
Q

Balance

A

● Balance involves the overlapping function of the visual system, the
proprioceptive system, and the vestibular system
○ Maintains equilibrium

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15
Q

The primary goal of the vestibular system is to ____

A

limit the slippage of
images on the retina during head movemen

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16
Q

Image tracking is maintained by three systems

A

○ Smooth-pursuit system
○ Optokinetic system
○ Vestibulo-Ocular reflex system

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17
Q

Head Impulse Test results

A

○ When the eyes make a compensatory movement after the head is stopped to reacquire
the target (a refixation saccade), the test results are abnormal
■ Refixation occurs when head is turned towards the affected side
○ This test can indicate if the output of one or both labyrinths is depressed
■ Acute vestibular disorders (vestibular neuronitis)

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18
Q

Sharpened Romberg test

A

○ The patient stands heel to toe with the dominant foot in front of the other
○ The patient closes his/her eyes while the examiner observes for 30-60
seconds
○ Positive if the patient move feet, uncrosses arms, or opens eyes
■ Peripheral neuropathy or proprioceptive changes associated with acute
vestibular disorders

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19
Q

Fukuda test

A

▪ The patient is asked to step in place for 20-30 seconds with arms
extended and eyes closed
▪ Rotation of the patient may indicate a unilateral loss of vestibular
tone

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20
Q

Diagnostic Labs and Imaging for dizziness

A

● Labs
○ CBC c diff
○ CMP
○ TSH
○ Free T3
○ Free T4
● Imaging
○ High resolution CT scan of the temporal bone
○ MRI brain with and without contrast with attention to the IACs

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21
Q

Benign Paroxysmal Positional Vertigo

A

● Most common cause of vertigo at 20%
● Average age is 50 yo
● Frequently associated with alcoholism
● Small calcium crystals in the semicircular canals

22
Q

Benign Paroxysmal Positional Vertigo pathophysiology

A

● 3 semicircular canals contain fluid and fine, hair-like sensors that monitor the
rotation of your head
● BPPV occurs when small, micro calcium crystals (otoconia) become dislodged from
their normal location on the utricle
● If the otoconia become detached, they are free to flow in the fluid filled spaces of
the inner ear
● Because they are heavy, they often migrate into the lowest part of the inner ear, the
posterior semicircular canal
● There, they may still move when the head changes position, causing an unwanted
flow of fluid in the semicircular canal even after the head has stopped moving
● This mismatch of sensory information results in the sensation of vertigo

23
Q

Benign Paroxysmal Positional Vertigo presentation

A

● Begins suddenly
● Typically patients first experience symptoms upon waking
● Episodes are generally brief, less than 1-2 minutes
● Triggered by sudden head movement, often in one direction
● No symptoms between episodes

24
Q

Benign Paroxysmal Positional Vertigo treatment

A

● Observation
● Medication to suppress the vestibular system
● Canalith repositioning (Epley maneuver) 80% response
● Vestibular rehabilitation
● Surgical options

25
Q

Benign Paroxysmal Positional Vertigo recurrence

A

● Most cases resolve within 6 weeks
● Recurrence rate of 15-20%

26
Q

Ménière’s Disease

A

◼ Idiopathic endolymphatic hydrops
◼ A condition of increased hydraulic pressure within the inner ear endolymphatic system
◼ Either tinnitus or aural fullness (or both) must be present on the affected
side to make the diagnosis

27
Q

Ménière’s Disease tetrad

A

▪ Fluctuating hearing loss
▪ Episodic vertigo
▪ Tinnitus
▪ Aural fullness in the affected ear

28
Q

Ménière’s Disease etiology

A

▪ Distortion of the membranous labyrinth resulting from over-accumulation
of endolymph
▪ Attacks of hydrops are likely caused by an increase in endolymphatic
pressure, which, in turn, causes a break in the membrane that separates
the perilymph from the endolymph
● Blockage of endolymphatic sac or duct
● Hypoplasia of vestibular aqueduct

29
Q

Ménière’s Disease - three types

A

● Genetic
○ Autosomal dominant inheritance – up to 15% of Meniere’s patients
● Viral
○ Improper immunologic response
● Vascular
○ Migraines more common in Meniere’s patients

30
Q

Ménière’s Disease Episodic attacks of true vertigo preceded by
____

A

a variable sense of ear pressure and fullness, decreased hearing, and a low-tone roaring tinnitus

31
Q

Ménière’s Disease exam findings

A

● Findings may be completely normal between attacks
● Otoscopy findings are usually normal
● The Romberg test and gait testing may show some instability
● The Fukuda marching step test may show significant deviation

32
Q

Ménière’s Disease - Glycerol dehydration test

A

○ After a baseline audiogram is performed, the patient takes 100 g of
95% glycerol with the same amount of water
○ Another audiogram is performed 90 minutes and 3 hours after ingestion
○ The test is considered positive when there is an improvement of 10 db
or more in pure-tone thresholds at two or more frequencies, or an improvement of 10% of speech discrimination scores

33
Q

Ménière’s Disease Tx

A

○ Lifestyle modifications
○ Medication
○ Meniett Device ($3500)
○ Surgical management

34
Q

Vestibular Neuritis (Neuronitis)

A

● Acute dysfunction of the peripheral vestibular system
● Viral infection of the vestibular nerve and/or labyrinth
○ Some cases are the result of reactivation of latent herpes simplex virus type 1
in the vestibular ganglia
● Mean age of onset is 41 years

35
Q

Vestibular Neuritis presentation

A

● Abrupt onset of severe, debilitating vertigo
○ Vertigo even when head remains still
○ Increases with head movement
● Unsteadiness
● Nausea and vomiting

36
Q

Vestibular Neuritis exam

A

● Nystagmus
● Positive head impulse test
● Patient tends to fall toward affected side when attempting
ambulation or during Romberg tests
● NO hearing loss, TM findings, mastoid tenderness, high fever, nuchal
rigidity
● Most distinguished from cerebellar stroke

37
Q

Vestibular Neuritis Tx

A

● Bed rest and hydration
● Meclizine
● Zofran
● Diazepam
● Transderm scopolamine
● Prednisone
● Valtrex

38
Q

Labyrinthitis

A

● An inflammatory disorder of the labyrinth
● Viral, bacterial, or autoimmune
● A sudden, unilateral loss of vestibular function
and hearing
● Acute onset of severe, often incapacitating, vertigo

39
Q

Labyrinthitis Audiogram

A

Sensorineural hearing loss is usually mild to moderate in the higher frequencies (>2000 Hz)

40
Q

Perilymph Fistula

A

A tear or defect in one or both of the small, thin membranes that separate the air-filled middle ear and the fluid-filled perilymphatic space of the inner ear

41
Q

___ is the most common cause of fistulas

A

Head trauma

42
Q

Fistula test

A

○ Air is insufflated into the canal
○ Pressure in the EAC will cause nystagmus

43
Q

Perilymph Fistula Tx

A

● May require middle ear exploration with repair when
found
● Severely restrict physical activity for 7-14 days
● Repeat audio in 2-3 weeks
● If repeat testing consistent with a fistula, refer to
ENT for surgical repair

44
Q

Barotrauma

A

● Trauma to the tympanic membrane, middle ear, or inner ear
structures as a result of changes in barometric pressure
● Direct hit to the ear

45
Q

Barotrauma risk factors

A

● Eustachian tube dysfunction
● Nasal congestion
● Allergies
● Hyperbaric chamber

46
Q

Barotrauma Presentation

A

● Plugged ear
● Diminished hearing
● Ear pain
● Dizziness

47
Q

Barotrauma can lead to

A

● Can lead to TM rupture
● Can lead to rupture of inner ear membranes and permanent
hearing loss and vertigo

48
Q

Barotrauma exam

A

○ Bulging of the TM
○ TM can appear somewhat injected
○ Fluid or blood visible in the middle ear space
■ Confirmed via pneumatic otoscopy or
tympanogram

49
Q

Barotrauma Tx

A

○ Observation
○ Oral steroids
○ Microperforations close spontaneously in several weeks
○ Refer to ENT

50
Q

Tinnitus

A

● The perception of sound in the head or the ears
○ Phantom noise or sound
● Usually perceived in the absence of outside sound
● 15% of the population, 20% in older populations
● Symptom, not a disease

51
Q

Common causes of Tinnitus

A

▪ Idiopathic
▪ Hearing loss
▪ Noise exposure
▪ Meniere’s
▪ Vascular abnormalities
▪ Tensor tympani myoclonus
▪ TMJ
▪ Neoplasm

52
Q

Tinnitus Tx

A

▪ Treat underlying cause if present
▪ Conservative measures
▪ Hearing aids
▪ Tinnitus retraining therapies
▪ Neuromonics- acoustic desensitization
▪ Stress reduction
▪ Electrical stimulation
▪ Acupuncture
▪ Herbal remedies/vitamins

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