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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
Benign Paroxysmal Positional Vertigo recurrence
● Most cases resolve within 6 weeks ● Recurrence rate of 15-20%
26
Ménière’s Disease
◼ 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
Ménière’s Disease tetrad
▪ Fluctuating hearing loss ▪ Episodic vertigo ▪ Tinnitus ▪ Aural fullness in the affected ear
28
Ménière’s Disease etiology
▪ 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
Ménière’s Disease - three types
● Genetic ○ Autosomal dominant inheritance – up to 15% of Meniere’s patients ● Viral ○ Improper immunologic response ● Vascular ○ Migraines more common in Meniere’s patients
30
Ménière’s Disease Episodic attacks of true vertigo preceded by ____
a variable sense of ear pressure and fullness, decreased hearing, and a low-tone roaring tinnitus
31
Ménière’s Disease exam findings
● 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
Ménière’s Disease - Glycerol dehydration test
○ 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
Ménière’s Disease Tx
○ Lifestyle modifications ○ Medication ○ Meniett Device ($3500) ○ Surgical management
34
Vestibular Neuritis (Neuronitis)
● 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
Vestibular Neuritis presentation
● Abrupt onset of severe, debilitating vertigo ○ Vertigo even when head remains still ○ Increases with head movement ● Unsteadiness ● Nausea and vomiting
36
Vestibular Neuritis exam
● 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
Vestibular Neuritis Tx
● Bed rest and hydration ● Meclizine ● Zofran ● Diazepam ● Transderm scopolamine ● Prednisone ● Valtrex
38
Labyrinthitis
● 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
Labyrinthitis Audiogram
Sensorineural hearing loss is usually mild to moderate in the higher frequencies (>2000 Hz)
40
Perilymph Fistula
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
___ is the most common cause of fistulas
Head trauma
42
Fistula test
○ Air is insufflated into the canal ○ Pressure in the EAC will cause nystagmus
43
Perilymph Fistula Tx
● 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
Barotrauma
● 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
Barotrauma risk factors
● Eustachian tube dysfunction ● Nasal congestion ● Allergies ● Hyperbaric chamber
46
Barotrauma Presentation
● Plugged ear ● Diminished hearing ● Ear pain ● Dizziness
47
Barotrauma can lead to
● Can lead to TM rupture ● Can lead to rupture of inner ear membranes and permanent hearing loss and vertigo
48
Barotrauma exam
○ 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
Barotrauma Tx
○ Observation ○ Oral steroids ○ Microperforations close spontaneously in several weeks ○ Refer to ENT
50
Tinnitus
● 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
Common causes of Tinnitus
▪ Idiopathic ▪ Hearing loss ▪ Noise exposure ▪ Meniere’s ▪ Vascular abnormalities ▪ Tensor tympani myoclonus ▪ TMJ ▪ Neoplasm
52
Tinnitus Tx
▪ Treat underlying cause if present ▪ Conservative measures ▪ Hearing aids ▪ Tinnitus retraining therapies ▪ Neuromonics- acoustic desensitization ▪ Stress reduction ▪ Electrical stimulation ▪ Acupuncture ▪ Herbal remedies/vitamins

EENT Exam 2 (5 decks)

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