Vertigo and Tinnitus Flashcards
Dizziness is a _____
symptom, not a diagnosis
Dizziness is also considered ____ - unsteady or loss of balance
“Disequilibrium”
Benign and serious causes of Vertigo
Benign- BPPV, etc
Serious- Brainstem ischemia and Cerebellar stroke, Tumor, Multiple sclerosis, Intracranial hemorrhage, etc
Benign and Serious causes of Lightheadedness
Benign- Syncope or presyncope, Vasovagal, Medication, etc
Serious- MI, Shock, Arrhythmia, etc
Vertigo is further divided into ____
peripheral (at the ear level), or central vertigo ( at the CNS level)
Inner Ear- Two parts
- Vestibular apparatus
- Auditory apparatus
Vertigo
○ The sensation of motion in a
stationary environment
○ Dizziness that creates the false
sense that you or your surroundings are spinning or moving
Nystagmus
● 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
Peripheral Vertigo with nystagmus
Horizontal w/ a rotary component, but never vertical
Central Vertigo with nystagmus
Horizontal, rotary or vertical
PE of the ears with vertigo
○ 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
T/F all patients with vertigo get a full neuro exam
T
positive Dix-Hallpike Maneuver
● Positive if vertigo reported, characteristic nystagmus seen
● Get a bucket ready
Balance
● Balance involves the overlapping function of the visual system, the
proprioceptive system, and the vestibular system
○ Maintains equilibrium
The primary goal of the vestibular system is to ____
limit the slippage of
images on the retina during head movemen
Image tracking is maintained by three systems
○ Smooth-pursuit system
○ Optokinetic system
○ Vestibulo-Ocular reflex system
Head Impulse Test results
○ 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)
Sharpened Romberg test
○ 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
Fukuda test
▪ 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
Diagnostic Labs and Imaging for dizziness
● 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
Benign Paroxysmal Positional Vertigo
● Most common cause of vertigo at 20%
● Average age is 50 yo
● Frequently associated with alcoholism
● Small calcium crystals in the semicircular canals
Benign Paroxysmal Positional Vertigo pathophysiology
● 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
Benign Paroxysmal Positional Vertigo presentation
● 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
Benign Paroxysmal Positional Vertigo treatment
● Observation
● Medication to suppress the vestibular system
● Canalith repositioning (Epley maneuver) 80% response
● Vestibular rehabilitation
● Surgical options
Benign Paroxysmal Positional Vertigo recurrence
● Most cases resolve within 6 weeks
● Recurrence rate of 15-20%
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
Ménière’s Disease tetrad
▪ Fluctuating hearing loss
▪ Episodic vertigo
▪ Tinnitus
▪ Aural fullness in the affected ear
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
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
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
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
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
Ménière’s Disease Tx
○ Lifestyle modifications
○ Medication
○ Meniett Device ($3500)
○ Surgical management
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
Vestibular Neuritis presentation
● Abrupt onset of severe, debilitating vertigo
○ Vertigo even when head remains still
○ Increases with head movement
● Unsteadiness
● Nausea and vomiting
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
Vestibular Neuritis Tx
● Bed rest and hydration
● Meclizine
● Zofran
● Diazepam
● Transderm scopolamine
● Prednisone
● Valtrex
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
Labyrinthitis Audiogram
Sensorineural hearing loss is usually mild to moderate in the higher frequencies (>2000 Hz)
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
___ is the most common cause of fistulas
Head trauma
Fistula test
○ Air is insufflated into the canal
○ Pressure in the EAC will cause nystagmus
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
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
Barotrauma risk factors
● Eustachian tube dysfunction
● Nasal congestion
● Allergies
● Hyperbaric chamber
Barotrauma Presentation
● Plugged ear
● Diminished hearing
● Ear pain
● Dizziness
Barotrauma can lead to
● Can lead to TM rupture
● Can lead to rupture of inner ear membranes and permanent
hearing loss and vertigo
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
Barotrauma Tx
○ Observation
○ Oral steroids
○ Microperforations close spontaneously in several weeks
○ Refer to ENT
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
Common causes of Tinnitus
▪ Idiopathic
▪ Hearing loss
▪ Noise exposure
▪ Meniere’s
▪ Vascular abnormalities
▪ Tensor tympani myoclonus
▪ TMJ
▪ Neoplasm
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
