Vertigo and Tinnitus

Question 1

Peripheral vs central vertigo location

Answer 1

Peripheral: vestibular system, inner ear CNVIII

Central: cerebellum, brainstem, high centers of cortical functioning

Question 2

Peripheral vs central vertigo history

Answer 2

Peripheral: Sudden onset, N/V, hearing loss, tinnitus; horizontal nystagmus

Central: gradual vertigo; vertical nystagmus

Question 3

Physical exam acronym

Answer 3

H-I: head impulse
N- nystagmus (unilateral horizontal - P; vertical/changes direction - V)
T-S: test of skew (brainstem involvement, + test is vertical deviation of the covered eye)

Question 4

Peripheral vertigo DDx

Answer 4

BPPV
Labyrinthitis
Meniere’s disease
Otitis media
Acoustic neuroma
Vestibular neuritis
Ototoxicity/otosclerosis

Question 5

Central vertigo DDx

Answer 5

Brainstem hemorrhage/infarction
Cerebellar hemorrhage/infarction
Migraines
Multiple sclerosis
Vertebral artery dissection
Vertebrobasilar insufficiency
Brain tumors
Neurogenerative disorders

Question 6

onset difference of 3 peripheral causes

Answer 6

seconds - BPPV
hours - Meniere’s disease
days - Labyrinthitis

Question 7

Vestibular suppressants to treat peripheral causes

Answer 7

Anticholinergics - scopolamine
Antihistamines - meclizine
Sedatives/Benzos - diazepam, clonazepam

Question 8

Antiemetics for vertigo

Answer 8

Promethazine and ondansetron

Question 9

Vertigo red flags

Answer 9

Focal neuro deficits
Chest pain, SOB, numbness/tingling
Severe head/neck pain
Loss of consciousness/syncope

Question 10

What is the most common cause of dizziness esp in older populations

Answer 10

BPPV

Question 11

What is the etiology of BPPV

Answer 11

Displacement of Otoconia

Question 12

What is the hallmark of BPPV

Answer 12

Brief episode of vertigo assoc with head position changes

Question 13

BPPV symptoms

Answer 13

Vertigo lasting seconds to a minute
Head movement/position change
Episodes over several days
Nausea, +/- vomiting
NO HEARING LOSS

Question 14

BPPV physical exam

Answer 14

PE consistent with peripheral vertigo
+ Dix Hallpike maneuver - vertigo with rotary nystagmus with delayed onset fatiguability

Question 15

How is BPPV treated?

Answer 15

Epley maneuver

Question 16

What is typically the cause of labyrinthitis

Answer 16

Viral*
Bacterial
Autoimmune disorder manifestation

Question 17

What can maternal CMV or rubella lead to

Answer 17

Congenital deafness

Question 18

Labyrinthitis symptoms

Answer 18

Acute onset of vertigo
Symptoms last several days then gradually improve
Assoc. N/V, unilateral tinnitus, HEARING LOSS
R/O CVA

Question 19

Labyrinthitis PE

Answer 19

+ nystagmus, horizontal and away from effected ear
Rinne and Weber - SN hearing loss
Neuro exam - ataxia, r/o cerebellar or meningeal involvement
PE consistent with underlying cause

Question 20

Labyrinthitis treatment

Answer 20

based on underlying cause
Viral - hydrate, rest
Bacterial - Abs
Autoimmune - CS
Vestibular suppressants
Antiemetics

Question 21

Labyrinthitis prognosis

Answer 21

Symptoms should resolve in a few days to a week but residual symptoms may remain

Vestibular rehabilitation for chronic symptoms

Question 22

What is Meniere’s disease also known as

Answer 22

Idiopathic endolymphatic hydrops

Question 23

What is the etiology of Meniere’s disease

Answer 23

Increased pressure within the endolymphatic system secondary to increased fluid

Exact cause of increase fluid unknown

Question 24

Meniere’s disease symptoms

Answer 24

Acute spontaneous episodes of vertigo

Episodes last minutes to hours with assoc fluctuation unilateral low frequency hearing loss and low tone roaring tinnitus

Ear pressure, fullness, N/V

May relate episodes to diet, stress, or menstrual cycle

Question 25

Meniere's disease PE

Answer 25

+nystagmus, horizontal or rotary Rinne and Weber - SN hearing loss Neuro exam - ataxia

Question 26

What test evaluates inner ear pressure

Answer 26

Electrocochleography

Question 27

Treatment of Meniere's disease

Answer 27

Lifestyle modifications: sodium restricted diet to 2g/day, limit caffeine and alcohol intake Med: Diuretics - acetazolamide, triamterene, spironolactone

Question 28

Treatment of refractory Meniere's disease

Answer 28

Intratympanic steroid injections Intratympanic gentamycin injections (end stage) Meniett device Shunt placement Labyrinthectomy

Question 29

Which of the 3 is most likely to have constant vertigo vs episodic

Answer 29

Labyrinthitis

Question 30

Which is the 3 is least likely to have erratic eye movements

Answer 30

Meniere's disease

Question 31

Which of the 3 will not have hearing loss or tinnitus

Answer 31

BPPV

Question 32

What is the common etiology of objective tinnitus

Answer 32

vascular or muscular in origin

Question 33

Describe tonal tinnitus

Answer 33

Ringing, blowing, roaring, high-pitched, white noise Subjective Can have assoc hearing loss and stress

Question 34

DDx of tonal tinnitus

Answer 34

Medications Noise trauma Presbycusis Stress

Question 35

Define pulsatile tinnitus

Answer 35

Perception of pulsing sound, like a heartbeat Can be subjective or objective

Question 36

DDx of pulsatile tinnitus

Answer 36

AVM Aneurysms Carotid artery disease HTN

Question 37

DDx of staccato tinnitus

Answer 37

Middle ear muscle spasms Palatal myoclonus TMJ dysfunction

Question 38

Define staccato tinnitus

Answer 38

Clicking, popping, tapping sound that can be intermittent Can be subjective or objective

Question 39

Common causes of tinnitus

Answer 39

Acoustic neuroma Medications Trauma Age - presbycusis AOM Obstruction - cerumen impaction, FB Meniere disease

Question 40

Tinnitus treatment

Answer 40

Treat underlying pathology Hearing aids/cochlear implants if hearing loss Tinnitus maskers Cognitive behavioral therapy Stress reduction Biofeedback therapy Avoid loud stimuli Avoid stimulant use (caffeine, tobacco)