Vertigo and Tinnitus - Exam 3 Flashcards
_____ imprecise - symptom used to describe a variety of sensations. Describe some common ones.
Dizziness
vertigo, lightheadedness/faintness (presyncope), imbalance, combination
_______ sensation of movement when there is no movement - asymmetry of vestibular inputs
Vertigo
______ is the cardinal symptom of vestibular disease. What are the 2 types?
Vertigo
Physiologic - sustained head rotation
Pathologic - vestibular dysfunction
_____ feeling faint; about to lose consciousness. Presyncopal sensation
Lightheadedness/Faintness
______ feeling off-balance. May be due to CNS lesion or vestibular dysfunction
Disequilibrium/Imbalance
What is the squared item called? The item not in the box?
Vestibular labyrinth
cochlea
_____ is contained within the vestibular labyrinth. What is contained within them?
3 semicircular canals
endolymph is located within the semicircular canals
when endolymph moves _____ information about movement is sent to the brain
stereocilia
_____ and ____ are otolith organs within the ______. What motions do they each detect?
Utricle: horizontal movements
Saccule: vertical movements
vestibular labyrinth
Within the utricle and saccule hair cells detect movement of _____ to determine movement
otoconia
In general terms, what does peripheral vertigo present like?
Onset: sudden, with unilateral tinnitus +/- hearing loss
N/V
horizontal nystagmus
In general terms, what does central vertigo present like?
gradual onset, no hearing symptoms if present, will be bilateral tinnitus
vertical nystagmus
What are some important historical questions to ask? What is one VERY important one?
uni or bilateral?
acute or chronic?
**How long have the symptoms lasted?
What are 3 important s/s that could point towards a brainstem or cerebellar lesion?
Double vision, ataxia, and/or numbness
______ involuntary back and forth movement of the eyes. ______ can suppress peripheral nystagmus
Nystagmus
visual fixation
_____ assesses vestibulo-ocular reflex. What is a normal and abnormal result?
head impulse test
focus on the examiner’s nose and the examiner focuses on the pt’s eyes. then the pt’s head is quickly turned to one side.
normal: the pts eyes remain focused on the examiner’s nose the entire time
abnormal: the pt’s eye have to readjust to the examiner’s nose, does NOT remain focused on the examiner’s nose the entire time
What is the Dix-Hallpike maneuver? When do you use it? What does a positive test look like?
head is rotated 45 degrees and then body is leaned backwards with the head taken 30 degrees below horizontal
BBPV: the maneuver should induce nystagmus in BBPV
What is an audiometry test?
person sits in a booth and different sounds over various tones, pitches and frequencies are played
What is caloric testing? What does warm and cold water do? What is a normal test? abnormal?
Procedure: 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
NORMAL: will induce nystagmus
warm: same side
cold: opposite side
**ABNORMAL: lack of nystagmus
What does an abnormal caloric test indicate? What are some things that could make it abnormally false?
Indicates damage to vestibular system, vestibular nerve, or brain
alcohol, antihistamines, sedatives within 24 hrs
What are some CI to caloric testing?
OM, middle ear effusion, TM perforation
epilepsy, psychosis, HTN, severe cardiac disease
2nd generation antihistamines, anxiolytics, antidepressants within the last 48 hrs
What is the helpful saying to remember the nystagmus directions of caloric testing?
When would you want to order an MRI on a pt with vertigo/tinnitus?
Indicated when H&P suggests a central etiology or an acoustic neuroma
What is an Electronystagmography (ENG)? What is a Videonystagmography (VNG)?
ENG: Placement of electrodes
Tracing of eye movements
Records presence of nystagmus
VNG: ENG while recording the eye movements
_____ applies repetitive sound stimulus to one ear then averaging the reaction of the muscle activity in response to each soundclick or pulse. What does it assess? What are the two different types?
Vestibular Evoked Myogenic Potential (VEMP)
Assesses otolith function
cervical and ocular
______ Loud sound is delivered to one ear
Triggers reflex to ipsilateral SCM muscle
SCM muscular activity recorded. What part of the vestibular labyrinth?
cervical VEMP
saccule
_____ Records EOM potentials during head vibration. What part of the vestibular labyrinth?
Ocular VEMP
utricle
What does BPPV stand for? What is it?
Benign Paroxysmal Positional Vertigo
vertigo that comes and goes based on your position due to calcium deposits in the semicircular canals
_____ calcium deposits in the semicircular canal. Usually free-floating _____ that have dislodged from utricle. What canal is MC?
Canalithiasis
otoconia
posterior semicircular canal
What are some risk factors for BPPV?
Age >50
Whiplash or trauma to head/ear
Chronic otitis media
female: due to increased hormonal fluctuations in menopause
Acute, Recurrent brief episodes of vertigo (<1 minute)
vertigo occurs after changes in head position
What am I?
What is the testing? What would you expect to see?
BPPV
Dix-Hallpike Maneuver: elicits vertigo and nystagmus
**Dix-Hallpike Maneuver with upward, rotary nystagmus, where is the stone?
Posterior Canal BPPV - upward, rotary nystagmus
**Dix-Hallpike Maneuver with downward, rotary nystagmus, where is the stone?
anterior canal BPPV
**Dix-Hallpike Maneuver with nystagmus beating towards floor, where is the stone?
Horizontal Canal BPPV
What is the treatment for BPPV?
medications are NOT helpful!!
Epley maneuver: repositioning
deconditioning: Brandt-Daroff Maneuver and/or Sermont Maneuver
Describe the Epley maneuver. When is it used?
rotating the head to maneuver the stone out of the canal to decrease vertigo
______ only vestibular division of CN VIII
_____ Vestibular and cochlear division of CN VIII
Vestibular Neuronitis
vestibular labyrinthitis
Asymmetry of labyrinthine inputs, simulating continuous ____
head rotation
sudden onset, persistent and continuous vertigo
N/V
gait instability
nystagmus
What am I?
What side will the gait instability go?
What side will the nystagmus go?
Vestibular Inflammation: Neuronitis
gait: sway toward affected side
nystagmus: horizontal, beating AWAY from affected side
Does not change direction, but suppresses with gaze fixation
sudden onset, persistent and continuous vertigo
N/V
gait instability
nystagmus
unilateral hearing impairment and/or tinnitus
What am I?
What does these s/s mimic that you need to cautious about?
Labyrinthitis
can mimic acute cerebellar or brainstem infarct or hemorrhage!
______ test will be normal in a central lesion etiology.
head impulse test
What is the tx for Vestibular Neuronitis/Labyrinthitis? What is the timeframe for optimal results?
methylprednisolone or prednisone
10 day to 3 week tapering dose
mainly helpful if given with 3 day of onset
What is the tx for Vestibular Neuronitis/Labyrinthitis with vertigo? For how long? Why?
methylprednisolone or prednisone
10 day to 3 week tapering dose
with:
Antihistamines - meclizine (Antivert)
Benzodiazepines - diazepam (Valium), lorazepam (Ativan)
Avoid after the first few days - may impede recovery
_____ etiology is thought to be related to excess fluid (endolymph) in the inner ear. What is two dz is it associated with? MC pt?
Meniere’s Disease
Endolymphatic Hydrops
syphilis and head trauma
Most often seen in women 20-40 y/o
**What is the classic triad of Meniere’s Disease?
Episodic vertigo - 20 min to several hours
Unilateral hearing impairment - sensorineural, usually low-frequency
Tinnitus - usually low-tone and “blowing”
Episodic vertigo
Unilateral hearing impairment
Tinnitus
Unilateral aural fullness, +/- pain
Hearing usually improves between attacks
usually unilaterl but can be bilateral
chronic and progressive
What am I?
What will audiometry show? caloric?
Meniere’s Disease
Audiometry - will show hearing loss during acute attacks
Caloric Testing - reduced or absent nystagmus on affected side
What is the clinical criteria to dx Meniere’s Dz? What lifestyle recommendation?
2 spontaneous episodes of vertigo lasting at least 20 min each
Unilateral sensorineural hearing loss
Tinnitus and/or aural fullness
Low salt diet
Restrict alcohol and caffeine
What is the tx for acute Meniere’s Disease?
Meclizine, diazepam, promethazine
**What is the tx for chronic Meniere’s Disease? Why?
**HCTZ
or Acetazolamide
Vestibular Rehab
hearing aid
Loss of salt and water into the urine will shrink the amount of fluid in the body generally as well as inner ear
What is the nondestructive interventions for refractory Meniere’s dz? destructive?
Nondestructive:
Intratympanic corticosteroid injections
Positive pressure pulse generator (Meniett)
Endolymphatic shunt
destructive:
Intratympanic gentamicin injections
Surgical labyrinthectomy
Vestibular nerve resection
______ leakage of perilymphatic fluid from inner ear into middle ear
______ abnormal thinning, or
absence of bone above the superior
semicircular canal
Perilymphatic Fistula
Semicircular Canal Dehiscence
What are some risk factors for Perilymphatic Fistula and Semicircular Canal Dehiscence?
injury: blunt head trauma, hand slap to ear
barotrauma: scuba diving, flying
Vigorous Valsalva maneuvers: weight lifting
Sensorineural hearing loss
Recurrent brief episodes of vertigo (seconds)
usually after: sneezing, coughing, heavy lifting, constipation, loud noises etc etc
What am I?
What is the next step? What will the result be?
Perilymphatic Fistula and Semicircular Canal Dehiscence
CT or MRI
Perilymphatic Fistula - fluid accumulation in round window recess
Semicircular Canal Dehiscence - thin or absent bone above canal
______ is dizziness or vertigo induced by sounds
Tullio phenomenon
What is the tx for Perilymphatic Fistula and Semicircular Canal Dehiscence? Tx for refractory cases?
Treatment:
Prompt ENT referral
Bed rest
Head elevation
Avoidance of straining
Symptomatic meds PRN
Refractory cases: surgical patch
______ is the leakage of fluid from the ____ to ____ due to trauma/pressure change with hearing loss and equilibrium issues
perilymph fistula
FROM inner ear INTO middle ear
_____ is the build-up of pressure between middle and inner ear. What are some risk factors?
Barotrauma: results from a negative pressure in the middle ear aka pulling ear down inward from negative pressure
Eustachian tube dysfunction
Barometric stressors: flight**
Ear pressure → pain
Vertigo
Hearing loss
Tinnitus
May see hemorrhage behind TM
May see TM perforation
What am I?
What is the tx? refractory tx?
barotrauma
treat the s/s:
pain relievers (most defects will heal over time)
refractory tx:
surgery
Myringotomy, tympanoplasty
What are some ways to prevent barotrauma?
Decongestants - several hours (oral) or 1 hour (nasal) before anticipated event
Diving - change depths slowly and in stages
swallow, yawn, autoinflate frequently
Chewing gum or pacifier in infants
______ sensation of sound in the absence of an exogenous sound source aka ringing in the ears. What is the difference between pulsatile and nonlulsatile?
tinnitus
pulsatile: usually vascular: occurs with the heart beat and tends to be vascular in nature
nonpulsatile: usually due to sensorineural Hearing Loss:
Ototoxic medications
Noise-induced HL
Presbycusis
What is the a major neuromuscular reason for pulsatile tinnitus?
Spasm - tensor tympani and/or stapedius muscle
______ benign vascular neuroendocrine tumor of middle ear. What does it arise from?
Paraganglioma (Glomus tumor)
Arises from paraganglia (collection of cells that come from nervous tissue) of the middle ear
______ is the MC neoplasm of the middle ear
Paraganglioma (Glomus tumor)
highly vascular
Reddish or bluish mass
May see bulging TM on exam
Pulsitile tinnitus, conductive hearing loss, vertigo
What am I?
What is the tx?
Paraganglioma (Glomus tumor)
surgery
_____ tube stays open inappropriately. What is MC seen after? What is the classic symptom?
Patulous Eustachian Tube
significant weight loss
“Roaring” tinnitus and autophony
_____ unusually loud hearing of one’s own voice. When do symptoms improve?
What is the tx?
Patulous Eustachian Tube
Symptoms improve when lowering head below level of heart
application of mucosal irritants such as premarin drops (estrogen) ->
Causes mucosal swelling
or surgery
____ is seen with high-frequency hearing loss. May occur with pathologic hearing loss or presbycusis. What is the loss association with? What is the tx?
Sensorineural Hearing Loss
Associated with loss or dysfunction of hair cells in cochlea
tx: hearing aids
_____ is very important to control for a pt who also has tinnitus
HTN
What are some exacerbating factors for tinnitus? What are some tx?
Depression
Insomnia
Tinnitus Retraining Therapy (TRT)
reduce stress, CBT
BZDs, intra-TM steroid shots, misoprostol
masking devices
Transcranial magnetic stimulation
