Vertigo disorders

Question 1

BPPV : Definition

Answer 1

• Recurrent episodes of vertigo triggered by head movement
• Peripheral vertigo : Pathology in the inner ear

Question 2

BPPV : Pathophysiology

Answer 2

1 . Inner ear : displacement of crystal in the semi-circular canal
- Displacement cause : Viral infection, head trauma, idiopathic

2 . Disruption of endolymph : crystal distrupt the normal flow , confusing the vestibular system

3 . Head movement : Create flow of endolymph, triggering episodes of vertigo

Question 3

BPPV : Clinical presentation

Answer 3

1. Vertigo triggered by head movement
2. Episode : 20 - 60 seconds
3. Prognosis : last severe weeks then resolve intermittently
4. No hearing loss or tinnitus

Question 4

BPPV : Diagnosis

Answer 4

1. Dix-Hallpike manoeuvre
   * Manoeuvre head movement to disrupt endolymph flow
2. Positive result for BPPV
   * Vertigo : triggered
   * Rotational Nystagmus : beats towards the effected ear

Direction of nystagmus is influenced by flow of endolymph

Question 5

BPPV : Management

Answer 5

1. Epley manoeuvre : treats vertigo
   * Moves crystals in semi circular canal in a position that does not disrupt endolymph flow

Question 6

Vestibular neuronitis : Definition

Answer 6

• Inflammation of the vestibular nerve
• Usually caused by a viral infection

Question 7

Vestibular neuronitis : Pathophysiology

Answer 7

1. Innervation of inner ear; to the brain
   * Vestibular nerve transmits signals from the semicircular canals and vestibule
   * Information for ‘Balance’

• Cochlear nerve transmits signals from cochlea to the brain
• Information for ‘Hearing’

2 . Inflammation of the vestibular nerve due to virus
* Affects transmission of signals of ‘Balance’ } Vertigo
* Cochlear nerve unaffected : no tinnitus or hearing loss

Question 8

Vestibular neuronitis : Clinical features

Answer 8

1 . Hx of URTI
2 . Acute onset of vertigo
* Severe and constant vertigo initially - then mainly triggered by head movement

3 . Issues with balance
4 . Nausea and vomitting

Question 9

Vestibular neuronitis : Management

Answer 9

1. R/O Central cause of vertigo ?Posterior circulation infarction
2. Sx relief : Prochloperazine
3. Vestibular rehabilitation therapy (VRT)

Question 10

Labyrinthitis : Definition

Answer 10

Caused by viral upper respiratory tract infection

1) Inflammation of the bony labyrinth of the inner ear
2) Bony labyrinth : Semicircular canal, vestibule and cochlea

Question 11

Labyrinthitis : Clinical presentation

Answer 11

1. Unlike vestibular neuronitis, labyrinthitis includes both cochlear and vestibular nerve

• Can also be associated with:
  1. Vertigo : not triggered/exacerbated by movement
  2. Hearing loss
  3. Tinnitus
  4. Association sx : N+V, URTI : coryzal sx

Question 12

Labyrinthitis : Clinical Signs

Answer 12

1. Horizontal nystagmus : Towards unaffected side due to compensation when one side of the vestibular system is affected
2. Sensorineural hearing loss
3. Gait disturbance : fill towards affected size

Question 13

Labyrinthitis : Management

Answer 13

• Episodes self-limiting
• Sx relief : Prochloperazine

Question 14

Labyrinthitis : Complication

Answer 14

Bacterial infection of Labyrinthitis : 2nd to otitis media or meningitis

Question 15

Meniere’s disease : Definition

Answer 15

Ménière’s disease is a long-term inner ear disorder that causes recurrent attacks of vertigo, and symptoms of hearing loss, tinnitus and a feeling of fullness in the ear.

Question 16

Meniere’s disease : Pathophysiology

Answer 16

• Excessive build up of endolymph in the labyrinth of the inner ear
• Causes a higher pressure than normal and disrupting the sensory signals.
• Affects both vestubar and chochlea due to high pressure created - may cause ishchaemia over time
• Endolymphatic hydrop : increased pressure of the endolymph

Question 17

Meniere’s disease : Clinical presentation

Answer 17

• Unilateral

Triad of symptoms
1 . Vertigo : 20 min - several hour episodes, occur in clusters intermittent resolving
-Not association with head movement
2 . Sensorineural hearing loss
3 . Tinnitus
Associated with : ‘Fullness’ in ear, imbalance leading to falls

Question 18

Meniere’s disease : Diagnosis

Answer 18

1. Clinical diagnosis
2. Audiology r/v of hearing loss

Question 19

Meniere’s disease : Management

Answer 19

REFER TO ENT

Sx relief : Prochloperazine
Propphylactic : Betahistine - histamne analogue which increases blood flow to vestibulocochlear system

Question 20

Acoustic Neuroma : Definition

Answer 20

Benign tumours of the Schwann cells surrounding the auditory nerve (vestibulocochlear nerve) that innervates the inner ear.

Question 21

Acoustic Neuroma : Pathophysiology

Answer 21

1. Tumors originate from schwann cells lining the vestibulocochlear nerve
2. Unilateral tumors : Occur at the cerebellopontine angle

Question 22

Acoustic Neuroma : Incidence

Answer 22

40 - 60 year olds

Question 23

Acoustic Neuroma : Clinical presentation

Answer 23

Gradual onset of symptoms
1. Unilateral sensorineural hearing loss } first sx
2. Unilateral tinnitus
3. Dizzyness/Imbalance (cerebellar sx)
4. Sensation of ‘Fullness’ in ear

Question 24

Acoustic Neuroma : Complications

Answer 24

• Facial nerve palsy : Large tutors can compress facial nerve

Question 25

Acoustic Neuroma : Genetic association

Answer 25

*neurofibromatosis type II* : causes bilateral acoustic neuromas

Question 26

Acoustic Neuroma : Diagnosis

Answer 26

1. CT scan : identifies tumor 2. Audiometry : identifies sensorineural hearing loss

Question 27

Acoustic Neuroma : Management

Answer 27

* *Conservative* management with monitoring  if there are no symptoms   * *Surgery* to remove the tumour (partial or total removal) * *Radiotherapy* to reduce the growth

Question 28

Vertigo : definition

Answer 28

* Movement between the patient and their environment * Vertigo is often associated with nausea, vomiting, sweating and feeling generally unwell.

Question 29

Vertigo : Physiology

Answer 29

**Vestibular apparatus : Inner ear** 1 . ***Semicircular canals*** : contain endolymph fluid which shifts during head movement 2 . ***Vestibular nerve*** : recieves sensory input from movement of endolymph and transmits it to; 3 . ***Vestibular nucleus*** : Brain stem and cerebellum which then transmits it to * Oculomotor,trochlear,abducens nuclei } coordinate eye movement * Spinal chord/cerebellum } coordinate movement throughout the body **Vestibular signals help the CNS coordinate eye movements + body movements**

Question 30

Vertigo : Pathophysiology

Answer 30

The sensory inputs that are responsible for maintaining balance and posture are: 1. Vision 2. Proprioception 3. Signals from the vestibular system **Vertigo is caused by a mismatch between these sensory inputs** *Cause :* ⦁ **Peripheral problem** : usually affecting the vestibular system ⦁ **Central problem** : usually involving the brainstem or the cerebellum

Question 31

Vertigo : Causes of peripheral vertigo

Answer 31

1. Benign paroxysmal positional vertigo 2. Ménière’s disease 3. Vestibular neuronitis 4. Labyrinthitis 5. Acoustic neuroma 6. Otosclerosis

Question 32

Vertigo : Causes of Central vertigo

Answer 32

*Pathology that affects the **cerebellum or the brainstem** disrupt the signals from the vestibular system and cause vertigo*. The most common pathology that results in a central cause of vertigo are: 1. **Posterior circulation infarction** * Sudden onset * Assoc with : ataxia, diplopia, cranial nerve defects or limb symptoms. 2. **Tumours in the cerebellum/brainstem** *Gradual onset * Assoc with : sx of cerebellar or brainstem dysfunction. 3. **Multiple sclerosis** * relapsing and remitting symptoms, * Assoc with : optic neuritis or transverse myelitis. 4. **Vestibular migraine** * Lasting minutes to hours, * Assoc with : visual aura, head ache and may be a trigger