Vertigo/ dizziness

Question 1

Define vertigo

Answer 1

Vertigo is the sensation that the environment is spinning around relative to oneself (objective vertigo) or vice versa (subjective vertigo).

Question 2

Pathophysiology of BPPV?

Answer 2

presence of debris in the semicircular canals of ears cause vertigo upon head movement

Question 3

Diagnostic test of BPPV?

Answer 3

Dix-hallpike manœuvre- rotatory nystagmus brings on symptoms

Question 4

What resolves BPPV?

Answer 4

Epley manœuvre

Question 5

How does BPPV present?

Answer 5

Vertigo on turning head
Gradual onset
Episodes last 10-20 secs

Question 6

What is acute labyrinthitis?

Answer 6

Inflammation of the vestibular nerve causes acute severe vertigo, may be associated with vomiting/

Question 7

How does acute labyrinthitis present?

Answer 7

Recent viral infection
Vertigo
N&V
hearing may be affected/tinnitus

Question 8

Vestibular neuritis presentation?

Answer 8

Recent viral infection
recurrent vertigo attacks lasting hours or days
Nausea and vomiting
Horizontal nystagmus
No hearing loss

Question 9

How do you differentiate between vestibular neuritis and acute labyrinthitis?

Answer 9

Vestibular neuritis will not have any hearing loss but acute labyrinthitis might

Question 10

Treatment for acute labyrinthitis?

Answer 10

Self-resolving in about a month, conservative treatment.
prochlorperazine or antihistamines may help reduce the sensation of dizziness

Question 11

Meniere’s disease features?

Answer 11

Recurrent episodes of vertigo, sensorineural hearing loss, tinnitus and feeling of aural fullness
Can be unilateral or bilateral

Question 12

Treatment of Menieres disease?

Answer 12

Antihistamines and bedrest

Question 13

Presentation of vestibular schwannoma?

Answer 13

The classical history of vestibular schwannoma includes a combination of:
* vertigo
* hearing loss
* tinnitus
* absent corneal reflex.

Features can be predicted by the affected cranial nerves:
* cranial nerve VIII: vertigo, unilateral sensorineural hearing loss, unilateral tinnitus
* cranial nerve V: absent corneal reflex
* cranial nerve VII: facial palsy

Question 14

What condition is vestibular schwanoma associated with?

Answer 14

Neurofibromatosis type 2

Question 15

What is Ramsay Hunt syndrome?

Answer 15

Herpetic infection of the facial N–> causes facial nerve palsy
With or without vertigo, tinnitus and hearing loss

Question 16

How do you treat Ramsay Hunt?

Answer 16

Aciclovir and prednisolone

Question 17

What causes ototoxicity?

Answer 17

Aminoglycoside abs
Loop diuretics

Question 18

Features of carbon monoxide poisoning?

Answer 18

Headache
Nausea and vomiting
Vertigo
Confusion
Subjective weakness

In severe toxicity: ‘pink’ skin and mucosae, hyperpyrexia, arrhythmias, extrapyramidal features, coma, death

Question 19

Investigations in carbon monoxide poisoning?

Answer 19

Pulse ox may be FALSELY high
VBG/ABG
ECG- for cardiac ischaemia

Question 20

What are typical carboxyhemoglobin levels?

Answer 20

< 3% non-smokers
< 10% smokers
10 - 30% symptomatic: headache, vomiting
> 30% severe toxicity

Question 21

Management of carbon monoxide poisoning?

Answer 21

100% high-flow oxygen via a non-breath mask, target sats are 100%
Treatment until all symptoms have resolved

Question 22

Indications of hyperbaric oxygen use in carbon monoxide poisoning?

Answer 22

Discussion with specialist should be considered in more severe cases: >25%

LOC
Neuro signs other than headache
Myocardial ischaemia or arythmie
Pregnancy

Question 23

What is a TIA?

Answer 23

a transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischaemia, without acute infarction.

Question 24

Features of TIA?

Answer 24

Usually resolve within one hour

Unilateral weakness or sensory loss
aphasia/dysarthria
Ataxia, vertigo, loss of balance
Visual problems (amaurosis fugax), diplopia, homonymous hemianopia

Question 25

Management of Vestibular neuronitis?

Answer 25

buccal or intramuscular prochlorperazine is often used to provide rapid relief for severe cases
a short oral course of prochlorperazine, or an antihistamine (cinnarizine, cyclizine, or promethazine) may be used to alleviate less severe cases
vestibular rehabilitation exercises are the preferred treatment for patients who experience chronic symptoms

Question 26

What is essential to determine about the cause of vertigo when assessing a pt? WHy?

Answer 26

Whether the vertigo is due to a central or peripheral cause.

why? cerebellar infarction / haemorrhage (central) is life threatening as opposed to non life threatening e.g. BPPV or mernieres (peripheral)

Question 27

What are DDx for a patient presenting with acute vertigo i.e. causes of vertigo

Answer 27

Mechanical
- BPPV (otoliths moving in semicirucalr canals)
- Menieres

Infectious (viral)
- Acute vestibular neuritis (semicircular canal function)

Vascular :
- Infarction in anterior vestibular artery territory (presents like v. neuritis - think pts with RF for stroke e.g. DM, HTN, AF)

• Brainstem stroke (accompanied by other signs, horners, dysarthuria, incoordination, diplopia, facial numbness)
• Inferior cerebellar artery infarction (present only with vertigo, nystagmus and postural instability)

MS
- plaque around VIII cranial nerve

Migraine
- diagnosis of exclusion

Migrainous vertigo

Question 28

what are clinical features of acute vertigo ?

Answer 28

vertgio
nausea
vomitting

Question 29

Compare clincial features of BPPV vs Menieres vs migraine

Answer 29

BPPV vertigo lasts for seconds

Meniere’s vertigo lasts for mins/hours

Migraine vertigo last for hours

Question 30

compare central vs peripheral vertigo charachteristics

Answer 30

Question 31

What examination can you do to determine if peripheral or central origin of vertigo?

Answer 31

HINNTs exam

involves:
Head impulse test
evaluation of nystagmus
test of skew

https://www.youtube.com/watch?v=1q-VTKPweuk