Vestibular dysfunction Flashcards
Cause of BPPV
Mostly idiopathic
Can follow vestibular neuritis
Crystals come out of semicicular canals and enter utricles
Symptoms of BPPV
Worsened by head movements, often in a particular direction
Rotational vertigo less commonly nausea, light headedness
Vertigo - 30s to 1 minute. Episodes can last months
Episodic
Rotational vertigo, less commonly naursea, light headedness
Treatment BPPV symptomatic
H1 receptor agonist - vasodilation ear
ABCD2 what is used for
Chances of stroke after TIA
Investgiation BPPV
Dix Hallpike test
Symptoms of labyrinthitis
- Nausea, vomitting
- Vertigo
- Unsteady
What is vestibular neuritis?
Disorder causing acute isolated, spontaneous, prolonged vertigo of peripheral origin
What causes vestibular neuritis?
Inflammation of the vestibular nerve, often after a viral infection
How is hearing affected in labyrinthitis vs vestibular neuritis?
vestibular neuritis - hearing not affected
Labyrinthtis - hearing loss
What can develop after vestibular neuritis?
BPPV - 1 in 10
Phobic postural vertigo - persistent dizziness and feelings of unsteadiness + fear of falling
Symptoms of vestibular neuronitis
Rotational vertigo occurs spontaneously
Exacerbated when move head
Initially constant when head is still
Nausea +/- vomitting, + other autonomic symptoms eg malaise, pallor, sweating
Balance
Test for differentiating vestibular neuritis and central lesion
Head impulse test
What is a positive on the head impulse test?
Corrective saccade - abnormal movement as eyes move to fix back on examiner
Disrupted vestibulo-ocular reflex
Moderate to severe loss of function horizontal semi-circular canal on side to which test is positive
How to do head impulse test
dvise the person to sit upright and to fix their gaze on the examiner.
Then rapidly turn the head 10–20 degrees to one side and watch the person’s eyes. In a normal response (indicating a normal peripheral vestibular system), the eyes stay fixed on the examiner. If the eyes are dragged off target by the head turn, a corrective abnormal movement (saccade) occurs as the eyes move back to fix on the examiner.
What is the prognosis of vestibular neuritis?
Worse for first few days, resolves in 2-6 weeks
Bed rest may be necessary
What factors can worsen balance in vestibular neuritis?
Alchool, tiredness, intercurrent illness
What med rapidly relieves severe nausea or vomitting ass with vertigo?
Buccal Prochloperazine
IM injection of above or cyclizine
Medications for nausea, vommitting, vertigo (longer term)
short oral course (3 days) porchlorperazone OR
antihistamine - cinnarizine, cyclizine (50mg), promethazine teoclate
Why should meds for vestibular neuritis be taken for as short as possible?
May delay recovery by affecting bodys compensatory mechanisms
Cyclizine contraindications
Prostatic hypertrophy, urinary retention, susceptibility to angle-closure glaucoma, and pyloroduodenal obstruction.
Hepatic disease.
Epilepsy.
Severe heart failure or acute myocardial infarction — cyclizine may cause a fall in cardiac output associated with increases in heart rate, mean arterial pressure, and pulmonary wedge pressure.
Phaeochromocytoma.
What is the difference between first and second gen antihistamines?
2nd gen don’t cause drowsiness and interact better with other medications
Examples of first gen anithistmaines
chlorphenamine (Piriton), cinnarizine, diphenhydramine, hydroxyzine and promethazine
Examples of 2nd gen antihistamines
acrivastine, cetirizine, fexofenadine and loratadine
Why do you do an MRI in Mennieres?
Rule out acoustic neuroma
What is Meniere’s disease?
disorder of the inner ear that causes vertigo, tinnitus, hearing loss, and a feeling of fullness or congestion in the ear
Risk factors for Menieres disease
Autoimmunity
Genetic susceptibility
Metabolic disturbances - balance of circulating levels of Na and K in fluid inner ear
Vascular factors - migraine
Viral infection
Head trauma
Complciations of Menieres
Falls, psychological effects - anxiety, depression, agrophobia , social effects - work, driving, limitations
Symptoms of Menieres
Episodes of spontaneous vertigo
Tinnitus - during attacks, later is permanent
Fluctuating sensorineural hearing loss - initally low then higher + permanent
Aural fullness - Sensation pressure in ear, in advance of vertigo attack
Features of acute attacks of Menieres disease
Preceded by chnage in tinitus, increased hearing loss, aural fullness
Vertigo
At least 20 mins, normally a few hours, not beyond 24 hours
Can occur in clusters over a few weeks
Can have months or years of remission
What is an otholitic crisis of tumarkin?
Drop attacks without LOC occur without warning
Exam in menieres
Head and neck
Rombergs test +VE
Unterbergers test - march on spot with eyes closed - move to side
During episode vertigo, nystagmusA
Audiometry - sensorineural hearing loss
What does a definite diagnosis of Menieres require?
Vertigo - at least 2 spontaneous episodes 20 mins to 12 hojurs
Fluctuating hearing, tinnitus, aural fullness
mHearing loss confirmed by audiometry to be sensorineural, low to mid frequency
No other more likely vestibular dysfunction
Refer to ENT to confirm
How does hearing loss start in Menireres?
Low to mid frequency
Progresses to high
Initially can regain, then becomes permanent
Differentials menieres
Acoustic neuroma
MS
Perilymph fistula
Vascular events - TIA
Migraine
BPPV
Vestibular neuitis/labyrinthis=tis
What medications use for alleviating nausea, vomitting + vertigo in Menieres?
7 dyas of prochlorperazine or antihistamine cinnarizine, cyclizine, or promethazine teoclate
14 if required previosuly
When admit someone with menieres
If severe that need IV labyrinthine sedatives and assessment of hydration and nutrition + maintenacnce of these with fluids
Preventation of recurrent arracks of Menieres disease?
Betahistines - reduce frequency and severity of attacks of hearing loss, tiniitis and vertigo
Betahistine amount and whne for menieres
16mg orally 3 times daily
Maintenance dose - 24-48 mg
What is acoustic neuroma?
Benign slow groiwing tumour of Schwann cells in vestibular nerve
Also known as vestibular schwannoma
Cuase of acoustic neuroma
Often unknown, 1 in 10 its Neurfobromatosis type 2 (causes bilateral)
Symptoms of acoustic neuroma what depend on?
Cna damage CNV,CNVII, CNVIII, CNIX X+XI - depends which one effected
Size - if small often asymptomatic
Symtpoms of acoustic neuroma
Sensorineural Hearing loss unilateral (unless NF2)
Tinnnitus
Vertigo
Facial numbness, tingling or pain - due to effect on other CNs
Less commonly:
Headache
Earache
Visual probelms, due to hydrocephalus
Fatigue
Why can acoustic neuromas cause a headache?
(blocks CSF fluid in brain -> raised ICP + hydrocephalus
Can lead to brain damage
Treatment for acoustic neuroma
Surgery - remove, dependring on size location on VC nerve
Small part left behind -> radiotherapy
Biologics new potential
Complications of acoustic neuroma treatment eg surgery
Damge to CNVII 0 facial nerve -> facial nerve palsy - one side of face droops
Damage to vestibulocochlear nerve -> deafness
Damage to CNV - facial numbness
What cranial nerve if damaged would cause facial numbness?
CNV - trigeminal
What cranial nerve if damaged would cause facial weakness?
CNVII - facial nerve
Treatment for hydrocephalus
Shunt inserted into brain - relieve pressure, reintroduce CSF flow
