week 2 dizzy patient

Question 1

what are the 5 vestibular end organs?

Answer 1

utricle, saccule, and three semicircular canals (horizontal, superior and posterior)

Question 2

function of horizontal SCC

Answer 2

works L+R (looking when crossing road)

Question 3

function of superior SCC

Answer 3

works on up/down (nodding)

Question 4

function of posterior SCC

Answer 4

works on rotation (touching ear to shoulder)

Question 5

what does the central pathways involve?

Answer 5

vestibulospinal tract

medial longitudinal fasciculus & ocular muscles

medial lemniscus & thalamus & cerebrum

cerebellum via inferior cerebellar peduncle

Question 6

what systems can affect the balance system?

Answer 6

CVS, ear, eye, joints, brain

Question 7

ear problems affecting balance

Answer 7

BPPV
Ménière’s
Vestibular Neuronitis

Question 8

heart problems affecting balance

Answer 8

Arrhythmias

Postural Hypotension

Question 9

joint problems affecting balance

Answer 9

DM
Arthritis
Neurology

Question 10

eye problems affecting balance

Answer 10

Cataracts

D. mellitus

Question 11

brain problems affecting balance

Answer 11

Stress causing hyperventilation
Migraine
SOL
MS

Question 12

what does problem with VOR (VESTIBULO-OCULAR REFLEX) indicate?

Answer 12

(neuro)vestibular problem

mainly vestibular problems

Question 13

what is nystagmus used for?? direction?

Answer 13

to check vestibular function

normally horizontal but can be any direction depending on structures involved

Question 14

how to take Hx of vertigo?

Answer 14

Triggers?
Time Course?
Associated symptoms?
Alleviating factors?
Medication?

Question 15

how to examine person with vertigo?

Answer 15

Otoscopy
Neurological
Blood pressure including lying/standing (with electronic machine)
Balance system
Audiometry

Question 16

common causes of vertigo and how to diagnose

Answer 16

Postural dizziness = History, Hb, Na, BP lying/standing

Side effect of medication = History

psycogenic

Question 17

specific causes of vertigo

Answer 17

Ménière's Disease
BPPV
Vestibular Neuronitis
Labyrinthitis
Migrainous Vertigo

Question 18

BPPV (benign Positional Paroxysmal Vertigo) incidence

Answer 18

IT IS VERY COMMON

It is the commonest cause of vertigo on looking up

Question 19

causes of BPPV

Answer 19

Head trauma, ear surgery, idiopathic

Question 20

pathogenesis of BPPV

Answer 20

Otolith material from utricle displaced into semicircular canals. (calcium carbonate) Most commonly in posterior SCC.

Question 21

what may BPPV be confused with?

Answer 21

Vertebrobasilar insufficiency/ VBI (ischemia to posterior part of brain)

Question 22

how to distinguish between BPPV and VBI

Answer 22

For a diagnosis of VBI need other symptoms of impaired circulation in posterior brain associated with the vertigo

e.g. visual disturbance
weakness
numbness

Question 23

PC of BPPV

Answer 23

• looking up
• turning in bed - often worse to one side
• first lying down in bed at night
• on first getting out of bed in the morning
• bending forward
• rising from bending
• moving head quickly – often only in one direction

-brief episodes + no tinnitus, hearing loss, aural fullness

Question 24

how to diagnose BPPV

Answer 24

hallpike’s test.

• look for nystagmus in eyes, delay 30 secs approx. test fatigues.

Question 25

how to treat BPPV

Answer 25

Epley Manoeuvre; in clinic

Brandt-Daroff exercise - if too big, immobile; at home

Question 26

Vestibular Neuronitis PC

Answer 26

Prolonged vertigo (days). most sever initially then gets better over 2/3weeks. nausea and vomiting may occur.
No associated tinnitus or hearing loss

Question 27

pathogenesis of Vestibular Neuronitis

Answer 27

Probable viral aetiology

May be viral prodromal symptoms

Question 28

Labyrinthitis PC

Answer 28

[]affects whole ear]
Prolonged vertigo (days),
May be associated tinnitus or hearing loss

Question 29

pathogenesis of Labyrinthitis

Answer 29

Probable viral aetiology

May be viral prodromal symptoms

Question 30

treating Labyrinthitis and Vestibular Neuronitis. complications

Answer 30

Reassure the person that symptoms will usually settle over several weeks: if prolonged/atypical refer.

vestibular sedatives: Cyclizine, Prochlorperazine = buccastem (given buccal so vomiting doesn’t affect dose)

may lead to permanent damage (prolonged) and need rehab (majority recover fine)

Question 31

Ménière’s Disease PC

Answer 31

History of recurrent, spontaneous, rotational vertigo with at least two episodes >20mins (often lasting hours)

preceding/Occurrence of tinnitus on the affected side and/or Documented Significant sensorineural hearing loss) on at least one occasion/of aural fullness on the affected side

gets worse over time (balance + hearing)

usually Ménière’s occurs in one ear or self-limitinh

Question 32

how to diagnose Ménière’s DiseasE?

Answer 32

Other causes excluded, diagnosis of excluding, rare so exclude other causes…

EG:vestibular schwanoma, intracranial lesion

Question 33

management of ménière’s DiseasE? mild; severe

Answer 33

Supportive treatment during episodes (buccostem/ prochlorperazine)
Tinnitus therapy
Hearing Aids
Prevention [Salt restriction / Betahistine / caffeine / alcohol / stress]

Grommet insertion / Meniette
Intratympanic Gentamicin / Steroids (Gent= destroy ear and balance function, stops disease - potentially can still get hearing loss/tinnitus; steroid = new treatment early days but may help)
Surgery
[can only do if one ear]

Question 34

what is aural fullness?

Answer 34

pressure in the ears

Question 35

Migrainous Vertigo PC

Answer 35

migrane (not always), vertigo and ataxia, motion sickness.

Phonophobia is the most common auditory symptom but hearing loss that fluctuates/acute permanent may occur in some

Question 36

diagnosing Definite Migrainous Vertigo

Answer 36

Episodic vestibular symptoms of at least moderate severity (interfere but not impede daily activities)
Migraine according to International Headache Society criteria
At least 1 of the following during at least 2 attacks:
Migrainous symptoms during vertigo, migraine-specific precipitants of vertigo, response to anti-migrainous drugs
Other causes ruled out

Question 37

diagnosing probable Migrainous Vertigo

Answer 37

Episodic vestibular symptoms of at least moderate severity (interfere but not impede daily activities)
At least 1 of:
Migrainous headache, photophobia, phonophobia, visual or other aura
Other causes ruled out