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Year 2(B6) - E.N.T > Week 2 - G - The Dizzy Patient > Flashcards

Week 2 - G - The Dizzy Patient Flashcards

1
Q

What does dizziness mean?

A

Non-specific term which may cover vertigo, pre-syncope, disequilibrium etc

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2
Q

Whats is vertigo?

A

A sensation of movement, usually spinning

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3
Q

What is the name given to the structure of the inner ear?

A

Labyrinth

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4
Q

What are the two layers of fluid and how are they separated?

A

perilymph and endolymph, separated by a membrane

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5
Q

What are the 5 vestibular end organs? (occur at the end of the semicircular canals or the utricle and saccule)

A

* ampullae of lateral, posterior and superior semicircular canals

* maculae of the utricle and saccule

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6
Q

What do the different end organs do?

A

Semicircular canals sense rotatory movements

Utricle and saccule sense linear acceleration (horizontal or vertical)

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7
Q

What connects the saccule to the cochlear duct?

A

The ductus reuniens

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8
Q

What are the 3 main ways that the inner ear can affect the balance system?

A

* BPPV

* Menieres

* Vestibular neuronitis

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9
Q

What are the some ways that the eye can affect the balance system?

A

* cataracts * DM - diabetes melliutuus * If you can’t see you may struggle to balance

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10
Q

What are the 3 main ways that the joints can affect the balance system?

A

* DM * arthritis * neurology * Can’t balance properly if your joints don’t keep you straight

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11
Q

What are the 2 main ways that the cardiovascular system can affect the balance system?

A

* arrhythmias * postral hypotension

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12
Q

What effects of the brain itself can affect the balance system?

A

* stress (hyperventilation) * migraine - sometimes won’t even have headache and dizziness is the main PC * MS - can mimic just about anything

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13
Q

What does the vestibulo-ocular reflex control?

A

* Allows you to continue to focus ahead despite your head turning

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14
Q

What is the sensory organ of rotation found in the ampullae of the semicircular canals?

A

The crista ampullaris

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15
Q

Where in the ampullae are the crista ampullaris located?

A

They are found within the cupula of the ampullae A vestibulr nerve branch pnetrates the crista ampullaris for balance

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16
Q

If the head moves left, what way does the fluid push the crista ampullaris to maintain balance as the eyes are keeping in focus?

A

The crista ampullaris move in the opposite direction from head movement - as do the eyes

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17
Q

In vestibular pathologies, what is the movement of the eye that may be observed?

A

* nystagmus (involuntary eye movement) will be observed in vestibular pathologies * Direction of nystagmus will depend on the structures that are pathological

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18
Q

Some of the reasons for dizziness?

A

* CV system, haematological (e.g. anaemia makes you SOB and dizzy) and metabolic

* anxiety (hyperventilation)

* neurological conditions; migraines

* trauma

* drug effects (LOTS)

* otological

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19
Q

What is important to ask about in a history for dizziness? (kindve like socrates)

A

https://s3.amazonaws.com/classconnection/111/flashcards/9781111/png/screen_shot_2017-02-08_at_153319-15A1E5BBAD33A2E4148.png

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20
Q

What sort of things may trigger dizziness?

A

* standing up - postural hypotension * turning over in bed - BPPV

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21
Q

What may be some associated symptoms with dizziness?

A

* Palpitations ? * LOC? * Vomiting? * Incontinent? * Hearing loss? * Tinnitus ? Does tinnitus change during dizzy spells?

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22
Q

What sort of examination may take place in a dizziness consultation?

A

* otoscopy * neurological exam * BP incl. lying/standing - difficult to get accurate results and observe a drop in a GP room * balance system * audiometry

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23
Q

What is the commonest cause of vertigo?

A

* Benign Paroxysmal Positional Vertigo (BPPV)

24
Q

When does BPPV cause vertgio?

A

It causes short intense episodes of vertigo when yu move your head in certain directions

25
Q

When moving the head into different positions, what is the problem in the inner ear whcih causes the vertigo?

A

Otolith crystals from the utricle become displaced and enter the semicircular canals and this interferes with the fluid movmement and the cupula (sensitive part containing the crista ampullaris)

26
Q

What are otoliths ?

A

Crystals normally found in the utricle

27
Q

What are some triggers for onset of BPPV?

A

* rolling over in bed, lying back in bed, reaching up high to get something, looking left and right at a T junction - basically makes everything spin for a few seconds until the otoliths settle

28
Q

What can cause BPPV?

A

Head trauma, ear surgery, idiopathic

29
Q

How does BPPV differ from vertebrobasilar insufficiency (as the 2 are commonly confused)?

A

* diagnosis of VBI requires other symptoms of impaired circulation in posterior brain associated with the vertigo e.g. visual disturbance, weakness, numbness

30
Q

What is BPPV not associated with (sometimes unlike VBI)?

A

No tinnitus, hearing loss or aural fullness

31
Q

What test can be done to confirm BPPV?

A

Hallpike’s test

32
Q

How can BPPV be treated?

A

* epley or semont manouvres - can get rid of symptoms when dizzy episode occurs

33
Q

How do you perform Dix-Hallpike test?

A

Head turned to 45 degrees

Head taken to 30degrees below horizontal

Latency of onset of vertigo and nystagmus

34
Q

What are you observing for in Hallpike test?

A

Looking for nystagmus which occurs about 30 seconds delayed.

It will only really work the first time so if patient shuts their eyes or perform manouevre incorrectly, must wait until it has reset until you can do it again

35
Q

What kind of movement will you expect to see for disruption of the posterior canal?

A

Tortional rotation

36
Q

Describe the epley manouevre to treat BPPV?

A

https://s3.amazonaws.com/classconnection/403/flashcards/11907403/png/pjpgpngjpg-174E11F47BD6A1F5CDE.png

37
Q

What is the brandt - daroff exercise?

A

exercises they can do themselves at home to treat the BBPV , termed vestibular rehabilitation, for example Brandt-Daroff exercises

38
Q

What is prolonged vertigo (days) with no associated tinnitus or hearing loss?

A

* This is vestibular neuronitis

39
Q

What is the usual cause of vestibular neuronitis?

A

usually due to a viral infection

40
Q

How does vestibular neuronitis differ to labyrinthitis?

A

* prolonged vertigo (days)

* can be associated with tinnitus or hearing loss

* probably viral

41
Q

What is the treatment for vestibular neuronitis and labyrinthitis ?

A

* vestibular sedatives

* usually self limiting

42
Q

What is vertigo on rotation lasting up to a minute? Diagnosed by Hallpike test and treated with Epley manoevure

A

Benign paroxysmal Positional vertigo

43
Q

What causes menieres disease?

A

Unknown

44
Q

How does it present?

A

Severe rotatory vertigo with episodes lasting at least 20 minutes but can last hours.

45
Q

Asscociated symptoms with menieres?

A

* occurrence of or worsening of tinnitus on the affected side

* occurrence of aural fullness on the affected side - deep insisde ear pressure

* SNHL on at least 1 occasion (sensorineural hearing loss)

* other causes excluded e.g. vestibular schwannoma

46
Q

What do we mean by patients in menieres often getting warning signs?

A

Their tinnitus usually starts getting worse or hearing drops

47
Q

How would the sensorineural hearing loss look on audiogram?

A

HL at low frequency which can fluctuate - get better and get worse

48
Q

Management of menieres?

A

* supportive treatment during episodes e.g. vestibular sedatives - usually ones given in buccal formation so that it has effect even if patient is vomiting - prochlorperazine (D2 receptor antagonist)

* tinnitus therapy and hearing aid in the long run

49
Q

What is given for the prophylactic management of Menier’s disease?

A

Give betahistine for prophylaxis - two mechanisms

* Primarily, it is a weak agonist on the H1 receptors located on blood vessels in the inner ear. This gives rise to local vasodilation & increased permeability,

* More importantly, betahistine has a powerful antagonistic effects at H3 receptors, thereby increasing the levels of neurotransmitters

The increased amounts of histamine can stimulate receptors.

This stimulation explains the potent vasodilatory effects of betahistine in the inner ear,.

Betahistine seems to dilate the blood vessels within the inner ear which can relieve pressure from excess fluid and act on the smooth muscle.

50
Q

What things may help with prevention of episodes in menieres?

A

* salt restriction (difficult but can reduce frequency of episodes) - diuretics may help

* Manage stress

* Caffeine and alcohol reduction

51
Q

How can persistent menieres be managed with simple procedures at the moment?

A

* grommet insertion +/- meniette - pulsed air pressure in the air canal which goes through into middle ear as a result of grommet

* gentamicin - injected through TM into middle ear - poisons vestibular apparatus so its dead and they can’t get dizziness.

52
Q

What is being developed atm to help menieres?

A

* Steroids - same idea as gentamicin but wouldn’t kill off vestibular apparatus so residual balance function remains

53
Q

More invasive treatment options for menieres?

A

* cut vestibular nerve - preserve hearing lose balance

* pull out labyrinth entirely - loss of hearing and balance

* Only used in patients who are severe and in labyrinth removal - in patients whose hearing is very poor anyway

54
Q

Summary of different forms of dizziness from the inner ear

A

https://s3.amazonaws.com/classconnection/111/flashcards/9781111/png/screen_shot_2017-02-08_at_170950-15A1EB4530A4075DCD6.png

55
Q

If the patient complains of aural fullness, what do you think in the dizzy patient?

A

Meniere’s disease

56
Q

If there is a clear positional trigger causing the vertigo what do you think? If deciding between labrynthitis and vestibular neuronitis, how do you rule out estibular neuronitis?

A

Clear psoitional trigger - BPPV

If the vertgio is associated with hearing loss and tinnitus then is labrynthitis

In vestibular neuronitis - the nystagmus is strictly unilateral

Year 2(B6) - E.N.T (32 decks)

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