1- Ears (Balance disorders + Tinnitus) Flashcards
balance disorders
- Vertigo
- Menieres disease
- Benign paraoxysmal positional vertigo
- Vestibular migraine
- Acute vestibular neuronitis
- Acute labyrinthitis
vertigo background
- Descriptive term for a sensation that there is movement between the patient and their environment
- May feel they are moving of that the room is moving
- Prevalence: male: female 1:3
Dizziness and vertigo
True vertigo is most often associated with a sensation of ‘spinning’ and movement of the surrounding environment. It is important to distinguish this from the more generalised dizziness of disequilibrium
The sensory inputs that are responsible for maintaining balance and posture are:
- Vision
- Proprioception
- Signals from the vestibular system
types of vertigo
o Peripheral vertigo
o Central vertigo
pathophysiology of vertgio
problems with either: vision, proprioception or signals from the vestibular system
- The vestibular system is the most important sensory system to understand when learning about vertigo. The vestibular apparatus is located in the inner ear. It consists of three loops called the semicircular canals that are filled with a fluid called endolymph. These semicircular canals are oriented in different directions to detect various movements of the head. As the head turns, the fluid shifts inside the canals. This fluid shift is detected by tiny hairs called stereocilia found in a section of the canal called the ampulla. This sensory input of shifting fluid is transmitted to the brain by the vestibular nerve and lets the brain know that the head is moving in a particular direction.
- The vestibular nerve carries signals from the vestibular apparatus to the vestibular nucleus in the brainstem and the cerebellum. The vestibular nucleus then sends signals to the oculomotor, trochlear and abducens nuclei that control eye movements and the thalamus, spinal cord and cerebellum. The cerebellum is responsible for coordinating movement throughout the body. Therefore, the vestibular signals help the central nervous system coordinate eye movements and other movements throughout the body.
vertgio often associated with
o Nausea
o Vomiting
o Sweating
o Feeling generally unwell
history for vertigo
- Distinguish between vertigo and light-headedness
- Differentiate between symptoms of peripheral and central vertigo
Key features that may point to a specific cause are:
- Recent viral illness (labyrinthitis or vestibular neuronitis)
- Headache (vestibular migraine, cerebrovascular accident or brain tumour)
- Typical triggers (vestibular migraine)
- Ear symptoms, such as pain or discharge (infection)
- Acute onset neurological symptoms (stroke)
Examination for vertigo
- Ear examination to look for signs of infection or other pathology
- Neurological examination to assess for central causes of vertigo (e.g., stroke or multiple sclerosis)
- Cardiovascular examination to assess for cardiovascular causes of dizziness (e.g., arrhythmias or valve disease)
- Special tests (see below)
Cerebellar examination
is an important part of a full neurological examination in patients with vertigo. The components can be remembered with the DANISH mnemonic:
- D – Dysdiadochokinesia
- A – Ataxic gait (ask the patient to walk heel-to-toe)
- N – Nystagmus (see below for more detail)
- I – Intention tremor
- S – Speech (slurred)
- H – Heel-shin test
special tests for vertigo
Special tests that may be helpful in patients with dizziness or vertigo include:
- Romberg’s test (screens for problems with proprioception or vestibular function)
- Dix-Hallpike manoeuvre (to diagnose BPPV)
- HINTS examination (to distinguish between central and peripheral vertigo)
which examination used to differentiate between peripheral and central causes of vertigo
HINTs exam
presentation of peripheral vertigo vs central vertigo
HINTS examintion
The HINTS examination can be used to distinguish between central and peripheral vertigo. It stands for:
- HI – Head Impulse
- N – Nystagmus
- TS – Test of Skew
causes of peripheral vertigo
- benign paroxysmal positional vertigo (BPPV)
- head injury.
- labyrinthitis.
- vestibular neuronitis.
- Ménière’s disease
causes of central vertigo
causes by disease or injury to the brain
- Head injuries
- Illness or infection
- Multiple sclerosis
- Migraines
- Brain tumors
- Strokes
- Transient ischemic attacks
patients with suspected central vertigo need to be
referred for further investigation (e.g., CT or MRI head) to establish the cause.
symptom management for peripheral vertigo
- Antiemetic e.g. Prochlorperazine
- Antihistamines (e.g., cyclizine, cinnarizine and promethazine)
Menieres: betahistine
BPPV: Epley manoeuvre
vestibular migraine
a type of migraine where people experience a combination of vertigo, dizziness or balance problems with other migraine symptoms.
Presentation
Rotatory vertigo can last minutes to hours to days
* Headaches
* Photophobia
* Visual disturbance
* Phonophobia
- Not always a headache or visual symptoms
- Can sometimes overlap (e.g. hearing loss) – hard to differentiate between conditions such as Meniere’s
vestibular migraine triggers
- Stress
- Bright lights
- Strong smells
- Certain foods (e.g. chocolate, cheese and caffeine)
- Dehydration
- Menstruation
- Abnormal sleep patterns
vestibular migraine management
Similar as normal migraine
1) Avoid triggers
2) Medication:
- Preventative : amitriptyline, propranolol, candesartan and flunarizine
- Acute attack: Paracetamol/NSAIDs and triptans
Benign paroxysmal positional vertigo
Background
- A common cause of recurrent episodes of vertigo triggered by head movement
- A peripheral cause of vertigo, meaning the problem is located in the inner ear rather than the brain
- More common in adults
BPPV pathophysiology
Pathophysiology
- Caused by calcium carbonate crystals (otoconia) that forms within the semi-circular canals (usually posterior) of the vestibular apparatus -> crystal dislodge -> create movement in the fluid -> movement of stereocilia -> signals via AP when we are still
causes of BPPV
viral infection, head trauma, ageing, idiopathic
presentation of BPPV
- Vertigo only (most common cause)- no hearing loss or tinnitus
-> Only upsets vestibular apparatus - Short lived episodes (seconds): triggered by movement of head e.g. tuning over in bed, bending down
-> 20-60 seconds (asymptomatic between attacks)
-> Cluster of attacks
BPPV investigation
- Dix-Hallpike manoeuvre
Management of BPPV
- Epley manoeuvre-> dislodging crystals
-
Brandt-Daroff exercises
->Can be performed by patient at home to improve symptoms of BPPV
Dix-Hallpike Manoeuvre
The Dix-Hallpike manoeuvre can be used to diagnose BPPV (Dix for Dx – diagnosis)
It involves moving the patient’s head in a way that moves endolymph through the semicircular canals and triggers vertigo in patients with BPPV. Check the patient can do the manoeuvre safely before performing it, for example, ensuring they have no neck pain or pathology.
Procedure:
* The patient sits upright on a flat examination couch with their head turned 45 degrees to one side (turned to the right to test the right ear and left to test the left ear)
* Support the patient’s head to stay in the 45 degree position while rapidly lowering the patient backwards until their head is hanging off the end of the couch, extended 20-30 degrees
* Hold the patient’s head still, turned 45 degrees to one side and extended 20-30 degrees below the level of the couch
* Watch the eyes closely for 30-60 seconds, looking for nystagmus
* Repeat the test with the head turned 45 degrees in the other direction
Epley manoeuvre
Used to treat BPPV by moving crystals in semi-circular canal into a position that does not disrupt endolymph flow.
Procedure
* Follow the steps of the Dix-Hallpike manoeuvre, having the patient go from an upright position with their head rotated 45 degrees (to the affected side) down to a lying position with their head extended off the end of the bed, still rotated 45 degrees
* Rotate the patient’s head 90 degrees past the central position
* Have the patient roll onto their side so their head rotates a further 90 degrees in the same direction
* Have the patient sit up sideways with the legs off the side of the couch
* Position the head in the central position with the neck flexed 45 Used to treat BPPV by moving crystals in semi-circular canal into a position that does not disrupt endolymph flow.
Procedure
* Follow the steps of the Dix-Hallpike manoeuvre, having the patient go from an upright position with their head rotated 45 degrees (to the affected side) down to a lying position with their head extended off the end of the bed, still rotated 45 degrees
* Rotate the patient’s head 90 degrees past the central position
* Have the patient roll onto their side so their head rotates a further 90 degrees in the same direction
* Have the patient sit up sideways with the legs off the side of the couch
* Position the head in the central position with the neck flexed 45 degrees, with the chin towards the chest
* At each stage, support the patient’s head in place for 30 seconds and wait for any nystagmus or dizziness to settle
The vestibular system
The inner ear is comprised of three parts:
* Semicircular canals
* Vestibule (middle section)- containing the utricles and saccule
* Cochlea
The semicircular canals and otolith organs within the vestibule (the utricle and saccule) are responsible for
Detecting movement of the - head. Together they form the vestibular system:
* The semicircular canals detect rotation of the head
* The otolith organs detect gravity and linear acceleration
investigations for vestibular neuronitis
Head impulse test:
Essential to differentiate between peripheral (inner ear) and central (brain) causes of vertigo -> should be assumed central cause until proven otherwise
e.g. could be posterior circulation infarction (stroke)
Procedure
- The head impulse test involves the patient sitting upright and fixing their gaze on the examiner’s nose.
- The examiner holds the patient’s head and rapidly jerks it 10-20 degrees in one direction while the patient continues looking at the examiner’s nose.
- The head is slowly moved back to the centre before repeating in the opposite direction.
- Ensure they have no neck pain or pathology before performing the test.
normal vs abnormal Head impulse tests
Normal response: Eyes remain on the target after the examiners movement
Abnormal response:
Eyes are dragged off the target by the turning of the head, followed by a corrective saccade back to the target after the turning of head.
Findings
- A patient with a normally functioning vestibular system will keep their eyes fixed on the examiner’s nose.
- In a patient with an abnormally functioning vestibular system (e.g., vestibular neuronitis or labyrinthitis), the eyes will saccade (rapidly move back and forth) as they eventually fix back on the examiner.
- The head impulse test helps diagnose a peripheral cause of vertigo but will be normal if the patient has no current symptoms or a central cause of vertigo.
presentation of acute labyrinthitis
- Acute onset vertigo
- Unlike vestibular neuronitis which also presents with acute onset vertigo
o Hearing loss
o Tinnitus - Coryzal symptoms
management of labyrinthitis
Management is the same as with vestibular neuronitis, with supportive care and short-term use (up to 3 days) of medication to suppress the symptoms. Options for managing symptoms are:
* Prochlorperazine (antiemetic)
* Antihistamines (e.g., cyclizine, cinnarizine and promethazine)
If bacterial labyrinthitis (think meningitis)
- Antibiotics
Menieres Presentation
HEARING LOSS, VERTIGO, TINNITUS
- 40-50 yo’s
- Unilateral episodes of vertigo, tinnitus, hearing loss, aural fullness
- Comes in episodes that last 20 mins to several hours
o Clusters over several weeks - Hearing loss can become more permanent -> sensorineural, unilateral and low frequencies first
- Tinnitus also becomes more permanent
- Spontaneous nystagmus during acute attacks
- H and N finding normal
- Romberg test negative
- Vertigo not triggered by movement or psoture
summary of vestibular conditions
primary tinnitus
has no identifiable cause and often occurs with sensorineural hearing loss.
