Vertigo (Ferguson)

Question 1

• ____________ indicates global cerebral hypoperfusion such as that noted in presyncope
• ______________ is a term that generally implies gait instability from balance impairment and does not necessarily implicate vertigo

Answer 1

• Lightheadedness
• Disequilibrium

Question 2

What is the definition of vertigo?

• What is the most common manifestation of vertigo?
• What is of paramount importance to correctly identify the etiology of vertigo?

Answer 2

A sensation of false movement

• Room spinning
• Localizing vertigo to central or peripheral

Question 3

How is vertigo treated?

• Vestibulosuppressants such as _______ or _______
• Antinausea medications such as ________

Answer 3

SYMPTOMATICALLY

• Meclizine, benzodiazepines
• Prochlorperazine

Question 4

What type?

• Emanates from the vestibular nuclei or the cerebellum
• Typically associated with:
  
  • Nystagmus, ataxia
  • Dysarthria
  • Dysphagia
  • Diplopia

Answer 4

Central Vertigo

Question 5

What type?

• Emanating from the labyrinth or vestibular nerve
• Typically associated with:
  
  • Nystagmus, ataxia
  • Tinnitus
  • Hearing loss

Answer 5

Peripheral vertigo

Question 6

What is the definition of nystagmus?

• May be horizontal, vertical, torsional, or any combination superimposed upon each other
• Etiologies? ______ or _______

Answer 6

A periodic rhythmic ocular oscillation of the eyes

• Congenital or acquired

Question 7

What type?

• Multidirectional nystagmus
  
  • Changes directions depending on gaze
  • Pure nystagmus
    
    • Rotary, horizontal, vertical presentation - NOT combinations
    • Purely vertical, or tosional is highly suspicious for _________

NEED TO IMAGE THESE PATIENTS

Answer 7

Centrally derived nystagmus

• Central origin

Question 8

What type?

• Unidirectional nystagmus
  
  • Fast phase ALWAYS goes in the direction of _______
    
    • Rotary component combined with either horizontal or vertical nystagmus in most patients, although pure presentations are also observed

Answer 8

Peripherallly derived nytagmus

• OF the LESION

Question 9

___________ are key to developing a good differential.

• Use the previously described localization tools to help discern central from peripheral

What tests can be done?

• ____ - can be abnormal in peripheral causes
• _____ - with and without Gadolineum with THIN cuts through the brainstem** preferred
• ____ - can help to localize the lesion to peripheral or central cause, not particularly reliable, seldom used

Answer 9

History and Physical

• Audiograms
• Neuroimaging
• Brainstem Auditory Evoked Potentials (BAER)

Question 10

In central vertigo -

Lesions emanating from the _______, _______, or ______ connections

Etiologies:

• (5)?

NEED NEUROIMAGING with MRI Brain!

Answer 10

Vestibular nuclei, cerebellum, cerebellar

• Cerebellar, or brainstem stroke
• Migraine
• Demyelinating lesions (MS, sarcoidosis)
• Abscess
• Malignancy (primary tumor vs mets)

Question 11

In peripheral vertigo -

what are the differential diagnoses for each:

• Single episode? (2)
• Relentless/Progressive? (2)
• Recurrent? (4)

Answer 11

• Acute labyrinthitis, acute idiopathic peripheral vestibulopathy
• Mass/malignancy, medication induced
• Benign paroxysmal positional vertigo, meniere’s disease, perilymph fistula, vestibular paroxysmia

Question 12

Diagnose:

• Sudden or subacute onset of severe vertigo
• ​Associated hearing loss
• Sx. usually last for days to weeks before gradually subsiding
• Generally thought to be viral but bacterial etiologies occur as well

Tx. If bacterial - antibiotics

• No clear indication for steroids

Answer 12

Acute labyrinthitis

Question 13

Diagnose:

• Symptoms develop over hours
• Intense vertigo with head movements and to a lesser degree at rest
• NO associated hearing loss
• Generally considered a viral or post-viral phenomenon

Tx. Corticosteroids - 100 mg prednisone for 3-5 days followed by a gradual taper; anti-nausea medications as well as meclizine

Answer 13

Acute Idiopathic Peripheral Vestibulopathy

Question 14

What medications can induce relentless/progressive vertigo?

• Toxic effects to the cochleovestibular system!
  
  • ____
  • ____ - ___ and to a lesser degree? (widely used in gyn, lung, cns, head and neck, testicular cancers)
  • ____
  • ____
  • ____

Answer 14

• Aminoglycosides
• Platinum based antineoplastic agents (Cisplatin, Carboplatin)
• Salicylates
• Quinine
• Loop diuretics

Question 15

Diagnose:

• Most common etiology of recurrent vertigo
• Due to otoliths that are dislodged from normal positioning in the semicircular canals (mc - posterior canal)
• Clinically patients complain of vertigo typically with head position change (extending neck and looking up, rolling over in bed)
  
  • Within 5 seconds of position change and last ~30 seconds
• Can be provoked with the Dix Hallpike Maneuver (+ test burst of upbeat or torsional nystagmus 10-30 seconds

Answer 15

Benign Paroxysmal Positional Vertigo

Question 16

Diagnose:

• Episodic vertigo and tinnitus with hearing loss - hearing loss reversible if detected and treated early
• Vertigo episodes last for hours and are typically preceded by a sensation of worsening tinnitus and ear fullness
• Attacks occur due to an increase in endolymphatic pressure - may have N/V

Tx: (2 each)

• Acute exacerbation - _______?
• Long term management - _______?
• Surgical (often have associated permanent hearing loss) - _______?

Answer 16

Meniere’s Disease

• Vestibulosuppressants, Nausea suppressing medications
• Diuretics (HCTZ), Sodium restriction
• Endolymphatic sac decompression/shunt, Labyrinthectomy (high cure rate, ablation of the diseased inner ear organs)

Question 17

Diagnose:

• Abnormal connection between perilymphatic space of the inner ear and the middle ear/mastoid
• Recurrent vertigo that is precipitated by sneezing, coughing, exertion, altitudinal changes (airplane, elevators)
• Tx.
  
  • Conservative management with ______ or ______
  • _____ to repair hole in the oval/round window

Answer 17

Perilymph Fistula

• Vestibulosuppressants, nausea suppressing medications
• Surgical fix

Question 18

Diagnose:

• Analogous to trigenimal neuralgia in that it is provoked by a vessel placing pressure upon the nerve and the symptoms are recurrent, brief, and in sudden onset
• Brief episodes of vertigo and hearing loss with or without tinnitus lasting seconds to a few minutes
• Thought to be the result of a vascular compression on CNVIII
• Tx.
  
  • No medications can mitigate this disorder
  • Can have microvascular decompression

Answer 18

Vestibular Paroxysmia

Question 19

Answer 19

B

Question 20

Answer 20

C

Question 21

Answer 21

C

Question 22

Answer 22

D