Balance disorders

Question 1

What causes BPPV?

Answer 1

• The presence of canaliths in the semi-circular canal instead of the utricle.
• Once in the canal, movement of the patient’s head will result movement of these crystals that cause an abnormal movement of endolymph, resulting in vertigo.
• BPPV can occur in patients following a head injury, previous history of labyrinthitis, and older patients.

Question 2

What are the signs and symptoms of BPPV?

Answer 2

• Vertigo attacks last seconds and result from the same head movement causing the onset of symptoms every time.
• Nausea and vomiting.

Question 3

How should BPPV be investigated?

Answer 3

• Dix-Hallpike Maneovre
• Nystagmus on movement
  
  • *Most commonly crystals form in the posterior canal, resulting in a rotatory nystagmus to be present; if in the horizontal canal then result in a horizontal nystagmus.
• The nystagmus fatigues in less than a minute.

Question 4

How is BPPV managed?

Answer 4

• Epley’s Manoeuvre, performed if the canalith are in the posterior canal.
• Patients post-Epley’s manoeuvre are advised not to drive, to keep sleep upright, not to bend down or look upwards for 48 hours.
• Resolution is not always complete, with some patients requiring repeated Epley’s as symptoms persist, and BPPV can also recur.
• Patients can also be advised to perform Brandt-Daroff exercises, positions they can practice at home that are beneficial in reducing symptom intensity.

Question 5

What is Meniere’s disease?

Answer 5

• Meniere’s Disease is an idiopathic disorder causing vertigo.
• Current theories in its pathophysiology suggest the symptoms result from an increase in endolymphatic pressure.
• Caused by dysfunctioning sodium channels, an osmotic gradient is subsequently set up that draws fluid into the endolymph, increasing the endolymphatic pressure to cause symptoms.

Question 6

What are the clinical features of menieres disease?

Answer 6

• severe paroxysmal vertigo
• sensorineural hearing loss
• tinnitus.
• Symptoms are predominantly unilateral, lasting for minutes to hours, and usually resolve within 24 hours.
• During remission between attacks, the symptoms will improve yet repeated attacks result in a sensorineural hearing loss that worsens over time.
• Whilst the disease will burn out eventually with time, permanent sensorineural hearing loss can remain.

Question 7

How is menieres disease investigated?

Answer 7

• Otoscopy will show a normal looking ear drum
• audiometry will typically show a sensorineural hearing loss
• tympanometry will be type A (normal)

Question 8

How is menieres disease managed?

Answer 8

• In acute attacks, the vertigo and nausea symptoms can be reduced by a short course of prochlorperazine (a vestibular sedative), given either buccal or intramuscular.
• Prophylaxis is required between attacks.
• Patients should be advised suitable lifestyle advice (reducing salt or avoiding chocolate and caffeine) and regular betahistine medication.
• If attacks persist despite prophylaxis, surgical intervention may be warranted.
  
  • This can include intratympanic gentamicin injections,
  • intratympanic steroid injections
  • endolymphatic sac destruction
  • labyrinthectomy (now rarely performed).

Question 9

Outline the aetiology of acute labyrinthitis

Answer 9

• Viral (mumps, CMV, herpes zoster, influenza)
• Bacterial (strep pneumonia, H.influenza, N. meningitis)
• Usually occurs 1-2 days after an URTI

Question 10

Discuss the pathophysiology of acute labyrinthitis

Answer 10

• Inflammation of the inner ear, spread from the mastoid cavity, middle ear, subarachnoid space

Question 11

What are the signs and symptoms of labyrinthitis?

Answer 11

• Abrupt onset of severe vertigo
• Nystagmus
• Vomiting
• No hearing loss or tinnitus

Question 12

How should acute labyrinthitis be investigated?

Answer 12

• Lumbar puncture if meneingitis suspected
• FBC/culture for systemic infection
• CT rule out mastoiditis
• MRI rule out acoustic neuroma

Question 13

How is acute labyrinthitis best managed?

Answer 13

• Anti-emetics for nausea
• Viral - bed rest and hydration
• Bacterial - Antibiotics
• Drain middle ear/mastoid infection

Question 14

What is vestibular neuritis?

Answer 14

• Vestibular neuronitis is inflammation of the vestibular nerve, resulting in vertigo that lasts for days.
• Most cases are due to a viral infection, therefore a URTI precedes around half of the cases.

Question 15

What are the signs and symptoms of vestibular neuritis?

Answer 15

• Symptoms are sudden onset and severely incapacitating
• Nausea and vomiting.
• On otoscopy, the ear drum will be normal
• Horizontal nystagmus will be present when examining the eyes.
• Neurological examination will be unremarkable and the hearing for these patients will be normal.
• Whilst most cases resolve fully within a week; long-term vestibular deficit after the acute episode can lead to unsteadiness over a period of weeks whilst the brain compensates for this.

Question 16

How is vestibular neuritis managed?

Answer 16

• Most patients can be managed at home.
• During the acute episode, a patient may require vestibular sedatives (to be stopped after the acute episode)
• IV fluids if the patient becomes dehydrated from vomiting.
• If there are persistent problems due to vestibular hypofunction, then the patient may require longer term vestibular rehabilitation via Cawthorne-Cooksey exercises.