Dizziness (BPPV and Menieres) Flashcards by Elizabeth McCabe

What three systems contribute to our sense of balance?

Visual system
Proprioception
Vestibular

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Define vertigo

The hallucination of movement or motion, of one self of the environment around you

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How common is vertigo?

Up to 3% of ED presentations
50% of over 60s experience vestibular dysfunction
80% over 80yrs
Common in GP, Falls and ENT clinics
Often high absence from work, falls and injury.

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What are some central causes of vertigo?

Stroke (posterior)
Space occupying lesion/tumour
MS/demyelination

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What are some peripheral causes of vertigo?

BPPV
Labyrinthitis
Vestibular neuritis
Menieres disease

These all affect the vestibular system

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What are the three most common causes of vertigo?

Posterior circulation stroke/TIA
Acute vestibulopathy (vestibular neuritis/labyrinthitis)
BPPV

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How does a central cause of vertigo tend to present?

Continuous vertigo with exacerbations lasting min/sec/hours/days

Also - imbalance, nausea, diplopia, dysphagia, dysarthria, dysmetria.

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How does a lanyrinthine cause of vertigo tend to present?

Vertigo is continuous with exacerbations lasting min/sec/hrs/days
Improving to only head provoked in 2 to 3 days

Commonly have imbalance and nausea, no central signs, may have possible hearing changes

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How does vertigo in BPPV tend to present?

Paroxysmal lasting only seconds
Tends to be very strong and often accompanied with nausea
Vague imbalance in the elderly
Brough on by certain head positions - commonly getting in/out of bed, reaching into cupboards, bending to tie shoe laces

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What is the relevant epidemiology of BPPV?

Peak between 60-70yrs
More common in females 3:1
More common than vestibular neuronitis and viral labyrinthitis.

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What are the key clinical features of BPPV?

Vertigo triggered by change in head position (rolling over in bed or gazing upwards)
May be associated with nausea
Each episode typically lasts 10-20 seconds
Adaptability
Fatigability
Positive Dix-Hallpike manoeuvre

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Define BPPV

Disorder of the inner each characterised by repeated episodes of positional vertigo triggered by changes in head position
It is caused by dislodged and misplaced otoconia within the semi-circular canals. (mechanical problem)

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What are the key risk factors for BPPV?

Head injury
T2DM
Vitamin D deficiency
Ageing (peak 60-70yrs)
Female sex
Osteoporosis/osteopenia

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How often are each types of semicircular canals affected in BPPV?

Posterior -90%
Horizontal - 18%
Anterior 2%

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What is the most common semicircular canal affected in BPPV?

Right posterior semicircular canal

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What is the nystagmus patterns seen in BPPV relevant to the semicircular canal that is affected?

Horiztonal - horizontal
Posterior - torsional upbeat
Anterior - torsional downbeat or vertical.

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What are the different diagnostic maneourves used for BPPV based on the semicircular canal effected?

Dix hallpike - posterior
Supine Rollt test - horizontal
Dix hallpike 0r semont - anterior

Describe the pathological process occuring in BPPV

Free-floating otoconia and debris move around in the semicircular canals and/or adhere to the cupula.
Changing head position triggers the problem
Leads to disruption of endolymph dynamics
Increased sensitivity of the semi-circular canals
Leads to abnormal stimulation of the vestibular apparatus -> abnormal sensation transmitted by the vestibulocochlear nerve.

What is the aetiology of BPPV?

Idiopathic
secondary to degeneration of acoustic macular
Head trauma (deceleration
Prior otologic surgery
Vestibular neuritisis
Menieuers disease
Migraine.

What are the signs and symtpoms of BPPV?

Episodic vertigo - paroxsysmal (appear suddenly and last only a few seconds to a minute(
Triggered by head movement.
+/- nystagmus
+/- nausea and vomiting
Risk of falls -> subsequent injury.

What are some common complications of BPPV?

Depression
Due to high fall risk - fractures, dislocations, traumatic brain injury (concussion)
Tends to reoccur 3-5yrs after diagnosis

What is the management for BPPV?

The Epley Manoeuvre - by a health care professional
Brandt-Daroff Exercises - performed by patients at home.

Define Menieres disease

Disorder of the inner ear of unknown cause.
Characterised by excessive pressure and progressive dilation of the endolymphatic system.
More common in middle-aged adults.

What is the relevant epidemiology of Meniere’s disease?

Peak incidence 40-50 years.
Females: males is equal ratio.

What are the risk factors of Menieres disease?

Age - 20 to 50yrs but occurs at any age Gender - slightly higher prevalence in women, but inconclusive Family history - genetic predisposition, first degree relative.

What are the underlying causes of Menieres disease?

Arises from an imbalance in the endolymphatic system -> leads to increased fluid pressure. Viral infections - HSV Allergies - inflammation Vascular factors - insufficiency or abnormal blood flow within the inner ear -> such as migraine and Raynauds phenomenon.

What are the key clinical features of Menieres disease?

Recurrent vertigo (prominent), tinnitus and hearing loss (sensorineural). Sensation of aural fullness or pressure May also have nystagmus and pos Romberg Falls without loss of consciousness Episodes last minutes to hours Typically symptoms are unilateral but may be bilateral.

What is the long term management of Menieres disease?

ENT assessment if required to confirm the diagnoses Must inform DVLA - cease until satisfactory control of symptoms Prevention - betahistine and vestibular rehabilitation exercises.

What is the natural history of menieres disease?

Symptoms tend to resolve in majority in 5-10yrs Majority left with hearing loss Psychological distress is common.

What is the triad of symptoms in Meniere's disease?

Vertigo Hearing loss Tinnitus

What is the pathophysiology of menieres disease?

Excessive endolymph in the labrinth of the inner ear (endolymphatic hydrops) Causes increased pressure This disrupts sensory signals by causing mechanical disturbance of the Organ of Corti, including distortation of the basillar membrane and associated hair cells.

What investigations may be done for hearing loss in meneires disease?

Audiogram - expect unilateral sensorineural hearing loss, mainly affecting the low decibel sounds.

What is the acute management for Meniere's disease?

Acute attacks can be treated with buccal or intramuscular prochlorperazine (anti-sickness) or anti-histamine (cyclizine to improve blood flow to inner ear )- may need admission

What more unusual treatment can be used for Menieres disease?

Sodium restriction diet Intratympaic steroid injections - reduce vertigo attacks Intratympanic gentamycin injections - ablates vestibular cells - consequence of sensorineural hearing loss Vestibular nerve cut through or laryrinthectomy Reduce caffeine (prevent nerve stimulation) Stop smoking (preserve blood flow to the inner ear) Hearing aids Physical therapy to help with balance Home modifications - grab bars, anti-slip strips, light sensor nigh lights.

What tests should you use to distinguish between a central and peripheral cause of vertigo?

HINTS Head impulse Test Nystagmus Test of Skew

What do the head impulse test results tell us?

Assess the vestibular ocular reflex. Positive result is abnormal - demonstrate catch up saccades - could be a central or negative cause of nystagmus/vertigo Negative result - normal - patient gaze remains fixed on point - reassuring that a peripheral cause occurs Important - stroke may still have a normal test result. Direction they were looking towards = side being tested

How should nystagmus be tested an interpreted in the HINTS test?

Ask patient to look straight forward, look to the left and look to the right. Is nystagmus remains in the same direction = peripheral cause If nystagmus changes direction = central cause.

How is the skew test/cover test completed and interpreted int eh HINTS exam?

Cover one eye - remove cover and look for change in position of the covered eye If vertical correction/refixation indicates a central cause of pathology.

What results on the HINTS exam can indicate a central cause of vertigo?

Impulse normal Fast-phase alternating direction nystagmus Refixation on the cover test INFARCT Any of these three is concerning

What results on the HINTS exam indicate a peripheral cause of vertigo?

Impulse positive (shows catch up saccades) Nystagmus unidirectional No refixation All three must be true to confirm