Dizzy patient

Question 1

What is the difference between dizziness and vertigo?

Answer 1

Dizziness is an umbrella term covering things like vertigo, pre syncope, disequilibrium etc. Vertigo is a specific thing

Question 2

Define vertigo

Answer 2

Sensation of movement, usually spinning movement.

Question 3

Dizziness is the most common cause of GP presentation over 74years of age - true/false

Answer 3

true

Question 4

there are 7 possible categories of causes of dizziness - what are they?

Answer 4

Cardiovascular causes
Haematological Causes
Anxiety (hyperventilation)
Neurological conditions
Migraines
Otological causes 
traumatic causes

Question 5

What is labyrinth?

Answer 5

This is the complex structure of the inner ear

Question 6

The labyrinth has a boney and membranous part with two separate fluid containing spaces - true/false

Answer 6

True

Question 7

There are ____ vestibular end organs which are the _____

Answer 7

5

Ampullae of the lateral, posterior and superior semicircular canals and the maculae of the utricle and saccule

Question 8

balance is about more than just the ear - explain why your eyesight impacts your balance.

Answer 8

The eyes and ears are telling you different things about where you are in space if your eyesight is poor; thus this throws your balance off.

Question 9

How do proprioceptors play into balance?

Answer 9

the proprioceptors in joints tell you where you are in space. if these aren’t working then your brain gets confused as to where you are, as your eyes/ears and proprioceptors are telling you different things.

Question 10

How does poor perfusion to the brain affect balance?

Answer 10

you will deck it if your brain has no oxygen and this is why the heart plays into balance.

Question 11

Vasovagal syncope, arrhythmia and postural hypotension all cause balance issues - true/false

Answer 11

true

Question 12

What is the vestibulo-ocular reflex?

Answer 12

This is when you focus your eye on one thing and turn your eye but your eyes move to remain fixed on that object.

Question 13

How does the vestibule-ocular reflex work?

Answer 13

The lateral semi-circular canal is constantly sending impulses. when the head moves, these impulses decrease and your eyes move in order to remain fixed on your object of sight.

Question 14

Why is the vestibule-ocular reflex important?

Answer 14

This is important for using nystagmus to distinguish between a vestibular and non-vestibular pathology

Question 15

Define nystagmus?

Answer 15

Dancing eyes - rapid, involuntary movement of the eyes

Question 16

Nystagmus will be present in non-vestibular pathology - true/false

Answer 16

False - it will only be present in a vestibular pathology

Question 17

What questions should you ask about dizziness?

Answer 17

Relevant socrates questions: 
- triggers
- better or worse
- how long/when started
- associated symptoms 
- alleviating factors
medications they take

Question 18

Examinations you would carry out for dizziness include: 
1. 
2.
3.
4. 
5.

Answer 18

1. Otoscopy
2. neurological examination
3. BP, lying and standing
4. balance system
5. Audiometry

Question 19

Other Investigations for dizziness include:
1.
2. 
3.
Why are you doing these?

Answer 19

1. FBC - look for anaemic
2. U+Es - sodium imbalance, hypotension and postural hypotension
3. lying and standing BP - postural hypotension

Question 20

What is the cause and incidence of Ménière’s Disease?

Answer 20

Cause - unknown

Incidence 50-200/100,000

Question 21

What are the symptoms of Ménière’s Disease

Answer 21

Recurrent, spontaneous, rotational vertigo with at least 2 episodes lasting more than 20mins (sometimes more than hours).
Tinnitus and a feeling of aural fullness on the affected side.
Documented sensorineural hearing loss on at least one occasion.

Question 22

Ménière’s Disease is a disease that is diagnosed clinically from the history- true/false

Answer 22

true as it doesn’t have any specific testing

also false as it is a diagnosis of exclusion, it is only diagnosed by excluding all other causes.

Question 23

management of Ménière’s Disease includes:
1. 
2.
3.
4.
5.
6.

Answer 23

1. supportive management and tinnitus therapy
2. hearing aids
3. Prevention e.g. avoiding excess salt, betahistine, caffeine, alcohol and stress
4. Grommet or meniette insertion
5. intratympanic gentamicin and/or steroids
6. Surgical

Question 24

What is the commonest cause of vertigo when you look upwards?

Answer 24

Benign positional paroxysmal vertigo (BPPV).

Question 25

Give three potential causes of BPPV

Answer 25

head trauma, ear surgery, idiopathic

Question 26

Describe the pathophysiology of BPPV

Answer 26

Otolith material of the utricle becomes displaced into semicircular canals. Most commonly seen in posterior squamous cell carcinoma.

Question 27

What other disease is BPPV often confused with? What must be present in this other disease?

Answer 27

Vertebrobasilar insufficiency Must have symptoms of impaired circulation in the posterior brain associated with the vertigo e.g. visual disturbance, weakness and numbness.

Question 28

``` Symptoms of BPPV include vertigo on: 1. 2. 3. 4. 5. 6. 7. ``` this is usually a brief episode with no tinnitus, hearing loss or aural fullness -true/false

Answer 28

1. Looking up 2. Turning in bed - often worse turning to one side 3. First lying down in bed at night 4. first getting out of bed in the morning 5. Bending forward 6. Rising from bending 7. Moving head too quickly - often in one direction true

Question 29

What is the Dix-Hallpike test and what is it used for?

Answer 29

It involves sitting a patient on a couch turning their head 45degrees to the affected side and putting them in a supine position as quickly as comfortable with their head hanging over the end of the couch and the neck in approximately 30degrees extension. Make sure they know they cannot close their eyes if they get dizzy Hold in position and observe. Usually delay up to 30seconds and then classical nystagmus. Used to diagnose BPPV.

Question 30

Why is the Dix-Hallpike test not able to be repeated numerous times?

Answer 30

The test fatigues

Question 31

Treatment for BPPV involves the _____ which can be repeated up to ___ times

Answer 31

Epley Manoeuvre. up to 2x so total of three procedures.

Question 32

Vestibular neuronitis is a prolonged vertigo lasting ____ with (no/some) associated tinnitus and hearing loss

Answer 32

Vestibular neuronitis is a prolonged vertigo lasting days with no associated tinnitus and hearing loss

Question 33

What may be the cause of vestibular neuronitis?

Answer 33

Viral

Question 34

Labyrinthitis is a prolonged vertigo lasting ____ with (no/some) associated tinnitus and hearing loss

Answer 34

Labyrinthitis is a prolonged vertigo lasting days with some associated tinnitus and hearing loss

Question 35

What may be the cause of Labyrinthitis?

Answer 35

Viral

Question 36

What is the treatment for Labyrinthitis/vestibular neuronitis?

Answer 36

Supportive management with the use of vestibular sedatives. Generally self-limiting

Question 37

If there is prolonged or atypical infection in a labyrinthitis/vestibular neuronitis further investigation is warranted. What other treatments may be helpful?

Answer 37

Rehabilitation exercise

Question 38

___% of the population are affected by migraine. of these ____% suffer spontaneous bouts of vertigo and ataxia.

Answer 38

15-20% | 25%

Question 39

Photophobia is the most common auditory symptoms of migraine - true or false? Define phonophobia

Answer 39

True | it is the fear of loud noises or sometimes the fear of voices/ones own voice.

Question 40

Fluctuating Hearing loss and acute permanent loss are common/uncommon in those affected with migraine

Answer 40

Uncommon - occur in a small percentage of migraine sufferers.

Question 41

Motion sensitivity with motion sickness occurs in ____% of migraine sufferers.

Answer 41

66% (2/3rds)

Question 42

Episodes of vertigo occur in ___% of migraine sufferers

Answer 42

25%.