The Dizzy Patient

Question 1

What is the difference between dizziness and vertigo?

Answer 1

Non-specific term which may cover vertigo, pre-syncope etc but vertigo is a sensation of movement (usually spinning- either them or the room)

Question 2

Is meniere’s disease common?

Answer 2

no

Question 3

Can vertigo be vertical?

Answer 3

yes

Question 4

What is vertigo ussually associated with?

Answer 4

Ear pathology

Question 5

What is the function of semi-circular canal?

Answer 5

Sensation of rotational movements

Question 6

What affects balance?

Answer 6

Ears (vestibulocochlear nerve, semi-circular canals etc) , eyesight, arthritis (joint sensation), heart problems (e.g. reduced perfusion of brain and low blood pressure), neurological problems (stress, hyperventilation, migraines)

Question 7

Explain the vestibulo-ocular reflex

Answer 7

-

Question 8

What can go wrong with the vestibulo-ocular reflex?

Answer 8

-

Question 9

What is nystagmus?

Answer 9

-

Question 10

What is the usual pathology in nystagmus?

Answer 10

Left to right

Question 11

When will nystagmus be observed?

Answer 11

Vestibular pathologies

Question 12

Will non-vestibular pathologies cause nystagmus?

Answer 12

No

Question 13

What is the most common cause of presentation to primary care in people over 74?

Answer 13

Dizziness

Question 14

What do you want to ask about when present with dizziness?

Answer 14

-

Question 15

What examinations would you do on a dizzy patient?

Answer 15

-

Question 16

How will patients with depression present with dizziness?

Answer 16

non-specific

Question 17

What is BPPV?

Answer 17

Benign positional paroxysmal vertigo -
Otolith material from the utricle (calcium carbonate crystals that attach to the hair follicles) have been displaced to the semi-circular canals (most commonly the posterior)

Question 18

Is BPPV common?

Answer 18

Yes

Question 19

What is a symptom of BPPV?

Answer 19

Brief vertigo on turning head in bed, leaning backwards or fowards.

Question 20

What are the causes of BPPV?

Answer 20

head trauma, ear surgery or idiopathic

Question 21

What can BPPV be confused with?

Answer 21

vertebrobasilar insufficiency

Question 22

What is the difference between BPPV and vertebrobasilar insufficiency?

Answer 22

VBI will have other symptoms of impaired circulation in the posterior brain ass with the vertigo such as visual disturbance, weakness and numbness (as is a neurological problem)

Question 23

Is tinnitus or hearing loss associated with BPPV?

Answer 23

no

Question 24

What test can you carry out to confirm BPPV?

Explain

Answer 24

Hallpike’s test - the patient is seated so their head will be off end of couch when lie back, turn head 45 degrees to one side, warn patient not to close eyes if dizzy, lie back quickly and observe for nystagmus.

Question 25

Can this test be repeated?

Answer 25

It loses effect quickly so may not get another positive reading

Question 26

If no movement seen after 30seconds of the Hallpike's test should you move on?

Answer 26

No - as there is the possibility of a positive result even up to a minute after leaning back.

Question 27

When would the hallpike test be less effective?

Answer 27

On repetition and if the crystals are in the lateral or superior SCC.

Question 28

What is the Epley Manoeuvre?

Answer 28

this is a series of movements of the head that attempt to move the otolith crystals back to the utricle.

Question 29

What is the Brandt-Daroff exercise?

Answer 29

This is an easy exercised for patients to do at home that is almost as effective as the epley manoeuvre.

Question 30

What are the symptoms of vestibular neuronitis?

Answer 30

prolonged vertigo (days) no associated tinnitus or hearing loss May have viral symptoms

Question 31

What is the most common cause of vestibular neuronitis?

Answer 31

Viral infection

Question 32

What are the symptoms of labyrinthitis?

Answer 32

``` Prolonged vertigo (days) with associated tinnutis and/or hearing loss. May have viral symptoms too ```

Question 33

What is the most likely cause of labyrinthitis?

Answer 33

Viral infection

Question 34

What is the treatment for vestibular neuronitis/labyrinthitis?

Answer 34

Supportive management as it is usually self-limiting. Vestibular sedatives e.g. clyclizine can reduce nausea. If prolonged then may required further investigations and if damage is done then rehab can be considered to re-train the brain to compensate and improve balance

Question 35

What is the cause of Meniere's disease?

Answer 35

Unknown cause

Question 36

What are the symptoms of Meniere's disease?

Answer 36

Recurrent and spontaneous episodes of rotational vertigo with at least two episodes lasting longer than 20mins (often hours) Tinnitus Aural fullness Sensorineural hearing loss

Question 37

How is Meniere's diagnosed?

Answer 37

Is usually a case of diagnosis by exclusion

Question 38

What should always be excluded when considering the diagnosis of Meniere's?

Answer 38

A vestibular schwannoma

Question 39

How is Meniere's treated?

Answer 39

Supportive treatment during episodes, tinnitus therapy, hearing aids, and prevention with salt restriction and avoidance of caffeine, alcohol and stress

Question 40

What are more advanced management techniques for Meniere's?

Answer 40

- Grommet insertion - Intratympanic gentamicin - Surgery

Question 41

How does grommet insertion help Meniere's?

Answer 41

acts as a form of micropressure therapy to reduce pressure within the ear.

Question 42

What is a side effect of gentamicin injections intratympanically?

Answer 42

does not stop hearing loss

Question 43

What percentage of migraine sufferers experience attacks of vertigo and ataxia?

Answer 43

25%

Question 44

What is a common side effect of migrain?

Answer 44

Phonophobia - fear of loud noises | Motion sensitivity

Question 45

What are the requirements for a diagnosis of definite migrainous vertigo?

Answer 45

Migrainous symptoms during vertigo, migrai-specific precipitant of vertigo and response to anti-migrainous drugs (1 of these on at least 2 accounts) and other causes ruled out.

Question 46

What are the requirements for a diagnosis of probable migrainous vertigo?

Answer 46

``` At least one of: migrainous headache photophobia phonophobia visual or other aura disturbances And other causes ruled out ```