Vertigo

Question 1

What causes benign paroxysmal positional vertigo (BPPV)?

Answer 1

BPPV is caused by otoliths

(1) = calcium carbonate crystals
(2) dislodging from the utricle - inner ear
(3) entering the semicircular canals

(4) disrupting normal endolymph flow
= triggering vertigo

Question 2

What is the most common trigger of BPPV symptoms?

Answer 2

Looking up

Question 3

What are some common causes of BPPV?

Answer 3

Head trauma
Ear surgery
Idiopathic (most common)

Question 4

How long do typical BPPV episodes last?

Answer 4

Seconds to minutes

Question 5

Which activities commonly provoke BPPV symptoms?

Answer 5

1. Turning in bed
   = especially to one side
2. Lying down
3. Getting out of bed
4. Looking up
5. Bending forward or standing up quickly

Question 6

What are the key associated symptoms of BPPV?

Answer 6

Nausea and vomiting
Nystagmus (rotatory, geotropic)
= jerking movement of the eyes

Question 7

What is the diagnostic test for BPPV and what does a positive result show?

Answer 7

The Dix-Hallpike manoeuvre
= A positive test produces vertigo and rotatory geotropic nystagmus

Question 8

What is the first-line treatment for BPPV?

Answer 8

Repositioning manoeuvres such as the Epley manoeuvre

Question 9

Name other treatment options for BPPV besides the Epley manoeuvre

Answer 9

1. Semont manoeuvre
2. Brandt-Daroff exercises

Question 10

A 78-year-old woman was brought in by ambulance following a fall at home. She describes recently feeling unsteady on her feet and dizzy with the room spinning when tying her shoelaces. She has hypertension, type 2 diabetes, knee osteoarthritis and COPD. On examination, her gait and balance were normal, with no focal neurology

What is likely to diagnose the underlying cause of her fall and why?

Answer 10

Dix-Hallpike manoeuvre
= This woman describes vertigo and dizziness on sudden head movements characteristic of benign paroxysmal positional vertigo, for which Dix-Hallpike is diagnostic

Question 11

What is the difference between vestibular neuritis and labyrinthitis?

Answer 11

1. Vestibular neuritis is inflammation of the vestibular nerve (CN VIII)
2. Labyrinthitis is inflammation of the entire labyrinth, affecting both balance and hearing

Question 12

What is the typical cause of both vestibular neuritis and labyrinthitis?

Answer 12

viral infection

Question 13

How does the clinical presentation of vestibular neuritis and labyrinthitis typically begin?

Answer 13

1. A sudden
2. Severe vertigo attack lasting hours
3. often with nausea and vomiting

Question 14

How can you distinguish labyrinthitis from vestibular neuritis?

Answer 14

Labyrinthitis presents with hearing loss and/or tinnitus, which are not seen in vestibular neuritis

Question 15

How long can vertigo last in vestibular neuritis or labyrinthitis?

Answer 15

several days, especially in vestibular neuritis

Question 16

What is the first-line treatment for vestibular neuritis and labyrinthitis?

Answer 16

Prochlorperazine
= a vestibular sedative, is commonly used for symptom relief

Question 17

What is Meniere’s disease?

Answer 17

An idiopathic disorder causing recurrent episodes of vertigo, sensorineural hearing loss, and tinnitus

typically due to excess endolymph in the membranous labyrinth

= There’s too much inner ear fluid (called endolymph) building up inside the delicate tubes and chambers of the inner ear (the membranous labyrinth).

This fluid helps with balance and hearing, but when there’s too much of it, it puts pressure on the inner ear structures, leading to the symptoms of Meniere’s disease — like vertigo, hearing loss, and tinnitus

Question 18

What is the proposed pathophysiology of Meniere’s disease?

Answer 18

An increase in endolymphatic pressure, possibly due to dysfunctional sodium channels, leads to inner ear disturbance and symptoms

Question 19

What is the classic triad of symptoms in Meniere’s disease?

Answer 19

1. Episodic vertigo
   = Lasting >20 mins to hours)
2. Sensorineural hearing loss
3. Tinnitus, often with a sensation of ear fullness

Question 20

How long do episodes of vertigo typically last in Meniere’s disease?

Answer 20

20 minutes to several hours, and are spontaneous and recurrent

Question 21

What symptom commonly occurs around the time of a dizzy spell?

Answer 21

A change in hearing (worsening or muffling) or tinnitus

Question 22

What type of hearing loss is associated with Meniere’s disease?

Answer 22

Low-frequency sensorineural hearing loss, especially early in the disease

Question 23

What is the first-line treatment during acute vertigo attacks in Meniere’s disease?

Answer 23

Prochlorperazine for symptom relief

Question 24

What is used to help prevent attacks in patients with Meniere’s disease?

Answer 24

Betahistine
= histamine analogue is commonly used

Question 25

What lifestyle modifications can help manage Meniere’s disease?

Answer 25

1. Reduce salt intake 2. Avoid caffeine and chocolate 3. Manage stress

Question 26

What is the name of the therapeutic manoeuvre for benign paroxysmal positional vertigo?

Answer 26

Epley manoeuvre

Question 27

A 45-year-old male presents to the ENT clinic with episodic vertigo, hearing loss, tinnitus, and ear fullness. The symptoms last for hours and then resolve spontaneously. The GP prescribed betahistine with little effect. On physical examination, there is hearing loss in the affected ear, and the Weber test lateralises to the unaffected ear What is the most appropriate initial step in the management of this patient?

Answer 27

The initial management of Meniere's disease involves a low-salt diet and diuretics to reduce the volume of endolymphatic fluid

Question 28

A 60-year-old woman presents to the Emergency Department with sudden onset vertigo and nausea that began this morning. It is associated with right-sided tinnitus, ear fullness and hearing loss. She has had similar episodes in the past which last about 1-2 hours in duration On examination, she has no focal neurological deficits What is the next best management option?

Answer 28

Prochlorperazine

Question 29

A 39-year-old male presents to the GP complaining of 'dizziness spells'. These episodes happen randomly and do not last longer than an hour, during which he often hears a 'ringing' sound in one ear. He describes his hearing as being worse during these episodes and that his ear feels 'full' Given the most likely diagnosis, what medication can be given to prevent these episodes?

Answer 29

Betahistine = Prochlorperazine, a dopamine antagonist, is used to manage acute vertigo symptoms or nausea but does not prevent episodes of Ménière's disease

Question 30

'false sensation that the body or environment is moving' This statement describes what?

Answer 30

Vertigo

Question 31

A 59-year-old man presents with recurrent attacks of vertigo and dizziness. These attacks are often precipitated by a change in head position and typically last around half a minute. Examination of the cranial nerves and ears is unremarkable. His blood pressure is 120/78 mmHg sitting and 116/76 mmHg standing. Given the likely diagnosis of benign paroxysmal positional vertigo, what is the most appropriate next step to help confirm the diagnosis?

Answer 31

Dix-Hallpike manoeuvre rotatory

Question 32

A 27-year-old female presented to her GP after one prolonged episode of dizziness. She felt that over 2 hours she was losing her balance easily as well as vomited 3 times. She has no other neurological symptoms and no past medical history. On examination, the only notable finding was a horizontal nystagmus on the left side. What is the most likely diagnosis and why?

Answer 32

Vestibular neuronitis = Unaffected hearing distinguishes vestibular neuronitis from labyrinthitis

Question 33

How is the Dix-Hallpike manoeuvre done?

Answer 33

the affected ear is downwardly turned

Question 34

A 57-year-old woman presents with a 3-day history of intermittent vertigo. This is triggered by moving her head and is accompanied by mild nausea. Each attack lasts for 10-20 seconds. After a full examination, you diagnose benign paroxysmal positional vertigo. The patient declines the Epley manoeuvre, as her neck is feeling a little sore following her gym workout this morning. You suggest some exercises to do at home to ease her symptoms instead. What is the name of these exercises?

Answer 34

Brandt-Daroff

Question 35

What medication is most useful for helping to prevent attacks of meniere's disease?

Answer 35

Betahistine

Question 36

A 42-year-old patient presents to their GP practice after experiencing episodes of dizziness recently. These symptoms occur randomly throughout the day and last around 30 minutes. When the symptoms occur the patient says they have to lie down as it feels like the room is spinning. The patient also describes experiencing a strange ringing sound in their ear when the attacks occur as well as a reduced sense of hearing. What type of hearing loss would this patient likely experience?

Answer 36

Unilateral sensorineural hearing loss

Question 37

A 30-year-old man presents to his GP surgery with symptoms of the room 'spinning', made worse by rolling over in bed, accompanied by a runny nose and sore throat. His GP advises conservative management with plenty of fluids and resting as required. The man contacts his GP six weeks later, concerned that the vertigo symptoms are better but have not fully resolved, despite his common cold symptoms long having disappeared. What is the most appropriate management option for the patient?

Answer 37

Vestibular rehabilitation exercises are the preferred treatment for chronic symptoms in vestibular neuronitis

Question 38

A 56-year-old woman has been suffering from ongoing symptoms of vertigo and nausea. The vertigo is present at all times and is interfering with her work. She first experienced dizziness and nausea three months ago after a short viral illness. She has no hearing loss. The HINTS test is negative. The otoscopy is unremarkable. Given the most likely diagnosis, what is the most appropriate long-term management?

Answer 38

Vestibular rehabilitation

Question 39

What exam can be used to distinguish vestibular neuronitis from posterior circulation stroke

Answer 39

HiNTs exam

Question 40

The presence of persistent horizontal nystagmus for a prolonged period is more characteristic of what?

Answer 40

vestibular neuronitis