vertigo

Question 1

what does the external ear include?

Answer 1

pinna, external auditory meatus, tympanic membrane, wax glands and hair follicles

Question 2

how much of the external ear is cartilaginous and bony

Answer 2

1/3 outer cartilaginous and 2/3 bony

Question 3

the inner ear resides where

Answer 3

pertrous part of the temporal bone

Question 4

what is the oval window

Answer 4

The stapes articulates with the oval window, causing movement of perilymph, and
a pressure change, compensated by the round window.

Question 5

how many semicircular canals are there adn their names

Answer 5

3
anterior semicircular canal
lateral semicircular canal
posterior semicircular canal

Question 6

what is perilymph

Answer 6

fluid that resembles CSF and the membranous labyrinth is suspended in perilymph

Question 7

the role of cochlea

Answer 7

responsible for the perception of hearing

Question 8

what area detects low and high frequency sounds

Answer 8

low - apex of the cochlea

high - base of the cochlea

Question 9

division of the vestibular system

Answer 9

semicircular canals
utricle
saccule

Question 10

which parts of the vestibule system detect movement

Answer 10

Utricle – Hair cells point Up – Detect linear/horizontal movement

Saccule – Hair cells stick out to the Side – Detect vertical movement

semicircular canals rotary movement

Question 11

role of the tectorial membrane

Answer 11

movement of that causes movement of hair cells and subsequent depolarisation of neuronal fibres allowing perception of sound

Question 12

Balance requires what elements

Answer 12

input from the vestibular system to be integrated centrally with proprioceptive and visual input.

Question 13

what is vestibulo ocular reflex

Answer 13

coordinates eye movement with head movement, in order to provide clear vision during motion and maintain balance.
impaired - then when you move your head left then the eye moves right but you seen nystagmus

Question 14

tests to differentiate central and peripheral vertigo

Answer 14

Head
Impulse - saccades peripheral cause of vertigo
Nystagmus
Test
Skew - central

Question 15

causes of vestibulo ocular reflex issues

Answer 15

trauma

viral infections especially in elderly

Question 16

importance of vestibulo ocular reflex

Answer 16

sports related activites
driving
walking

Question 17

symptoms of vestibulo ocular reflex impairment

Answer 17

ovement-related dizziness, blurry vision, difficulty maintaining balance with head movements, and even nausea

Question 18

what is the fovea

Answer 18

macula part of the retina clearest image

Question 19

what parts of the body maintain balance

Answer 19

vestibular system
eyes
proprioception
sensation

Question 20

causes of vestibular disorders

Answer 20

central
stroke
neoplasms
drugs
brain tumor
MS - demyelination
migraine
cerebrovascular disease

peripheral
semicircular canals
utricle
saccule
BPPV
meniere's
vestibular neuronitis

Question 21

define vertigo

Answer 21

Hallucination of rotatory movement
◦ “Room spinning”
Cardinal symptom of disease of the vestibular
system

Question 22

define BPPV

Answer 22

Acute rotatory vertigo lasting seconds

triggered by certain head movements. Distressing for the patient and at times disabling

Question 23

cause of BPPV

Answer 23

The underlying cause are otoliths (crystals) in the semicircular canals (most commonly posterior) causing abnormal stimulation of the hair cells giving a hallucination of movement i.e. vertigo.

Question 24

How is BPPV diagnosed

Answer 24

Diagnosis
◦ Dix Hall-pike manoeuvre
o Diagnose Posterior Semi-circular canal if rotatory (left ear affected then itll be clockwise and right ear affected then itll be anti-clockwise), upbeating nystagmus is noted

Question 25

Treatment for BPPV

Answer 25

Treatment ◦ Epley manoeuvre ◦ Brandt-Darrof exercises

Question 26

define positional nystagmus

Answer 26

when nystagmus is observed when the head position changes

Question 27

Most common type of BPPV

Answer 27

Posterior canal BPPV

Question 28

Risk factors of BPPV

Answer 28

``` ear surgery previous ear pathologies head trauma asso with sleep position prolonged recumbent positions ```

Question 29

complications of the patient

Answer 29

- Falls – old people - Difficulty performing daily activities - Adverse effects on quality of life - Increased likelihood of depression

Question 30

presentation of BPPV patient

Answer 30

- Ask if it is triggered by specific movements and positions of the head relative to gravity – lying down, looking up, bending over, turning over in bed - May modify movements to limit symptoms - Transient episodes with head movements - Nausea and vomiting may occur - Light headedness and imbalance - SURGICAL HISTORY - PAST EAR ISSUES HEARING IS NOT AFFECTED TINNITIS IS NOT A FEATURE

Question 31

exceptions for doing Dix Hallpike manoeuvre

Answer 31

If the patient has back, neck or cardiovascular problem such as carotid sinus syncope then BE CAUTION DOING DIX-HALLPIKE MANOUEVRE.

Question 32

what to advice to patient with BPPV

Answer 32

- Most recover over several weeks without treatment however symptoms may last longer or even recur - Simple repositioning manoeuvre can help alleviate the symptoms - Get out of bed slowly and to avoid tasks looking upwards - The Driver and Vehicle Licensing Agency (DVLA) states that people with 'liability to sudden and unprovoked or unprecipitated episodes of disabling dizziness' should stop driving and inform the DVLA. - HOWEVER BPPV IS NOT SPONTANEOUS OR UNPROVOKED - Workplace o Have to inform if they use heavy machinery or ladders or drive. A vehicle - Falls in the home – how to reduce it

Question 33

Management of BPPV

Answer 33

- Watchful waiting – see if it resolves without treatment - If patient wants treatment o EPLEY MANOEUVRE  BE CAUTION IF PATIENT HAS NECK OR BACK PROBLEMS, CARDIAC DISEASE, SUSPECTED VERTEBROBASILAR DISEASE, CAROTID STENOSIS OR MORBID OBESITY  Symptoms may improve shortly after treatment but full recovery may require a couple of weeks  If they do not settle after 1 week then repeat if you are confident it is BPPV  Semont manoeuvre is less common  Brandt-Daroff exercises – do at home – GOOD IF EPLEY CANNOT BE PERFOMED IMMEDIATELY OR IS INAPPROPRIATE  Return after 4 weeks if symptoms have not been resolved

Question 34

When to refer a BPPV patient

Answer 34

* Admit the person to hospital if they have severe nausea and vomiting and are unable to tolerate oral fluids. * (for example the Epley manoeuvre) is not available in primary care. * Physical limitations affect the safety or practicality * A canalith repositioning procedure (for example the Epley manoeuvre) has been performed and repeated, and symptoms are still present. * Symptoms or signs are atypical. * Symptoms and signs have not resolved in 4 weeks. * There have been three or more periods during which the person has experienced episodes of vertigo

Question 35

what is vestibular neuritis

Answer 35

acute, isolated, spontaneous, and prolonged vertigo of peripheral origin due to inflammation of the vestibular nerve and may occur after a viral infection HEARING IS NOT AFFECTED

Question 36

Complications of vestibular neuritis

Answer 36

BPPV Phobic postural vertigo, which presents with persistent dizziness and feelings of unsteadiness and fear of falling, despite lack of actual falls Adverse effects on quality of life and independence (for example daily functioning and employment). Increased risk of falls.

Question 37

symptoms of vestibular neuritis

Answer 37

rotational vertigo - spontaneously, sudden, develop on waking, or may worsen over the course of the day. It is exacerbated by changes of head position, but is initially constant even when the head is still. Acute symptoms usually settle in a few days and gradual recovery occurs over 2–6 weeks. nausea, malaise, pallor and sweating Balance may be affected, increasing the risk of falls. People with vestibular neuritis may be unsteady and veer to the affected side. ask about recent viral illness

Question 38

signs of vestibular neuronitis

Answer 38

nystagmus - fine horizontal - mixed horizontal-torsional, beats in the same direction head impulse teat may be positive

Question 39

differentials of vertigo

Answer 39

BPPV menieres labyrinthitis vestibular neuronitis Acoustic neuroma vertebrobasillar ischaemia central causes - migraine stroke cerebellar tumour and MS posterior circulation stroke trauma multiple sclerosis ototoxicity e.g. gentamicin

Question 40

what advise to give a pt with vestbular neuritis

Answer 40

symptoms will settle over several weeks alcohol, tiredness or intercurrent illness may worsen this bed rest necessary do not drive if feeling dizzy or gonna get vertigo workplace - using laders, heavy machineryor driving is not good falls

Question 41

when to refer a patient with vestibular neuronitis

Answer 41

Symptoms are not typical of vestibular neuronitis (for example additional neurological symptoms). Symptoms persist without improvement for more than 1 week despite treatment (urgently refer). Symptoms persist for longer than 6 weeks — investigation to exclude other causes, or vestibular rehabilitation may be required.

Question 42

how to treat vertigo symptoms

Answer 42

To rapidly relieve severe nausea or vomiting associated with vertigo, consider giving buccal prochlorperazine, or an intramuscular injection of prochlorperazine or cyclizine. To alleviate less severe nausea, vomiting, and vertigo, consider prescribing a short oral course of prochlorperazine, or an antihistamine (cinnarizine, cyclizine, or promethazine teoclate). Advise the person to take medication regularly for up to 3 days

Question 43

side effects of quininue

Answer 43

tinnitus, sweating, low platelets and increased sweating ototoxic

Question 44

ototoxic medicines

Answer 44

gentamicin, quinine, furosemide, aspirin and some chemotherapy agents

Question 45

smaller causes of vertigo

Answer 45

posterior circulation stroke trauma multiple sclerosis ototoxicity e.g. gentamicin

Question 46

vertigo when extending neck

Answer 46

vertebrobasillar ischaemia

Question 47

risk factor for vertibrobasillar ischaemia

Answer 47

CVS disease therosclerosis in the vertebrobasilar distribution is exacerbated by changes in head position, causing ischaemia and resultant symptoms.

Question 48

viral labyrinthitis

Answer 48

``` Recent viral infection Sudden onset vertigo Nausea and vomiting Hearing may be affected tinnitus ```

Question 49

vertebrobasillar ischaemia

Answer 49

Elderly patient | Dizziness on extension of neck

Question 50

treatment for labyrinthitis

Answer 50

anithistamines upto 3 days

Question 51

how to differentiate between peripheral and central causes of vertigo

Answer 51

head impulse test positive in peripheral causes