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Vertigo And Tinnitus Flashcards

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1
Q

Symptom of vertigo, lightheadedness/faintness, imbalance, combination

A

Dizziness

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2
Q

Cardinal symptom of vestibular disease, sensation of movement where there is no movement, asymmetry of vestibular inputs

A

Vertigo

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3
Q

Vertigo can be either ____ or ____

A

Physiologic (sustained head rotation), pathologic (vestibular dysfunction)

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4
Q

Feeling faint, about to lose consciousness Presyncopal sensation, typically related to brain hypoperfusion

A

Lightheadedness/faintness

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5
Q

Feeling off-balance

A

Disequilibrium/imbalance

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6
Q

What are causes of disequilibrium/imbalance

A

CNS lesion or vestibular dysfunction

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7
Q

Is this vertigo, lightheadedness, or disequilibrium: i felt like I was about to pass out

A

Lightheadedness

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8
Q

Is this vertigo, lightheadedness, or disequilibrium: the room was spinning around me

A

Vertigo

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9
Q

Is this vertigo, lightheadedness, or disequilibrium: i felt unsteady while I was walking?

A

Disequilibrium

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10
Q

Is this vertigo, lightheadedness, or disequilibrium: my head felt like it was whirling around like a top

A

Vertigo

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11
Q

Is this vertigo, disequilibrium, or lightheadedness: i thought i might just tip over at any minute

A

Disequilibrium

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12
Q

Is this vertigo, lightheadedness, or disequilibrium: everything started to go black- i had to lay down

A

Lightheadedness

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13
Q

What are the differences between peripheral and central vertigo?

A

Peripheral is sudden onset with associated tinnitus/hearing loss, may have nausea/vomiting, may have horizontal nystagmus

Central is gradual onset usually without hearing symptoms; if tinnitus, will likely be bilateral; may have vertical nystagmus

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14
Q

What do you need to differentiate with dizziness?

A

Type of dizziness? Danger? Is it vestibular? Peripheral or central?

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15
Q

Talking about history of symptom and duration

A
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16
Q

If movement/position change triggers the symptom, what would you think?

A

BPPV, orthostasis

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17
Q

If a patient presents with aural fullness, what should you suspect?

A

Meniere’s

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18
Q

If a patient presents with double vision, ataxia, and/or numbness, what should you think?

A

Brain stem or cerebellar lesion

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19
Q

What neurologic assessments can you do on hearing loss/tinnitus?

A

Gait
Romberg
Cranial nerves: EOM- pursuit/saccades: abnormal can indicate cerebellar pathology
Nystagmus: involuntary back and forth movement of the eyes
Head impulse test: assess vestíbulo-ocular reflex

Hearing evaluation: whisper test, Weber, Rinne

Dix-Hallpike maneuver

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20
Q

When would you perform audiometery and what does it measure?

A

If history or exam indicate comorbid hearing impairment

Hearing acuity, tones, pitches, and frequencies

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21
Q

Cold and/or warm water or air is irrigated into the ear. Warm water mimics a head turn to the ipsilateral side. Cold water mimics a head turn to the contralateral side

A

Caloric testing

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22
Q

Normally, adding cold and/or warm water or air to ear with cause what?

A

Warm- nystagmus towards ipsilateral ear
Cold-nystagmus towards contralateral ear

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23
Q

What is an abnormal finding on caloric testing?

A

Lack of nystagmus indicates damage to vestibular system, vestibular nerve, or brain

Alcohol, antihistamines, sedatives within 24 hours can cause false abnormal

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24
Q

Go back to contraindications for caloric testing

A
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25
When would you perform brain imaging? What is the procedure of choice/backup?
If suspecting central etiology or acoustic neuroma MRI/MRA, CT if not available
26
What is electronystagmography?
Electrodes placed and eye movements traced to record presence of nystagmus
27
VNG
28
What test assesses saccule?
Cervical VEMP, should trigger reflex on ipsilateral SCM
29
What test assesses utricle?
Ocular VEMP, records EOM potentials during head vibration
30
What is the etiology of BPPV?
Canalithiasis (calcium deposits in semicircular canal) Usually free-floating otoconia that have dislodged from utricle, most commonly in posterior semicircular canal (first place that is hit)
31
What are risk factors for BPPV?
Age >50 Whiplash or trauma to head/ear Chronic otitis media Female gender (increased hormonal fluctuations in menopause)
32
What is the presentation of BPPV?
Acute, brief episodes of vertigo (<1 minute) that occur after changes in head position ie rolling over in bed without other neurologic deficits
33
What evaluations should be done when suspecting BPPV?
Dix-Hallpike maneuver- will elicit vertigo and nystagmus Posterior canal BPPV will cause upward, rotary Anterior canal BPPV will cause downward, rotary Horizontal canal will cause nystagmus toward floor
34
How is BPPV treated?
Repositioning otoliths: Epley maneuver is most effective treatment Reconditioning exercises: Brandt-Daroff Maneuver- exposure therapy or Serumont Maneuver Recurrence is common
35
What is the etiology of vestibular Neuronitis/labyrinth it is
Thought to be viral or post viral inflammatory response Vestibular neuronitis: only vestibular division of CN VIII Labyrinthitis: vestibular and cochlear division of CN VIII Asymmetry of labyrinth inputs, simulating continuous head rotation
36
What is the presentation of vestibular neuronitis/labyrinthitis?
Sudden onset persistent vertigo, event when not moving GI: nausea and vomiting Gait instability toward affected side Nystagmus beating away from affected side Labyrinthitis will also have unilateral hearing impairment and/or tinnitus Evaluate for central infarct
37
How should vestibular inflammation be evaluated?
Clinical- no specific diagnostic studies May need brain MRI/CT to rule out central etiology
38
How is vestibular neuronitis/labyrinthitis treated?
Corticosteroids: methyl prednisone or prednisone 10 day to 3 week tapering dose Antimicrobials: not consistently effective Symptomatic: vertigo suppression with meclizine (antihistamine), benzodiazepines (Valium, Ativan), avoid after first few days Nausea and vomiting: promethazine or ondansetron Vestibular rehabilitation therapy: may require for months-years
39
What is the etiology of Ménière’s disease?
Excess fluid in the inner ear with unclear etiology: related to syphilis and head trauma, genetic component, blocked endo lymphatic ducts, most often seen in women 20-40 y/o
40
What is the presentation of Ménière’s disease?
Classic triad: episodic vertigo: 20 mins-several hours Unilateral hearing impairment: sensorineural, usually low-frequency Tinnitus-usually low-tone and blowing Unilateral aural fullness, +/- pain Episodic N/V with vertigo episodes Hearing usually improves between attacks Usually unilateral, can be bilateral Usually chronic, progressive, remitting/relapsing course
41
How is Ménière’s disease evaluated?
Clinical: 2 spontaneous episodes of vertigo lasting at least 20 minutes each Unilateral sensorineural hearing loss Tinnitus and/or aural fullness Audiometry- will show hearing loss during acute attacks Caloric testing- reduced or absent nystagmus on affected side Brain imaging- if central lesion suspected
42
What is treatment of Ménière’s disease?
Early ENT referral Lifestyle modifications: low salt diet, restrict alcohol and caffeine + more (was looking at sub menu)
43
What is the etiology of peri lymphatic fistula?
Fistula: leakage of peri lymphatic fluid from inner ear into middle ear Dehiscence: abnormal thinning or absence of bone above the superior semicircular canal
44
What are risk factors for peri lymphatic fistula?
Physical injury: blunt head trauma, hand slap to ear Barotrauma: scuba diving, flight Vigorous valsalva maneuvers: weight lifting
45
What is the presentation of peri lymphatic fistula?
Sensorineural hearing loss, recurrent brief episodes of vertigo specific triggers for symptoms: sneezing and coughing straining- heavy lifting, constipation, valsalva loud noises: dizziness or vertigo induced by sounds
46
What is the evaluation/diagnosis of peril y photic fistula?
Often based on clinical presentation CT or MRI of head: perilymphatic fistula will show fluid accumulation in round window recess Semicircular canal dehiscence thin or absent bone above canal
47
Treatment for perilymphatic fistula
48
Etiology/risk factors for barotrauma
49
What is the presentation of barotrauma?
Ear pressure —> pain Vertigo Hearing loss Tinnitus
50
What is evaluation/diagnosis of barotrauma?
History of recent flight or diving, congruent s/s ENT exam: may see hemorrhage behind TM or TM perforation
51
How is barotrauma treated?
Symptomatic- analgesics Refractory- surgery: myringotomy, tympanoplasty
52
What is patient education for barotrauma?
Decongestants several hours or 1 hour before anticipated event Diving- change depths slowly and in stages Swallow, yawn, auto inflate frequently, chewing gum or pacifier in infants
53
What is tinnitus?
Sensation of sound in the absence of an exogenous sound source Can be buzzing, ringing, roaring, hissing, clicking Pulsatile or non-Pulsatile Continuous or intermittent And may accompany any form of hearing loss
54
What is the epidemiology of tinnitus
55
What are the most common causes of Pulsatile tinnitus (occurs with patients heart beat)?
Vascular Neuromuscular Eustachian tube: patulous Eustachian tube
56
what are the common causes of non Pulsatile tinnitus?
Sensorineural hearing loss ….
57
What is a paraganglioma, which can cause tinnitus?
Benign vascular Neuro endocrine tumor of middle ear that arises from paraganglia of middle ear
58
What are presentations of tinnitus due to paraganglioma?
Reddish or bluish madd, may see bulging TM on exam, Pulsatile tinnitus, conductive hearing loss, vertigo
59
What is treatment of paraganglioma?
Surgery
60
What is a patulous Eustachian tube?
Tube stays open inappropriately MC after significant weight loss causing a roaring tinnitus that often accompanies breathing and autophony (hearing one’s own voice), symptoms improve when lowering head below heart
61
What is treatment of patulous Eustachian tube?
Application of mucosal irritants such as Premarin drops, causes mucosal swelling Surgery
62
What is the presentation of sensorineural hearing loss causing tinnitus?
63
What is treatment of sensorineural hearing loss?
Hearing aid
64
How is tinnitus diagnosed?
Exam-ENT, cardiovascular, cranial nerves Audiometry- evaluate for associated hearing loss MRI/MRA- to rule out mass, vascular abnormality ENT referral
65
How is tinnitus treated?
Treatment of underlying disorder—> Hearing loss- hearing aid Removal of masses Control of HTN Review medications Exacerbating factors: depression, insomnia-white noise
66
What is treatment of tinnitus?
Behavior therapy: tinnitus retraining therapy- noise inducing generators PLUS counseling to habituate patient to tinnitus Stress reduction programs, CBT Meds- BZDs, intra-TM steroid shots, misoprostol Masking devices Transcranial magnetic stimulation

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