Chronic Dizziness

Question 1

What is the key feature of vestibular neuritis in a chronic dizzy patient?

Answer 1

A single, disabling attack of vertigo lasting several days.

Question 2

How long does the vertigo in vestibular neuritis typically last?

Answer 2

A few days.

Question 3

What characterizes benign paroxysmal positional vertigo (BPPV)?

Answer 3

Multiple brief episodes of rotational vertigo, typically lasting seconds, triggered by position changes such as looking up or turning over in bed.

Question 4

How long do BPPV attacks usually last?

Answer 4

Only a few seconds.

Question 5

What are common triggers for BPPV episodes?

Answer 5

Looking up, lying down, or turning over in bed.

Question 6

Can BPPV recur or persist for years?

Answer 6

Yes, patients can have recurrent, undiagnosed, or untreated BPPV for decades.

Question 7

What are the typical features of migrainous vertigo?

Answer 7

Recurrent attacks of vertigo lasting minutes to a few days (usually hours), often associated with migrainous symptoms like headache, photophobia, and visual aura.

Question 8

Are there any abnormalities between attacks in migrainous vertigo?

Answer 8

No, there are no interictal (between attacks) abnormalities.

Question 9

What are the characteristic features of Ménière’s disease (endolymphatic hydrops)?

Answer 9

Attacks of auditory distortion, ear fullness, tinnitus, and vertigo.

Question 10

What is the long-term outcome of Ménière’s disease?

Answer 10

Progressive unilateral audiovestibular failure.

Question 11

Which vertigo cause presents with both hearing and balance symptoms?

Answer 11

Ménière’s disease

Question 12

Which vertigo cause is most likely if vertigo is brief and position-related?

Answer 12

Benign paroxysmal positional vertigo (BPPV).

Question 13

Which cause of vertigo presents as a single, prolonged episode without hearing loss

Answer 13

Vestibular neuritis.

Question 14

Which cause of vertigo is linked to migraine symptoms such as photophobia and aura?

Answer 14

Migrainous vertigo.

Question 15

What are the two systems that mediate vestibular control of eye movements and perception?

Answer 15

A brainstem system and a perceptual (presumably cortical) system.

Question 16

In acute vertigo, how are eye movements and perception related?

Answer 16

They are strongly coupled

Question 17

In chronic vertigo, how do eye movements correlate with symptoms?

Answer 17

Poorly correlated—eye movements and symptoms often don’t match.

Question 18

What psychological factors are often associated with long-term vestibular symptoms?

Answer 18

Anxiety and depression

Question 19

Why is it difficult to separate chronic vestibular migraine from anxiety and depression?

Answer 19

Because the conditions are often deeply intertwined.

Question 20

What secondary problems can develop from chronic vestibular dysfunction?

Answer 20

Neck muscle pain, stress, fatigue, and chronic anxiety.

Question 21

How does inactivity (from bed rest, fear, or anxiety) affect vestibular compensation?

Answer 21

It delays and impairs full compensation.

Question 22

Which tests are part of functional assessment in dizziness evaluation?

Answer 22

Romberg test, gait assessment, tandem gait, and heel-to-toe gait.

Question 23

What is the main distinction between chronic dizziness and true gait unsteadiness?

Answer 23

Chronic dizziness is a subjective sense of imbalance (felt “in the head”), while gait unsteadiness causes objective balance problems noticeable to others.

Question 24

How might a patient describe chronic dizziness?

Answer 24

As feeling “drunk” or light-headed, but others usually do not notice any imbalance.

Question 25

How might a patient with gait unsteadiness describe their symptoms?

Answer 25

They and others notice clear loss of balance or unsteady walking.

Question 26

How can falls help distinguish disequilibrium from chronic dizziness?

Answer 26

Patients with disequilibrium tend to fall, whereas those with chronic dizziness rarely do.

Question 27

Is MRI alone sufficient for diagnosing disequilibrium?

Answer 27

No. MRI is not a substitute for thorough neurological history and examination.

Question 28

What are classic symptoms of bilateral vestibular failure (BVF)?

Answer 28

Oscillopsia during walking and balance problems in the dark.

Question 29

What does “oscillopsia” mean?

Answer 29

The visual perception that the environment moves or bounces during head motion.

Question 30

What are common causes of bilateral vestibular failure?

Answer 30

Gentamicin toxicity, meningitis, and idiopathic causes.

Question 31

What feature helps distinguish gentamicin-induced from meningitic bilateral vestibular failure?

Answer 31

Gentamicin patients are typically not deaf, while meningitic patients usually are.

Question 32

What is the typical course of idiopathic bilateral vestibular failure?

Answer 32

Slowly progressive balance difficulty and oscillopsia during walking, running, or riding.

Question 33

Can bilateral vestibular failure develop after episodes of vertigo?

Answer 33

Yes, some patients have paroxysmal vertigo or oscillopsia that gradually progresses to chronic BVF.

Question 34

How is bilateral vestibular failure diagnosed clinically?

Answer 34

With bedside tests like the head thrust (head impulse) test.

Question 35

How do patients without vertigo or disequilibrium typically describe their symptoms?

Answer 35

As vague, chronic dizziness without true spinning or unsteady gait.

Question 36

Why should orthostatic hypotension be checked in elderly dizzy patients?

Answer 36

Because dizziness may be due to postural drops in blood pressure, especially with antihypertensive medications.

Question 37

What are good predictors of a cardiovascular cause for dizziness in older adults?

Answer 37

Syncope, light-headedness, and dizziness that improves with sitting or lying down.

Question 38

What are predictors of a cardiovascular cause for dizziness in older adults?

Answer 38

Syncope, light-headedness, dizziness relieved by sitting or lying down, pallor during symptoms, precipitation by prolonged standing, and coexisting vascular disease.

Question 39

Why may dizziness history be unreliable in the elderly?

Answer 39

Age-related cognitive decline can impair recall and even the perception of dizziness.

Question 40

What is an example of a lost sensory percept in the elderly?

Answer 40

Older patients may not perceive dizziness during caloric testing despite strong nystagmus.

Question 41

What common vestibular condition should always be checked for in elderly patients with vague disequilibrium?

Answer 41

Benign Paroxysmal Positional Vertigo (BPPV).

Question 42

What investigations are often done for patients with vague imbalance?

Answer 42

Blood tests (for anaemia, thyroid or endocrine disorders, diabetes, hypoglycaemia), brain imaging, and vestibular function tests.

Question 43

When investigations are negative and the history is non-specific, what diagnosis is often made?

Answer 43

Psychogenic dizziness.

Question 44

What are symptoms suggesting hyperventilation-related dizziness?

Answer 44

Perioral or distal paraesthesia, anxiety episodes, and a sense of light-headedness.

Question 45

Why is the active hyperventilation test generally unreliable?

Answer 45

Because hyperventilation causes dizziness in everyone

Question 46

When is the hyperventilation test considered useful?

Answer 46

When the patient recognises their typical dizziness symptoms during the test.

Question 47

What are the four main components of managing a chronic dizzy patient?

Answer 47

1. Treat the specific vestibular condition (e.g., BPPV, migraine). 2. Short-term nonspecific pharmacological treatment for vertigo and nausea. 3. Physical rehabilitation. 4. Information, counselling, and reassurance.

Question 48

What is the goal of treating the specific vestibular condition?

Answer 48

To address the underlying cause, such as repositioning manoeuvres for BPPV or migraine therapy for migrainous vertigo.

Question 49

Why is it important to treat migraine in patients with vertigo?

Answer 49

Migraine can both cause vertigo and be triggered by vertigo.

Question 50

Why should long-term use of vestibular suppressants be avoided?

Answer 50

They interfere with vestibular compensation — the brain needs to sense vertigo to trigger adaptation.

Question 51

What is the principle behind vestibular compensation?

Answer 51

The brain adapts to imbalance signals; to trigger this, it must experience some vertigo — “no vertigo, no compensation.”

Question 52

What systems interact to maintain balance?

Answer 52

The vestibular, visual, proprioceptive, cerebellar, cortical, brainstem, and spinal systems.

Question 53

What is vestibular compensation?

Answer 53

A plastic CNS process that restores functional symmetry after a unilateral vestibular lesion.

Question 54

What is sensory substitution in vestibular loss?

Answer 54

When patients use visual and proprioceptive cues to compensate for reduced vestibular input.

Question 55

What problem can arise from overreliance on visual input for balance?

Answer 55

Visual vertigo — dizziness triggered by visual motion (e.g., crowds, scrolling, moving patterns).

Question 56

What is visual vertigo and how is it treated?

Answer 56

Dizziness due to visual motion stimulation; treated with specialised vestibular rehab including optic flow techniques.

Question 57

What is visual vertigo?

Answer 57

A form of chronic dizziness worsened by visually busy environments (e.g. supermarkets, traffic, films, or moving patterns).

Question 58

What causes visual vertigo?

Answer 58

Excessive visual dependence following vestibular injury (sensory substitution gone too far). Migraine is a known predisposing factor.

Question 59

What is motorist disorientation syndrome?

Answer 59

A condition where patients feel that the car is tilting or veering while driving, often due to visual-vestibular mismatch.

Question 60

What vestibular structure may be involved in symptoms during curves while driving?

Answer 60

The otolith system, which senses linear acceleration — damaged otoliths can cause disorientation when turning or cornering.

Question 61

How is motorist disorientation syndrome treated?

Answer 61

• If vestibular origin: vestibular rehab with visuo-vestibular conflict and optic flow training. • If psychogenic origin: psychiatric therapy (CBT + medication). • If mixed: combination of both.

Question 62

What is phobic postural vertigo?

Answer 62

Episodes of subjective unsteadiness in patients with normal balance on examination, often linked to anxiety or obsessive traits.