1
Q
What are the 4 main types of dizziness (sensation, temporal characteristics, simulation tests, and differential diagnosis).
A
2
Q
What is important to determine when a patient complains of being dizzy?
A
- Describe it without the word “dizzy” or “lightheaded”
3
Q
What is important to determine for all episodes of dizziness on history?
A
- Time course of episodes – acute vs chronic vs recurrent
- Constant vs Episodic
- Duration of warning
- How long have the symptoms been experienced
- Are things getting worse
- Triggers/Relief
- Assess for medication complications
- Associated focal neurologic findings – CN findings
- Nausea/Vomiting and how severe (less with Central)
- Recent viral illness
- Prodromal leading to headache – Migraine?
4
Q
What are 4 ways to differentiate central from peripheral vertigo?
A
5
Q
What are 6 causes of central vertigo?
A
- Vascular ischemia: TIA
- Vascular ischemia: Stroke
- Vertiginous migraine
- Cerebellar degeneration
- Cerebellar tumour
- Multiple sclerosis
6
Q
What are 3 symptoms commonly associated with vertigo?
A
- Aural fullness
- Tinnitus
- Hearing loss
7
Q
Can vertigo be a symptom of a stroke?
A
- Yes – Inner Ear (in theory)
8
Q
What are 5 causes of peripheral vertigo, how long does a vertigo episode typically last for each, are there auditory symptoms, and how common are they?
A
Disorder
Duration
Auditory
Prevalence
BPPV
Seconds
No
Common
Meniere’s disease
Hours
Yes
Common
Labyrinthitis
Days
Yes
Common
Vestibular Neuronitis
Days
No
Common
Acoustic neuroma
Months
Yes
Uncommon
9
Q
What is a distinguishing feature between Neuronitis and Labyrinthitis
A
- Neuronitis = No Hearing Loss
- Labyrinthitis = Hearing Loss
10
Q
Which of Neuronitis and Labyrinthitis is a medical emergency?
A
- Labyrinthitis – meningitis precursor
11
Q
What are 4 symptoms seen in Meniere’s disease?
A
- Vertigo – disappears with time (minutes to hours)
- Hearing loss – persists and later can progress
- Tinnitus
- Aural fullness
12
Q
What is the diagnostic criteria for Meniere’s disease? (TN)
A
- Must have ALL 3
- Two spontaneous episodes of rotational vertigo 20 minutes
- Audiometric confirmation of SNHL (often low frequency)
- Tinnitus and/or aural fullness
13
Q
Differentiate between vestibular neuronitis and labyrinthitis. (TN)
A
- Vestibular neuronitis: acute onset of disabling vertigo
- May be due to viral infection (30% of cases have associated URTI symptoms)
- Labyrinthitis: acute infection of the inner ear resulting in vertigo and hearing loss
- May be serous (viral) or purulent (bacterial)
- Complication of acute and chronic OM, bacterial meningitis, cholesteatoma, and temporal bone fractures
14
Q
How do vestibular neuronitis and labyrinthitis present? (TN)
A
- Vestibular Neuronitis
- Acute phase
- Severe vertigo with nausea, vomiting, and imbalance lasting 1 to 5 days
- Irritate nystagmus (fast phase towards the offending ear)
- Patient tends to veer towards affected side
- Convalescent phase
- Imbalance and motion sickness lasting days to weeks
- Spontaneous nystagmus away from affected side
- Gradual vestibular adaptation requires weeks to months
- Acute phase
- Labyrinthitis
- Sudden onset of vertigo, nausea, vomiting, tinnitus, and unilateral hearing loss, with no associated fever or pain
- Meningitis is a serious complication
15
Q
What investigations should be considered in a patient with labyrinthitis (but not vestibular neuronitis)? (TN)
A
- CT head
- If meningitis suspected: lumbar puncture, blood cultures
16
Q
What is an acoustic neuroma? (TN)
A
- Vestibular schwannoma of the vestibular portion of CN VIII
17
Q
What is unilateral tinnitus or SNHL in the elderly until proven otherwise? (TN)
A
- Acoustic neuroma
18
Q
How is an acoustic neuroma diagnosed? (TN)
A
- MRI with gadolinium contrast (gold standard)
19
Q
What should be asked on history in a patient presenting with dizziness?
A
- Presyncope
- CP, SOB, palpitations
- With standing
- Disequilibrium
- Is the dizziness in your legs or in your head?
- Recent falls
- Prior neurologic disease (stroke, Parkinson’s, diabetes)
- Medications
- May not find any specific cause
- In elderly population is a multifactorial problem
- Lightheaded
- Floating sensation
- Psychiatric illness
- Mood, Anxiety
20
Q
What should be performed on the physical exam in a patient presenting with vertigo?
A
- Dix-Hallpike – suggestive of BPPV
- Geotropic (upbeat) nystagmus after 5 seconds, goes away within 1 min
- Rare is to have horizontal nystagmus
- Geotropic (upbeat) nystagmus after 5 seconds, goes away within 1 min
- Otoscopy
- Complete neurologic exam for focal signs
- HINTS Exam – if any of 3 is suggest central vertigo then need to rule out stroke
- To INFARCT – Impulse Normal; Fast-phase Alternating; Refixation on Cover Test
- Applicable to Acute Vestibular Syndromes – some require vertigo >24h
- Rapid onset (over seconds to hours) of continuous vertigo, nausea/vomiting, and gait unsteadiness in association with head-motion intolerance and nystagmus lasting days to weeks
- More specific for central vertigo than early diffusion weighted MRI
- Head Impulse – tests VOR by quickly turning head while patient fixated
- Central can fixate – normal exam
- Peripheral with saccade back
- Will often only be with impulse to one side (diagnostic to that side and have fast beat nystagmus to the opposite side)
- Nystagmus
- Central – can look exactly like peripheral
- Changing direction, gaze-evoked, or unidirectional
- Horizontal, vertical or torsional
- Jerk or Pendular (no fast phase, just back and forth – often congenital)
- Peripheral – eyes drift to the sick eye and fast saccade back
- Unidirectional, worse with looking towards fast phase
- i.e. worse looking left with left beating nystagmus, when looking right, it can appear to disappear
- Horizontal/torsional only
- Jerk only
- Suppression with fixation
- Unidirectional, worse with looking towards fast phase
- Central – can look exactly like peripheral
- Test of Skew – cover and uncover alternating eyes as fixated
- Central cause – Vertical misalignment of eyes when not fixated
- The test shows eyes that must realign with uncovering (like testing for strabismus)
21
Q
What should be performed on the physical exam in a patient presenting with presyncope?
A
- Orthostatic BP and HR
- Primary – multiple system atrophy, pure autonomic failure, Parkinson’s
- Secondary – volume depletion, medications, alcohol, diabetes neuropathy
- Cardiac exam or AS murmur
- If true hypotensive
- Exclude MI, AAA, Sepsis, GI bleeds, etc.
22
Q
What should be performed on the physical exam in a patient presenting with imbalance?
A
- Assess motor, sensory and gait
- Romberg: stand with hands out, close eyes
- Require 2/3: proprioception, vestibular function or sight to remain still
- Pull-Back test: postural instability in parkinsonism
23
Q
What should be performed on the physical exam in a patient presenting with lightheadedness?
A
- Can have them hyperventilate for 3 minutes into paper towel 6 inches away
24
Q
What investigations should be considered in a patient presenting with vertigo?
A
- None if likely benign peripheral
- MRI if Meniere’s to rule out neuroma (cerebellarpontine angle tumor)
- Also get audiogram
- CT/MRI if considering Central
- Signs of symptoms of central vertigo
- A history of trauma
- Signs, symptoms, or other reasons (e.g. anticoagulation) to suspect a possible serious underlying cause
25
**What investigations should be considered in a patient presenting with presyncope?**
* CBC, ECG
* Consider outpatient echo (if signs of failure) or holter (if arrhythmia concern)
26
**What investigations should be considered in a patient presenting with imbalance?**
* Consider neurologic/geriatrics follow-up
27
**What treatment options are available for different causes of vertigo?**
* Meniere’s Disease – SERC (betahistine) 8-16 mg TID or 24 mg BID
* Low salt diet, diuretics, corticosteroids may be tried
* Intratympanic dexamethasone or gentamicin
* Epley maneuver for BPPV
* **Brandt-Daroff Vestibular Exercises** (performed by patient)
* Neuronitis vertigo resolves in days, but can have lasting imbalance in vestibular tone resulting in sensation of imbalance
* Bed rest, vestibular sedatives (Gravol), diazepam in acute phase
* Depo-medrol 100 mg orally daily then tapered to 10 mg orally daily over 3 weeks for vestibular neuronitis
* Vestibular physiotherapy for long-standing peripheral vertigo
* Non-specific
* Antihistamines – Benadryl 50 mg QID
* Antiemetics – Prochlorperazine 5-10 mg up to QID
28
**What is the pathophysiology behind syncope?**
* Transient loss of consciousness followed by prompt recovery due to cerebral hypoperfusion
29
**What is the differential diagnosis for syncope?**
* First must differentiate from seizures, coma and shock
* NEUROLOGIC
* **Vasovagal** – young women, stress, pain, lightheaded prodrome
* **Situational** – elderly with urination, cough, swallow, defecation
* **Carotid Sinus Dysfunction** – elderly with atherosclerotic disease
* **Cerebrovascular disease** – TIA or stroke symptoms or risk factors
* Often a vertebrobasilar insufficiency, overhead work (subclavian steal) or neck movement
* CARDIAC
* **Anemia** – pale, female
* **Orthostatic** – elderly, lightheaded with sit to stand, new meds
* **Arrhythmia** – palpitations, often no prodrome
* **Structural** – with exertion, SOB, murmur, CHF
* IDIOPATHIC
* Initially 1/3 may not have an identifiable cause
30
**What should be asked on physical in a patient presenting with syncope?**
* Typical Hx: complete LOC, rapid onset/offset, spontaneous recovery, loss of postural tone
* Position when first start: supine suggests cardiac
* Exertional?
* Duration of warning/offset
* How long was the loss of consciousness and was it complete
* Seizure-like activity, witness accounts, post-syncopal residual symptoms
* Associated symptoms: SOB, chest pain, palpitations, H/A, focal neuro
* FHx: sudden death
* Meds: new or illicit
31
**What should be performed on physical examination in a patient presenting with syncope?**
* Orthostatic changes (decrease BP 20/10 or increase pulse 30 bpm)
* Precordial: murmurs, CHF, carotid bruits
* Neuro exam
32
**What investigations should be considered in a patient presenting with syncope?**
* CBC and ECG are the only routine tests
* Echo: if suggestive of structural disease
* Stress test if at risk of CAD
* Holter: if no prodrome or palpitations
* Tilt-table: unexplained recurrent syncope once other causes excluded
* Abnormal results suggest vasovagal syncope
* Neuro imaging: only if focal findings, suggestive of seizure or TIA symptoms
33
**What are 4 potential cardiac causes of sudden death/arrest arrhythmias?**
* Wolf-Parkinson-White
* Brugada syndrome
* Long QTc
* Cardiomyopathy
34
**How does Wolf-Parkinson-White appear on ECG?**
* Short PR, delta wave, widened QRS, inverted T
* Important to rule out in young patients
35
**How does Brugada syndrome appear on ECG?**
* Type 1 – elevated ST segment (≥2 mm) descends with an upward convexity to an inverted T wave
* Type 2/3 – “saddle back” ST-T wave configuration
* The elevated ST segment descends toward the baseline, then rises again to an upright or biphasic T wave
* The ST segment is elevated ≥1 mm in type 2 and \<1 mm in type 3
36
**How is long QT syndrome measured on ECG?**
* Men \>440 ms
* Women \>460 ms
37
**What are potential causes of Long QTc syndrome?**
* Congenital
* Acquired
* Amiodarone, Sotalol
* Macrolides
* Fluroquinolones
* TCAs, antipsychotics, SSRIs
38
**How does cardiomyopathy appear on ECG?**
* QRS voltage is typically increased in association with ST-T changes
* Q waves in inferior and lateral leads, “Daggers”
* LVH
* LAD
39
**What factors are important when considering admission for a patient with syncope?**
* San Francisco Syncope Rule:
* Hx of CHF
* Hx of dyspnea
* Anemia
* Abnormal ECG
* SBP \<90
* Also consider if elderly with short duration of warning or structural cardiac
* Consider Cardio/Neuro consultation if specific indication
* Consider Psych if young/healthy frequently faint without any associated injury
40
**What would you counsel a patient with a history of syncope and no concerning features?**
* Counsel regarding stress, prolonged standing, crowded/hot rooms
* Encourage hydration
* Lie down if have prodrome
* Adjust orthostatic predisposing medication and encourage slow sit to stand
41
**In a patient with syncope, when would restrictions need to be placed regarding driving?**
* Single episode vasovagal or reversible cause – no restriction
* Situational syncope – 1 week
* Single unexplained episode or recurrent vasovagal
* Private – 1 week
* Commercial – 12 months
* Recurrent and Explained
* Private – 3 months
* Commercial – 12 months
* Diagnosed and treated permanent cause
* Private – 1 week
* Commercial – 1 month
42
**Define tinnitus.**
* An auditory perception in the absence of an external auditory stimuli
43
**What is tinnitus most commonly associated with?**
* SNHL
44
**How can the sound be described?**
* Central Pathology – Ringing, Hissing, Buzzing
* External or Palatal Pathology – Popping, Clicking, Banging
45
**How can tinnitus be characterized? (3)**
1. Subjective (only heard by patient - common) vs Objective (can be heard by others – rare)
2. Continuous vs Vibratory vs Pulsatile
3. Unilateral vs Bilateral
46
**What symptoms can be associated with tinnitus? (6)**
1. Hearing loss
2. Vertigo
3. Aural fullness
4. Otalgia
5. Otorrhea
6. Headache
47
**What are 9 questions to ask in patients with tinnitus?**
1. Classification – Subjective vs Objective
2. Onset – Progressive vs Sudden
3. Location – Bilateral vs Unilateral
4. Type – Buzzing, Ringing, Snapping, Hissing
5. Duration – Continuous vs Intermittent vs Pulsatile
6. Positional changes
7. Temporal worsening (e.g. ?night)
8. Head trauma
9. Noise exposure
48
**What are 3 Red Flags for tinnitus?**
1. Pulsatile tinnitus
2. Unilateral tinnitus
3. Tinnitus associated with other unilateral otologic symptom
49
**What are 6 components of the physical exam for tinnitus?**
1. Head and neck exam, including external ear, canal, tympanic membrane
2. Oral cavity and TMJ joint
3. Cranial nerve exam
4. Auscultation over neck, periauricular region, orbits
5. To assess for venous vascular pathology, compression of the ipsilateral jugular vein can lead to improvement of the tinnitus
6. Weber and Rinne tests will help determine the location and type of hearing deficits
50
**What are 3 investigations to consider in unilateral tinnitus?**
1. ABR (auditory brainstem response), gadolinium enhanced MRI to exclude a retrocochlear lesion (e.g. acoustic neuroma)
2. CT to diagnose glomus tympanicum (rare)
3. MRI or angiogram to diagnose AVM
51
**What are 4 blood tests to consider ordering for tinnitus?**
1. CBC
2. TSH
3. B12
4. Lipid profile
52
**What are two common causes of subjective tinnitus?**
1. Presbycusis (age-related hearing loss) – bilateral symmetrical age-related SNHL
2. ASA
53
**What are five other categories for subjective tinnitus?**
1. Otologic
1. Presbycusis
2. Noise-induced hearing loss
3. Otitis media with effusion
4. Meniere’s disease
5. Otosclerosis
6. Cerumen
7. Foreign body against TM
2. Drugs
1. ASA
2. NSAIDs
3. Aminoglycosides
4. Antihypertensives (Furosemide)
5. Heavy metals (Mercury, Lead
3. Metabolic
1. Hyper/hypothyroidism
2. Hyperlipidemia
3. Vitamin A, B12, Zinc deficiency
4. Neurologic
1. Head trauma
2. Multiple sclerosis
3. CPA tumours
5. Psychiatric
1. Anxiety
2. Depression
54
**What is a common cause of objective tinnitus?**
* Benign intracranial hypertension
55
**What are 7 causes of objective tinnitus? (Mnemonic)**
* **B**ig **A**nd **G**larin**G** **AVM**
* **B**enign intracranial hypertension
* **A**rteriovenous malformation
* **G**lomus tympanicum
* **G**lomus jugulare
* **A**rterial bruits – high-riding carotid artery, vascular loop, persistent stapedial artery, carotid stenosis
* **V**enous hum – high jugular bulb, hypertension, hyper/hypothyroidism
* **M**echanical – patulous Eustachian tube, palatal myoclonus, stapedius muscle spasm
56
**Name 4 signs and symptoms of Glomus Tympanicum / Glomus Jugulare Tumour**
1. Pulsatile tinnitus
2. Hearing loss
3. Blue mass behind TM
4. Brown’s sign (blanching of the TM with pneumatic otoscopy)
57
**If no treatable cause can be found for tinnitus, what is the prognosis?**
* 50% improve
* 25% worsen
* 25% same
58
**What should be done as a treatment for all patients with tinnitus if possible?**
* Discontinue any ototoxic drugs
59
**For patients with mild tinnitus (not affecting function), other than reassurance what can be offered for treatment?**
* Lifestyle modification (reduce caffeine, sodium, alcohol, sugar intake, smoking and loud noise) for 1 month
60
**For patient with moderate tinnitus (affecting sleep and some interference with daily functioning), what can be offered for treatment? (4)**
1. Assess need for hearing aids (if coexistent hearing loss)
2. Tinnitus clinics
3. Mask tinnitus with ambient noise or soft music - “white noise”
4. Hearing aid if coexistent hearing loss
5. Tinnitus instrument: combines hearing aid with white noise masker
6. Trial of tocainamide
Primary Care
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