Dizziness

Question 1

What are 6 common differentials for dizziness?

Answer 1

1. Benign paroxysmal positional vertigo (BPPV)
2. Vestibular neuritis
3. Labyrinthitis
4. Meniere’s disease
5. Vestibular migraine
6. Syncope or pre-syncope

Question 2

What is the difference in aetiology between vestibular neuritis and labyrinthitis?

Answer 2

Vestibular neuritis = inflammation of the vestibular nerve, while labyrinthitis = inflammation of the inner ear structures i.e. semicircular canals and cochlea

Question 3

What are 5 rare/ urgent causes of dizziness?

Answer 3

1. Cholesteatoma
2. Vestibular schwannoma
3. Central vertigo: cerebellar stroke or cervical artery dissection
4. Cardiovascular disease (if syncope + chest pain)
5. Multiple sclerosis

Question 4

What are 11 key things to ask in the history for a symptom of ‘dizziness’?

Answer 4

1. Differentiate between dizziness and vertigo: vertigo= rotatory sensation
2. Determine whether vertigo better with eyes open or closed. If does not decrease with visual fixation, suggests central origin
3. Determine duration - seconds, minutes to hours, hours to days
4. Positional triggers - BPPV (head movement), getting up quickly (orthostatic hypotension, syncope)
5. Tinnitus
6. Hearing loss
7. Otalgia - otitis media
8. Nausea and vomiting
9. How did episodes begin - preceding URTI, barotrauma
10. Cardiac symptoms: chest pain, dyspnoea
11. Migraine features: aura, visual disturbance, photophobia, phonophobia, ± headaches

Question 5

What should physical examination involve for a dizziness symptoms?

Answer 5

1. Inspect ear
2. Otoscopy
3. observe eye for nystagmus/eye movements
4. Head impulse test
5. Dix-Hallpike
6. Supine roll - if suspect BPPV but Dix-Hallpike negative
7. CN exam
8. Romberg and Unterberger

Question 6

What is the head impulse test and what does it involve? What do the results mean?

Answer 6

• Useful to differentiate between acute vestibular neuritis and cerebellar stroke in patients with acute vertigo
• Examiner turns head as rapidly as possible 15 degrees to one side and observes patient’s ability to keep fixating on distant target
• If peripheral vestibular lesion, saccade occurs as vestibulo-ocular reflex fails
• If cerebellar stroke has occurred, no catch-up saccade occurs

Question 7

What does the supine roll test invovle and what do the results mean?

Answer 7

If Dix-Hallpike negative in a patient who has a history suggestive of BPPV, perform this test

Position patient supine with head in neutral position, then rotate head 90 degrees to one side, observing for nystagmus

Head returned to face up, alowing dizziness and nystagmus to subside

then turn rapidly to opposite side

Question 8

What is the diagnosis of benign paroxysmal positional vertigo (BPPV) based upon?

Answer 8

Suggestive history and physical examination with positive Dix-Hallpike manouevre or positive supine lateral head turn

Question 9

What are 7 common symptoms of BPPV?

Answer 9

1. Vertigo provoked by specific head movements e.g. looking up or bending down, getting up, turning head, rolling over in bed to one side
2. Episodic - repeated attacks over days - weeks - months
3. Brief episodes, lasting <30s
4. Sudden onset
5. Nausea
6. Imbalance
7. Lightheadedness

Question 10

What are 3 features of BPPV on examination?

Answer 10

1. Positive Dix-Hallpike manoeuvre or positive supine lateral head turn
2. Normal neurological examination
3. Normal otological examination

Question 11

What is the definition of BPPV?

Answer 11

Disorder of the inner ear characterised by repeated episodes of positional vertigo i.e. symptoms occur with changes in position of the head

Question 12

What are 5 risk factors for BPPV?

Answer 12

1. Head injury
2. Prolonged recumbent position e.g. during visit to dentist or hairdresser
3. Ear surgery
4. Following episode of any inner ear pathology e.g. vestibular neuronitis, labyrinthitis, Meniere’s disease
5. Sleep position: people with BPPV more likely to lie on side of affected ear

Question 13

What are 2 demographic risk factors for BPPV?

Answer 13

1. Fifth - seventh decades (40s-60s)
2. Women

Question 14

What is the typical course of BPPV?

Answer 14

Relapsing and remitting course: recovery can occur spontaneously without treatment, but recurrence is common

Question 15

What are 3 things necessary to diagnose BPPV?

Answer 15

1. Confirm history of vertigo: symptoms brough on by specific movements of head (turning over in bed, looking upwards, bending over)
2. Dix-Hallpike should be used to demonstrate characteristic BPPV findings
3. Other causes considered including Meniere’s, vestibular neuronitis, anxiety disorder

Question 16

Should imaging be used for BPPV?

Answer 16

not required to confirm diagnosis, unless necessary to exclude another condition (e.g. if atypical nystagmus or additional neurological symptoms)

Question 17

What are 4 aspects of the management of BPPV?

Answer 17

1. Option of watchful waiting (active monitoring) discussed to see if symptoms settle without treatment - explain tx may help resolve more quickly
2. If pt presers treatment, particle repositioning manoeuvre e.g. Epley manoeuvre should eb offered and Brandt-Daroff exercises considered
3. Symptomatic drug treatment not usually helpful
4. Advise to return for follow up in 4 weeks if symptoms have not resolved in case BPPV has been incorrectly diagnosed

Question 18

What are the exercises that patients can do for BPPV called?

Answer 18

Brandt-Daroff exercises

Question 19

When should urgent admission to hospital in BPPV be arranged?

Answer 19

If there is severe nausea and vomiting and an inability to tolerate oral fluids

Question 20

What are 3 types of specialist physicians that you may consider referring a patient with BPPV to if required? What determines who you would refer to?

Answer 20

1. ENT specialist
2. Audiovestibular specialist physician
3. Care of the elderly physician with special interest

Depends on local protocol

Question 21

What are 6 situations when you may consider referral to a specialist for BPPV?

Answer 21

1. if expertise to provide canalith repositioning procedure (e.g. Epley) is not available in primary care
2. physical limitations affect safety/practicality of carrying out canalith repositioning procedures in primary care
3. canalith repositioning procedure has been performed and repeated and symptoms are still present
4. symptoms or signs are atypical
5. symptoms and signs have not resolved in 4 weeks
6. there have been three or more periods during which person has experienced episodes of vertigo

Question 22

What are the 2 prevailing pathophysiological mechanisms of BPPV?

Answer 22

1. Canalithiasis: free-floating endolymph particles called canaliths migrate into semicircular canals. denser than surrounding fluid so respond to gravity. eventually accumulate and drag downwards, which deflects cupula and stimualtes hair cells, activating vestibulo-ocular reflex
2. Cupulolithiasis: dense canalth particles adhere to the cupula (within ampullae of each semicircular canal) causing it to be gravity-sensitive. (Particle repositioning not as effective)

Question 23

Which cause of BPPV is most common?

Answer 23

Canalithiasis: canaliths (/otoconia, calcium carbonate debris) move into semicircular canals, causing motion in endolymph of inner ear + inducing vertigo

Question 24

Which semicircular canal is most commonly affected in BPPV?

Answer 24

Posterior semicircular canal: 85-95%

Question 25

What 2 things should a positive Dix-Hallpike manoeuvre evoke?

Answer 25

1. Vertigo 2. Torsional (rotatory) upbeating nystagmus: upper pole of eye beats towards dependent ear with vertical component towards forehead when looking straight ahead (left ear = clockwise, right ear = anticlockwise)

Question 26

How do you cary out the Dix-Hallpike manoeuvre?

Answer 26

* Advise pt may experience transient vertigo. Ask to keep eyes open throughout and look straight ahead * Ask to sit upright on couch with head turned 45^o to one side * From this position, lie person down rapidly (over 2 seconds), supporting head and neck, until head is extended 20-30^o over end of couch with chin pointing slightly up and test ear downwards. * Support head to maintain position for at least 30s * Observe eyes closely for up to 30s for nystagmus. If present, maintain position for its duration: maximum 2 minutes. * Record duration, severity, latency of any vertigo * Support head in position and slowly sit person up * Repeat with other side

Question 27

How long does it take for BPPV to resolve?

Answer 27

several weeks (even without treatment)

Question 28

What are 4 safety issues to advise pts with BPPV on?

Answer 28

1. Get out of bed slowly and avoid tasks that involve looking upwards 2. **Driving**: don't drive when dizy, or if might experience episode while driving. if liable to 'sudden and unprovoked or unprecipitated episodes of disabling dizziness' - stop driving, inform DVLA. usually not spontaneous/ unprovoked though 3. **Workplace** - inform employe if poses risk 4. **Falls** in home - suggests measures to reduce risk

Question 29

What is the name of the alternative to the Epley manoeuvre? When is it used?

Answer 29

Semont manoeuvre: if skills to perform it are available, less commonly used in primary care than Epley manoeuvre

Question 30

What are Brandt-Daroff exercises particularly useful?

Answer 30

If Epley manoeuvre cannot be performed immediately or is inappropriate

Question 31

What follow up advice should you give to a patient with BPPV?

Answer 31

* After Epley manoeuvre: symptoms may improve shortly after treatment, but full recovery can take days to a couple of weeks. If don't settle after 1 week, advise to return and consider repeating Epley * Advise person to return for follow up in 4 weeks if symptoms have not resolved

Question 32

How is the Epley manoeuvre performed?

Answer 32

* Advise will experience transient vertigo * Stand at side or behind person to guide head movements. Maintain each head position for at least 30s. If vertigo continues, wait until it has subisided * movements should ideally be rapid, within 1 second. sometimes not possible in older people * Start with person sitting upright with head turned 45 degrees, then lie back with head still turned, until head dependent 30 degrees over edge of cough. wait for at least 30s * with face upwards, but still tilted backwards by 30 degrees, rotate head through 90 egrees to opposite side * hold head in position for 0s and ask person to roll onto same side as they're facing * rotate head so facing obliquely downward with nose 45 degrees below horizontal * sit person up sideways while head remains rotated and tilted to side * rotate head to central position and move chin downwards by 45 degrees

Question 33

What is a key difference between the symptoms of labyrinthitis and vestibular neuronitis?

Answer 33

Hearing loss is a feature of labyrinthitis but hearing not affected in vestibular neuronitis

Question 34

What is vestibular neuronitis?

Answer 34

Acute, isolated, spontaneous and prolonged vertigo of peripheral origin

Question 35

What is the usual time course of vestibular neuronitis?

Answer 35

Severe initial symptoms usually last **2-3 days**, people with vestibular neuronitis usually recover gradually over a **period of weeks** (2-6 weeks) through process of CNS compensation

Question 36

What are 7 symptoms of vestibular neuronitis?

Answer 36

1. Spontaneous onset vertigo 2. nausea 3. vomiting 4. unsteadiness 5. hearing loss not present 6. tinnitus not present 7. no focal neurological symptoms

Question 37

What are 2 signs of vestibular neuronitis?

Answer 37

1. presence of nystagmus 2. head impulse test may be positive (may also be positive for other peripheral cause of vertigo

Question 38

What is the character of nystagmus in vestibular neuronitis?

Answer 38

usually fine horiontal but may be mixed horizontal-torsional with fast phase away from affected ear. Always beats in same direction, even if head rotated, and reduced when vision fixed

Question 39

What are 3 aspects of management of vestibular neuronitis in the community?

Answer 39

1. Advice re resuming activity as soon as possible, safety issues such as driving, work and prevention of falls 2. If symptoms severe, short-term symptomatic drug treatment can be offered: buccal or IM **prochlorperazine** or IM **cyclizine** 3. Short course of oral prochlorperazine, cinnarizine, cyclizine or promethazine teoclate can be considered for less severe nausea, vomiting and vertigo

Question 40

When should a patient with vestibular neuronitis be admitted to hospital?

Answer 40

Nausea and vomiting so severe they cannot tolerate oral fluids or symptomatic drug treatment

Question 41

When is referral indicated in vestibular neuronitis? 3 situations

Answer 41

1. Atypical symptoms e.g. additional neurological symptoms 2. Symptoms not improving after week of treatment 3. Symptoms persist for more than 6 weeks

Question 42

What might precede vestibular neuronitis to trigger it, that you should enquire about?

Answer 42

Viral illness e.g. upper respiratory tract infection, or contacts with similar symptoms

Question 43

What is the test that may be useful to help diagnose vestibular neuronitis?

Answer 43

head impulse test

Question 44

What can the head impulse test help to differentiate between?

Answer 44

differentiate vestibular neuronitis from central lesion

Question 45

What are 7 things to advise a patient with vestibular neuronitis on?

Answer 45

1. Reassure symptoms will settle over several weeks, even if no treatment 2. Advise alcohol, tiredness, intercurrent illness may have greater than usual effect on balance 3. Explain may be periods during recovery when symptoms appear to be worsening again 4. Advise not to drive when dizzy, or if likely to experience vertigo episode while driving. DVLA says 'liability to sudden and unprovoked or unprecipitated episodes of disabling dizziness' should stop driving and inform DVLA 5. Workplace - inform employer if poses risk in workplace 6. Risks of falls in home, measures to reduce 7. Offer written info e.g. provided by NHS

Question 46

What are the 4 oral drugs that can be used in a short course for sympomatic relief in vestibular neuronitis?

Answer 46

1. Prochlorperazine 2. Cinnarizine 3. Cyclizine 4. Promethazine teoclate

Question 47

What dose of oral cinnarizine should be prescribed for vestibular neuronitis symptoms?

Answer 47

oral cinnarizine 30mg tds

Question 48

What dose of oral cyclizine should be prescribed for vestibular neuronitis symptoms?

Answer 48

oral 50mg up to tds

Question 49

What dose of IM cyclizine can be given for severe symptoms in vestibular neuronitis?

Answer 49

50mg IM, up to tds

Question 50

What dose of prochlorperazine can be given in vestibular neuronitis in the oral form as a short course?

Answer 50

5mg orally tds (maximum dose 30mg daily)

Question 51

If the oral route is not appropriate for prochloperazine in vestibular neuronitis, what else can be given as a short course and what dose?

Answer 51

Buccal tablets 3-6mg twice a day (placed high in bucal cavity and allowed to dissolve)

Question 52

What is the one-off dosing for prochlorperazine IM for symptom treatment in vestibular neuronitis?

Answer 52

12.5mg deep IM injection followed by oral medication after interval of 6 hours, if required

Question 53

What dosage of oral promethazine can be prescribed for vestibular neuronitis?

Answer 53

25mg orally at night. May be icnreased to 100mg daily

Question 54

What is the most common cause of labyrinthitis?

Answer 54

Viral infections

Question 55

What is bacterial labyrinthitis?

Answer 55

Complication of otitis media or meningitis

Question 56

What are 7 key diagnostic features of labyrinthitis?

Answer 56

1. Vertigo 2. Nausea and vomiting 3. Hearing loss 4. Otorrhoea 5. Nystagmus 6. Tinnitus 7. Flu-like symptoms

Question 57

What type of hearing loss is present in labyrinthitis?

Answer 57

Sensorineurla

Question 58

How long may the acute vertigo last in labyrinthitis?

Answer 58

Up to 72 hours

Question 59

What should you consider in labyrinthitis/ vestibular neuronitis if more than one episode of room-spinning vertigo occurs?

Answer 59

Meniere's disease

Question 60

What are 5 questions to ask to rule out a cerebrovascular accident as a cause for dizziness?

Answer 60

1. Dysarthria 2. Dysphagia 3. Facial pain or numbness 4. Facial weakness 5. Extremity weakness or numbness

Question 61

What does the management of labyrinthitis closely resemble?

Answer 61

Vestibular neuronitis - self care, anti-emetics IM and short term oral

Question 62

What is a possible treatment option for the sudden hearing loss which may occur in labyrinthitis?

Answer 62

Short course oral corticosteroids

Question 63

What are 6 risk factors for labyrinthitis?

Answer 63

1. Viral infections 2. Chronic suppurative otitis media 3. Acute otitis media 4. Cholesteatoma 5. Meningitis 6. Inner ear malformations

Question 64

What is Meniere's disease?

Answer 64

Disorder affecting inner ear which can affect balance and hearing; characterised by episodes of vertigo, fluctuating hearing loss, tinnitus. Associated with a feeling of fullness in the affected ear

Question 65

What is thought to be the cause of Meniere's disease?

Answer 65

Not known but may be associated with endolymphatic hydrops (raised endolymph pressure in the membranous labyrinth of the inner ear)

Question 66

What are 6 risk factors for Meniere's disease?

Answer 66

1. Autoimmunity 2. Genetic susceptibility 3. Metabolic disturbances involving levels of sodium and potassium in inner ear 4. Vascular factors (there is an association between migraine and Meniere's disease) 5. Viral infection 6. Head trauma

Question 67

What are 3 key complications of Meniere's disease?

Answer 67

1. Falls 2. Adverse psychological impact 3. Social effects

Question 68

What are the 4 criteria needed to diagnose Meniere's disease?

Answer 68

1. Vertigo - at least two spontaneous episodes lasting between 20 minutes and 12 hours 2. Fluctuating hearing, tinnitus, and/or perception of aural fullness in the affected ear 3. Hearing loss confirmed by audiometry to be sensorineural, low-to-mid frequency, and defining the affected ear on one or more occasions before, during, or after an episode of vertigo 4. No alternative vestibular diagnosis

Question 69

What are 4 classic symptoms of Meniere's disease?

Answer 69

1. Spontaneous vertigo 2. Tinnitus 3. Fluctuating sensorineural hearing loss 4. Aural fullness

Question 70

What is the typical course of the symptoms of Meniere's disease?

Answer 70

Initially they **fluctuate**, resolving between episodes. **Progression** results in further hearing loss and persistent tinnitus. Eventually, vertigo symptoms may resolve by the person may have **residual hearing loss** and **tinnitus**

Question 71

What is required for a diagnosis of Meniere's disease to be confirmed?

Answer 71

Referral to ENT consultant and formal audiology assessment

Question 72

What are 5 elements of the management of Meniere's disease?

Answer 72

1. If frequent, sudden attacks: advise to keep medication readily accessible 2. Consider risks before starting potentially dangerous activities like driving, swimming, operating machinery 3. Consider short course of **prochlorperazine** or an antihistamine (**cinnarizine, cyclizine, promethazine teoclate**) for nausea, vomiting, vertigo 4. If symptoms severe, may need hospital admission for IV labyrinthine sedatives and fluids to maintain hydration and nutrition 5. Trial of betahistine can be considered to reduce frequency and severity of attacks

Question 73

What may precede an acute attack of Meniere's disease?

Answer 73

change in tinnitus, increased hearing loss, or sensation of aural fullness shortly before onset of vertigo

Question 74

How long do acute attacks last in Meniere's disease?

Answer 74

present for at least 20 minutes, typically last a few hours (no more than 24 hours)

Question 75

What is the typical time course of acute attacks of Meniere's disease?

Answer 75

can occur in clusters over a few weeks, although months or years of remission can also occur

Question 76

What are otolithic crises of Tumarkin?

Answer 76

Drop attacks seen in 1 in 10 people with Meniere's disease. No loss of consciousness, no warning. Normal activities can be resumed immediately afterwards

Question 77

What are 4 possible signs on examination of Meniere's disease?

Answer 77

1. Head and neck: usually normal 2. May be unable to stand with feet together and eyes closed (Romberg's test) or walk heel to toe in straight line 3. If asked to march on spot with eyes closed, may be unable to maintain position and turn to affected side (Unterberger's test) 4. Unidirectional, horizontal-torsional nystagmus may be seen during episode of vertigo

Question 78

When should people with Meniere's disease be admitted to hospital and why?

Answer 78

If severe symptoms, admit for IV labyrinthine sedatives and fluids to maintain hydration and nutrition

Question 79

Who should be involved in the care of a patient with Meniere's disease? 6 people

Answer 79

1. ENT 2. Physiotherapist 3. Hearing therapist 4. Audiologist 5. Counsellor 6. Psychologist

Question 80

What are 5 things to advise patients with Meniere's disease about?

Answer 80

1. Reassure person it is a long-term condition but vertigo usually improves with treatment 2. Advise acute attack of vertigo will normally settle within 24h in most people. If no improvement 5-7 days, or deterioration, ask to return to exclude alternative diagnosis 3. Advise if sudden attacks: keep medication readily accessible, consider risks before using machinery, ladders, going swimming 4. Advise not to drive if dizzy or might experience episode. If liability to sudden and unprovoked or unprecipitated episodes of dizziness - stop driving, inform DVLA 5. Discuss sources of info and support e.g. Meniere's society website

Question 81

What are 2 options to rapidly relieve severe nausea or vomiting in Meniere's disease?

Answer 81

1. Buccal prochlorperazine 2. Deep IM injection of prochlorperazine or cyclizine

Question 82

What are the options for oral medications to alleviate nausea, vomiting and vertigo in people with Meniere's disease?

Answer 82

Consider prescribing 7 or 14 day course of prochlorperazine or antihistamin e(cinnarizine, cyclizine, promethazine teoclate)

Question 83

What are 2 things to do to prevent recurrent attacks of Meniere's disease?

Answer 83

1. Consider prescribing trial of betahistine to reduce frequency and severity of attacks of hearing loss, tinnitus and vertigo 2. If betahistine doesn't provide clinical benefit required, and there are recurrent attacks, refer to ENT specialist for consideration of other interventions

Question 84

What is a cholesteatoma?

Answer 84

Abnormal sac of **keratinising squamous epithelium** and accumulation of **keratin** within the _middle ear or mastoid air cell spaces_ which can become infected and also erode neighbouring structures

Question 85

What are the symptoms of a cholesteatoma?

Answer 85

* May be asymptomatic in early stages * Most commonly presents with **persistent or recurrent discharge from ear** that is often **foul-smelling** * Assoiated **conductive hearing loss** may also occur

Question 86

What are 5 rarer complications of cholesteatoma that may occur if it progresses?

Answer 86

1. Vertigo 2. Sensorineural hearing loss 3. Facial nerve palsy 4. Meningitis 5. Intracranial abscess

Question 87

What are 5 things seen on otoscopy that should cause you to suspect cholesteatoma?

Answer 87

1. Ear discharge 2. Deep traction pocket, with or without granulation tissue and skin debris 3. Crust or keratin in upper part of tympanic membrane 4. Tympanic membrane may be perforated 5. Congenital cholesteatoma may appear as white mass behind intact tympanic membrane, in person with no ear discharge, perforation or surgical procedures

Question 88

What might be the appropriate step to take if there is significant discharge occluding the tympanic membrane in suspected cholesteatoma? 2 options

Answer 88

1. **Referral for examination** with an otomicroscope and micro-suctioning of the ear may be appropriate 2. Use clinical judgement to decide whether to **treat for infection** * for either otitis externa if signs in external auditory canal or * acute otitis media if acute if acute pain + purulent discharge

Question 89

When should emergency admission be arranged for patients with cholesteatoma? 3 things

Answer 89

1. **Facial nerve palsy** 2. **Vertigo** 3. Other neurological symptoms (including pain) or signs that could be associated with development of **intracranial** **abscess** or **meningitis**

Question 90

When shouuld you consider referring due to suspected vestibular schwannoma and to whom? 2 things

Answer 90

1. Unilateral or assymetric gradual onset hearing loss as main symptom 2. Unilateral hearing loss associated with persistent tinnitus Refer routinely to ENT or audiovestibular medicine