What are the features of BPPV?
- Head movements can trigger vertigo - common one is turning over in bed
- Symptoms settle after 20-60 secs
- Patients are asymptomatic between attacks
- Episodes can occur over several weeks and then resolve but can reoccur weeks/months later
- No hearing loss or tinnitus
What is used to diagnose BPPV?
Dix-Hallpike manoeuvre - trigger vertigo and rotational nystagmus (rotational beats towards affected ear)
What is the treatment for BPPV?
- Epley manoeuvre in clinical setting
- Patient can do Brandt-Daroff exercises at home several times a day until symptoms improve
What is the presentation of vestibular neuronitis?
- Inflammation of vestibular nerve due to viral infection
- Acute onset of vertigo
- Hx of viral URTI
- Symptoms severe for first few days, initially vertigo may be constant then triggered/worsened by head movements
- N+v
- Balance problems
- No loss of hearing or tinnitus
What is the head impulse test?
- Abnormal vestibular system e.g. vestibular neuronitis or labyrinthitis -head is moved and eyes saccade as they fix back on examiner
- Normal if central cause of vertigo
What is the management of vestibular neuronitis?
- Prochlorperazine or antihistamines e.g. cyclizine (up to 3 days)
- If symptoms don’t improve after 1 week or resolve after 6 weeks - further investigation or vestibular rehabilitation therapy (VRT)
What is the HINTs exam?
Hi - head impulse, N - nystagmus TS - test of skew
- Hi - normal in central cause
- Bilateral/vertical nystagmus - central
- Vertical correction - central
What are the features of viral labyrinthitis?
- Acute onset vertigo, exacerbated by movement
- N+V
- Hearing loss (uni/bilateral)
- Tinnitus
- Preceding or concurrent/symptoms of URTI
- Need to exclude central cause of vertigo
What are the signs of viral labyrinthitis?
- Spontaneous unidirectional horizontal nystagmus towards unaffected side
- Sensorineural hearing loss: Rinne’s and Weber
- Abnormal head impulse test: impaired vestibulo-ocular reflex
- Gait disturbance: may fall to affected side
What is the management for viral labyrinthitis?
- Usually self-limiting - support care and short term (3 days) of medications for symptoms e.g. prochlorperazine, cyclizine
- Audiology assessment due to hearing loss as a complication
What is the triad for Meniere’s disease?
- Hearing loss
- Veritgo
- Tinnitus
What are the features of Meniere’s disease?
- 40-50 years, unilateral
- Vertigo lasts 20 mins to several hours - clusters of episodes followed by months without, not triggered by movement
- Hearing loss - fluctuates at first, then more permanent unilateral sensorineural, affects low frequencies first
- Tinnitus occurs with episodes of vertigo, becomes more permanent, usually unilateral
- Other symptoms: sensation of fullness in ear, unexplained falls with no LOC, imbalance, spontaneous nystagmus
What are the investigations for Meniere’s disease?
- Clinical diagnosis - can do Romberg’s
- Audiology assessment
What is the management for Meniere’s disease?
- Acute attacks: prochlorperazine (buccal or IM), antihistamines (cyclizine)
- Prophylaxis: betahistine or vestibular rehabilitation exercises
- Need to inform DVLA - cease driving until satisfactory control of symptoms
- Can last 5-10 years
What is acoustic neuroma/vestibular schwanoma?
Benign tumour of Schwann cells (provide myelin sheath) around auditory nerve - usually unilateral. Bilateral is neurofibromatosis II
What is the presentation of acoustic neuroma?
- 40-60yrs and gradual onset
- Unilateral sensorineural hearing loss
- Unilateral tinnitus
- Dizziness or imbalance
- Sensation of fullness in the ear
- Facial nerve palsy (LMN) - with big tumour
What are the investigations of acoustic neuroma?
- Audiometry
- MRI/CT or brain/cerebellopontine angle
What is the management of acoustic neuroma?
- Conservative: if no symptoms treatment is inappropriate
- Surgery to remove tumour
- Radiotherapy to reduce growth
- Risks to vestibulocochlear nerve or facial nerve
What are the features of cranial nerves being affected in acoustic neuroma?
- CN VIII: vertigo, unilateral sensorineural hearing loss, unilateral tinnitus
- CN V: absent corneal reflex
- CN VII: facial palsy
