Vertigo

Question 1

How to tell vertigo caused by central postural instability?

Answer 1

Inability to stand up or walk even with the eyes open.

Question 2

How to tell vertigo caused by peripheral instability?

Answer 2

Can walk, although may be unstable and may not wish to mobilise

Question 3

How to tell vertigo caused by central hearing loss/tinnitus?

Answer 3

Uncommon but may occur (for example stroke or intracranial tumour).

Question 4

How to tell vertigo caused by peripheral hearing loss/tinnitus?§

Answer 4

Possible with some causes (for example Meniere’s disease, labyrinthitis).

Question 5

How to tell vertigo caused by central nystagmus?

Answer 5

Direction-changing nystagmus on lateral gaze (right beating on right gaze, left beating on left gaze). Purely vertical or torsional. Not suppressed by visual fixation. Non-fatiguable. Commonly large amplitude nystagmus.

Question 6

How to tell vertigo caused by peripheral nystagmus?

Answer 6

Horizontal nystagmus with a torsional component that does not alter in direction when the gaze changes. Beats away from the affected side. Disappears with fixation of the gaze.

Large amplitude nystagmus is usually only seen early in the course of Meniere’s disease or vestibular neuronitis

Question 7

How to tell vertigo caused by central cause in Dix-Hallpike manoevre?

Answer 7

Dix-Hallpike: provoking dizziness and observing for characteristic eye movements (nystagmus) when moving a patient from sitting to a specific lying-down position, helping pinpoint which inner ear canal is affected

Abnormal response (for example vertical nystagmus without latency or fatiguability; direction not classical horizontal towards the downward ear).

Question 8

How to tell vertigo caused by peripheral cause in Dix-Hallpike manoevre?

Answer 8

Dix-Hallpike: provoking dizziness and observing for characteristic eye movements (nystagmus) when moving a patient from sitting to a specific lying-down position, helping pinpoint which inner ear canal is affected

In BPPV: latency of symptoms and nystagmus with fatiguability and habituation; severe vertigo.

Question 9

How to tell vertigo caused by peripheral cause in head impulse test?

Answer 9

The head impulse test (HIT) is a bedside clinical examination used to evaluate the horizontal vestibulo-ocular reflex (VOR) and detect peripheral vestibular dysfunction. By rapidly turning a patient’s head ~20° while they fixate on a target, a positive result (corrective saccade) indicates a malfunctioning ear on the side of the head turn

May be positive with acute unilateral vestibular loss.

Question 10

How to tell vertigo caused by central cause in head impulse test?

Answer 10

The head impulse test (HIT) is a bedside clinical examination used to evaluate the horizontal vestibulo-ocular reflex (VOR) and detect peripheral vestibular dysfunction. By rapidly turning a patient’s head ~20° while they fixate on a target, a positive result (corrective saccade) indicates a malfunctioning ear on the side of the head turn

Negative, indicating a normal vestibulo-ocular reflex.

Question 11

How to tell BPPV?

Answer 11

Characterised by vertigo with positional change and fatiguable nystagmus and positive Dix-hallpike manoeuvre

Question 12

How to tell vertigo with acute labyrinthitis?

Answer 12

Presents with severe, acute vertigo, associated with nausea and vomiting. Hearing loss and tinnitus may be present.

Question 13

How to tell vertigo with Ménière’s;s disease?

Answer 13

Features recurrent episodes of vertigo, sensorineural hearing loss, tinnitus, and a feeling of fullness in the ear.

Question 14

How to tell vertigo with acoustic neuroma?

Answer 14

Usually presents with unilateral hearing loss and cranial nerve dysfunction

Question 15

What is the positive test for BPPV?

Answer 15

Rotatory nystagmus on Dix-Hallpike manoeuvre

Question 16

What is the positive sign of Ménière’s
S disease?

Answer 16

Low-to-medium frequency fluctuating sensorineural hearing loss

Question 17

Why does Ménière’s disease affect lower frequency sounds?

Answer 17

fluid levels of the inner ear (endolymphatic hydrops), which increases the pressure and therefore the stiffness within the cochlear
. This disproportionately affects the low frequency end as lower stiffness is needed at this end to transmit the sounds.

Question 18

What does vertigo and normal head impulse test indicate?

Answer 18

Indicates central case, s vestibulospinal-ocular reflex is intact.

Question 19

What is positive with stroke?

Answer 19

Normal head impulse test, bidirectional nystagmus, vertical skew

Question 20

What causes vertigo spontaneously with hearing loss or tinnitus?

Answer 20

Ménière’s disease

Question 21

What causes vertigo with mild past pointing and ysdiadochokinesis?

Answer 21

Central posterior circulation stroke which requires urgent hospital admission, ith no need to do Dix-hallpike test or employ manoeuvre

Question 22

What causes an Elderly patient dizzy on extending neck?

Answer 22

Vertebrobasilar ischaemia

Question 23

What is a risk factor for vertebrobasilar ischaemia?

Answer 23

Cardiovascular isease

Question 24

What is a classic feature of vertebrobasilar ischaemia?

Answer 24

Dizziness on neck extension

Question 25

What is Eustachian tube dysfunction?

Answer 25

Caused by inability to equalise air pressure, disrupting the fluid balance. It is commonly caused by a viral URTI.

Question 26

What is the presentation of Eustachian tube dysfunction?

Answer 26

*Ear fullness *Otalgia *Tinnitus * reduced hearing * Popping noise/sensation

Question 27

What is the aetiology of Eustachian tube dysfunction?

Question 28

How is Eustachian tube dysfunction diagnosed?

Answer 28

Audiometry Tympanometry

Question 29

What does tympanometry involve?

Answer 29

creating different air pressures in canal to measure admittance, the amount of sound not absorbed by the tympanic membrane and reflected back to the tympanometer. Sound should be absorbed best when the air pressure in middle ear is equal to the ambient air pressures of the environment.

Question 30

What are the findings on the tympanogram for Eustachian tube dysfunction?

Answer 30

Peak admittance with negative ea canal pressure compared to ambient air pressure.

Question 31

What is the management of Eustachian tube dysfunction?

Answer 31

Valsalva Otovent Short term relief with decongestant nasal spray Anti-histamines Steroid nasal spray Anti-histamines Surgery for severe and persistent

Question 32

What is otovent?

Answer 32

Patient blows into balloon with single nostril to inflate Eustachian tube

Question 33

What are the surgical management of Eustachian dysfunction?

Answer 33

Grommets to relieve fluid in middle ear, using local anaesthetic Balloon dilation Eustachian tube tympopalsty