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60 Cards in this Set

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What are the three types of dizziness and how are they different?
Lightheadedness - feeling like you may pass out
Dysequilibrium - feeling unsteady in gait, like walking on a boat/dock, "dizzy from the neck down"
Vertigo - spinning sensation - like the you or the room is spinning/moving
What is presyncope?
Feeling as though you're about to faint
What causes presyncope?
Brain hypoperfusion
What are the symptoms of presyncope?
lightheadedness
blurred or tunnel vision
graying or blacking out
Possibly: pale appearance, diaphoresis, palpitations, nausea, feeling distant
What causes syncope?
Hypoperfusion to both hemispheres or to the brainstem
What causes hypoperfusion to the brain?
- Cardiac etiologies: arrythmias, outflow obstruction, valve disease, myocardial infarction
- Hypovolemia: dehydration, blood loss
- Medications (BP, prostate)
- Vasovagal - excessive vasodilation w/ bradycardia
- Orthostatic blood pressure
Why does a person drop to the ground during syncope?
Body becomes level, so the heart doesn't have to pump against gravity and can more quickly perfuse the brain/brainstem
In what conditions/states may presyncope be observed?
`Hyperventillation
Hypoglycemia
Anxiety
What are some general causes of dysequilibrium?
Cerebellar dysfunction/Ataxia
Proprioception dysfunction (DCML)
Extrapyramidal (Ventromedial => Balance/Posture)
Visual input abnormalities

Rare = mild/resolving vertigo
What can cause cerebellar ataxias yielding disequilibrium?
Acute stroke
Hemorrhage
Mass
Demyelination
Inflammation
Infection
Alcohol and drugs (e.g. benzo)
Alcoholic cerebellar degeneration
Paraneoplastic
Inherited ataxias
Metabolic disorders
Postinfectious cerebellitis
What can cause proprioceptive abnormalities yielding dysequilibrium?
B12 deficiency
Tabes dorsalis (syphilis)
Cervical spondylosis (myelopathy)
Peripheral neuropathy
What can cause extrapyramidal lesions, yielding dysequilibrium?
Parkinsons disease - loss of dopaminergic neurons in substantia nigra --> postural instability
Why are the elderly prone to feel dizzy?
Visual loss
Medication effects
Decreased position sense
Aging vestibular apparatus
What are the two types of vertigo?
Physiologic

Pathologic
What causes physiologic vertigo?
Mismatch between vestibular system, visual system, and somatosensory system

Physically spinning around and suddenly stopping

Vestibular system subjected to unfamiliar head movements (seasickness)

Unusual head/neck positions (hyperextension at museum, movies)
What is the cause of pathologic vertigo?
Lesion to vestibular system
How can you distinguish from physiologic and pathologic vertigo?
Other signs> nystagmus
What are some signs of central vertigo?
Presence of brainstem signs, motor and sensory findings, ataxia

Less severe spinning sensation

Nystagmus can be bilateral, cannot be suppressed with visual fixation

Person can fall in either direction
What are some signs of peripheral vertigo?
Vertigo is brought on solely by movement (acute onset)

More severe spinning sensation

No other signs (except perhaps tinnitis or hearing loss)

Nystagmus is bilateral & suppressible with fixation

Person tends to fall towards the lesioned side

Nausea, Vomiting
What clinical test can you do to differentiate between central and peripherally caused vertigo?
Caloric testing - irrigate the external canal with ice water

Central - normal response - nystagmus will beat toward quickly toward opposite ear

Peripheral - impaired response - eye will not beat toward opposite ear on the lesioned side
Where can lesions causing central vertigo be localized?
**Cerebellum, brainstem**

Less common: vestibular cortex, thalamus
What is the clinical presentation of vestibular neuronitis and Labyrinthitis?
Both present with acute onset vertigo, nausea, vomiting (within minutes)

Peaks over 24 hours, resolves over days-weeks
What is the difference between acute labyrinthitis and vestibular neuronitis?
Acute labyrinthitis can cause hearing loss

- can be permanent mild-moderate loss of higher frequencies
What is the cause and treatment for labyrinthitis?
Viral or bacterial

Treated with antibiotics or surgical drainage
What is Ramsay-Hunt Syndrome?
A type of labyrinthitis caused by reactivation of latent virus

Presents with deep burning ear pain, vesicular rash in ear canal, unilateral facial weakness (sometimes)
What is the clinical presentation of Meniere's Disease?
recurrent, episodic vertigo attacks that last 30-60min
Nausea/Vomiting
Progressive unilateral hearing loss, tinnitus
Pressure/Fullness in ear
What causes Meniere's Disease?
Intermittent increase in endolymph production and volume
How is Meniere's Disease treated?
Vertigo treated by Low-salt diet, diuretics
Occasionally steroids
Rarely surgery

No treatment for hearing loss
What is the clinical presentation of a Perilymph Fistula?
At onset: pt hears "pop," sudden increased middle ear pressure, sneezing, blowing nose, coughing, then abrupt onset vertigo

Acute, unilateral
Symptoms are often recurrent
What is the Valsalva maneuver?
Moderately forceful expiration with mouth shut and nose pinched

Used normally to equalize pressure between ears and sinuses
What occurs in a pt with Perilymph Fistula when he/she performs the Valsalva maneuver?
Feels increased dizziness
What causes Perilymph Fistula?
Hole between the fluid-filled inner ear and air-filled middle ear, disrupts endolymphatic system
What is the treatment for Perilymph Fistula?
Usually nothing - heals on its own in 90% cases

Some will require surgery
What is an Acoustic Neuroma?
Schwannoma along the 8th nerve or at the cerebellopontine angle (CPA)
What is the clinical presentation of an Acoustic Neuroma?
Dysequilibrium, slow progression, tinnitus, hearing loss

Dx with MRI
Treatment for Acoustic Neuroma?
Surgical - radiosurgery or conventional
How does Benign Paroxysmal Positional Vertigo (BVVP) clinically present?
*Most common cause of vertigo*
Sudden onset severe vertigo, triggered by movement, short latency period (seconds) followed by less than one min of vertigo

Pt feels worse when lying on affected side, better when still
What causes Benign Paroxysmal Positional Vertigo?
Otolithic debris in semicircular canals stimulate hair cells
What causes Perilymph Fistula?
Barotrauma, head injury, surgical effect, spontaneous onset
What can an Acoustic Neuroma be mistaken for at Dx?
Meningioma located at CP angle
How is Benign Paroxysmal Positional Vertigo diagnosed?
Dix-Hallpike Maneuver - performed at bedside

Latency of symptoms should last for ~1 min when pt is lying down, but recur when pt sits up again with fatiguable vertigo

Generally elicited when offending ear is down

May observe torsional nystagmus

*aka Nyelin-Barany positional testing
How is Benign Paroxysmal Positional Vertigo treated?
Epley Maneuver

*does not work in every case and only works in treating vertigo caused by BPPV
What treatment works for all peripheral vertigo?
Brandt-Daroff exercises: pt sits, lies down on one side with ear to ground, alternates to other side, other ear pointed to ground

10x on each side

Desensitizes the central nervous system
What medications provide acute relief for adverse symptoms of peripheral vertigo (eg. vomiting)?
Meclizine (Antivert) - antihistamine
Scopolamine - anticholinergic
Diazepam (Valium) - benzodiazepine
What is Meclizine (Antivert)?
Antihistamine

Given to treat acute symptoms of peripheral vertigo
What is Scopolamine?
Anticholinergic

Given to treat acute symptoms of peripheral vertigo
What is Diazepam (Valium)?
Benzodiazepine

Given to treat acute symptoms of peripheral vertigo
What affect do aminoglycoside antibiotics have on the vestibular system?
Cause permanent vestibular dysfunction & damage hair cells, leading to gait ataxia (more so than vertigo)
What is Streptomycin?
Very effective aminoglycoside antibiotic

damages hair cells, vestibular dysfunction
What is gentamicin?
Aminoglycoside antibiotic

damages hair cells, vestibular dysfunction
What can cause bilateral nerve or labyrinth dysfunction?
Aminoglycoside antibiotics (streptomycin, gentamicin)
Alcohol or drug intoxication
Chronic meningitis (lyme, cryptococcus)
Autoimmune vestibulopathy
What pt observation will help you localize the side of a cerebellar lesion?
Pt falls or sways toward the lesion

Nystagmus direction can vary, but is most prominent to the side of the lesion
What cerebellar lesions can cause central vertigo?
Cerebellar stroke - presents with headache (911)
PICA distribution infarct - presents w/ vertigo & ataxia (911)
When would you suspect Vertebrobasilar Vascular Disease?
Sudden onset vertigo/nausea w/ brainstem findings:

crossed motor/sensory signs
diplopia
dysarthria
dysphagia
ataxia
What is an ominous sign for a patient who presents with sudden onset vertigo with brainstem signs?
Somnolence (sleepy/drowsiness)

Likely brainstem infarct
How could you tell if a pt has vertebrobasilar insufficiency?
Pt will present with transient brainstem symptoms, because under-perfusion to brainstem causes recurrent, selective ischemia
What is Chiari Malformation Type I?
Hereditary condition
Cerebellar tonsils hang below foramen magnum
Generally asymptomatic
When symptomatic:
Headache
Vertigo
Ataxia
Dysphagia dysarthria, hoarseness
Long tract signs
What is the clinical presentation for Basilar Migraine?
Vertigo with nausea & vomiting lasting minutes to hours
May or may not occur with photo/phonophobia
Attacks can be recurrent

*No Dx tests
What is psychogenic vertigo?
Similar to panic attacks and often associated with agoraphobia

Nystagmus absent during vertiginous episode

Tx = Cognitive-Behavioral Therapy
What is true of vertigo in epilepsy?
Vestibular sense is an "aura" that usually accompanies other symptoms

*Purely vestibular epilepsy is rare*