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56 Cards in this Set
- Front
- Back
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What is the difference between dizziness and vertigo?
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Dizziness - unsteadiness or lightheadedness, encompasses all types of equilibrium disorders: 1. Vertigo - episodic sudden sensation of circular motion of the body or the surroundings, or an illusion of motion. 2. Pseudovertigo: - Giddiness or lightheadedness - Fainting or syncopal episodes - Dysequilibirum |
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What precipitates an episode of vertigo? |
Standing or turning the head or by movement. Patients have to walk carefully and may become nervous about descending stairs or crossing the road and usually seek support. Patients feel as though they are being impelled by some outside force that tends to pull them to one side, especially while walking. |
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What are some of the associated symptoms with vertigo? |
Nystagmus Tinnitus hearing disorders Reflex autonomic discharge - sweating, pallor, nausea and vomiting |
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What peripheral disorders cause vertigo? |
Labyrinth: Labyrinthitis - viral or suppurative Menieres syndrome BPPV Drugs Trauma Chronic suppurative otitis media 8th nerve: Vetibular neuronitis Acoustic neuroma Drugs Cervical vertigo |
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What central disorders cause vertigo? |
Brain stem (TIA or stroke): Vertebrobasilar insufficiency Infarction Cerebellum: Degeneration Tumours Migraine Multiple sclerosis - 5% cases present with vertigo |
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What are the red flags for dizziness/vertigo? What is the commonest brain tumour? |
Neurological signs Ataxia out of proportion to vertigo Nystagmus out of proportion to vertigo Central nystagmus Central eye movement abnormalities Metastatic deposit from lung cancer |
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A patient presents with: DxT: (unilateral) tinnitus + hearing loss + unsteady gait what is the diagnosis? |
Acoustic neuroma Uncommon tumour Headache may occasionally be present Dx - high resolution MRI Audiometry + auditory evoked responses |
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A patient presents with dramatic onset of vertigo with severe ataxia and vomiting, what is the diagnosis? |
Posterior inferior cerebellar artery thrombosis Dramatic onset vertigo + cerebellar signs Ipsilateral cranial nerve signs Dx - CT or MRI |
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What drugs can cause dizziness? |
ETOH Antibiotics - streptomycin, gentamicin, kanamycin, tetracyclines Antidepressants Anti-epileptics - phenytoin Antihistamines Antihypertensives Aspirin or salicylates Cocaine Diuretics in large doses GTN Quinine-quinidine Tranquillisers |
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For a patient presenting with vertigo what essential areas need to be covered in examination? |
Ears - inspection, hearing tests Eyes - visual acuity, movements for nystagmus CVS - BP sitting/standing, ?arrhythmias Cranial nerves - 2nd, 3rd, 4th, 6th, 7th, corneal response, 8th auditory nerve Cerebellum - gait, coordination, reflexes, romberg test, finger nose test Neck - C-spine General search for - anaemia, polycythemia, ETOH dependence |
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What are some of the office tests for dizziness? |
Preform any manoeuvre that may provoke symptoms Head positional testing to induce vertigo and/or nystagmus BP in 3 positions Palpate carotid arteries and carotid sinus +/- forced hyperventilation |
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A young patient presents with a sudden attack of vertigo following a recent URTI, what is the diagnosis? |
Vestibular neuritis (covers both vestibular neuritis and labyrinthitis) - viral infection of the vestibular nerve and labyrinth respectively. Causes prolonged attack of vertigo that can last days to weeks. Abrupt onset vertigo, ataxia, nausea and vomiting, without tints or deafness. |
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What is the treatment of vestibular neuritis? |
Rest in bed, lying very still Gaze in one direction that eases symptoms. Stemetil 12.5mg IM (if severe vomiting) or 5-10mg TDS OR Promethazine 10-25mg IM or slow IV then 10-25mg for 48/24 OR Diazepam 5-10mg IM for the acute attack, then 5mg TDS for 2-3 days. A short course of coritcosteroids may promote recovery. |
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DxT: acute vertigo + nausea + vomiting DxT: same symptoms + hearing loss +/- tinnitus |
Vestibular neuritis Acute labyrinthitis |
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An elderly female patient comes in complaining of vertigo that is induced by changing head position, what is the most likely diagnosis? |
Benign paroxysmal positional vertigo BPPV Common type of acute vertigo Induced by changing head position - tilting head backwards, changing from recumbent to sitting, turning to side. Affects all age, esp elderly, F:M ratio 2:1 Recurs periodically for several days Each attack is brief, lasts 10-60secs, subsides rapidly Severe when getting out of bed Associated nausea - no vomiting/tinnitus/deaf |
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How is the dx of BPPV confirmed? What is the expected outcome of BPPV? |
head position testing - dix hall pike - observe for vertigo or nystagmus tests hearing and vestibular function = normal spontaneous recovery in weeks recurrences are common, attacks occur in clusters |
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What is the management of BPPV? |
Give appropriate explanation and reassurance Avoidance measures Drugs not recommended Special exercises Cervical traction may help Particle reposition manoeuvres - self patient exercises, or with a therapist Surgery - rarely, occlusion posterior semicircular canal |
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A patient presents with: dTx: vertigo + tinnitus + deafness what is the dx? |
Meniere syndrome Caused by a build up of endolymph Commonest 30-50yrs Characterised by paroxysmal attacks of vertigo, tinnitus, N/V, sweating, pallor, progressive deafness Onset is abrupt Attacks last 30mins - several hours Variable interval b/w attacks - 2/mth or 2/yr Nystagmus during attack |
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How is Meniere syndrome diagnosed? |
Sensorineural deafness - low tones Caloric test - impaired vestibular function audiometry - sensorineural deafness, loudness recruitment Special test - characteristic changes in electrocochleography |
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What is the treatment of Meniere syndrome? |
Aim to reduce endolymphatic pressure by reducing Na/water contact of the endolymph Acute attack - anticipated: Prochlorperazine 25mg suppository Diazepam Long term: Reassurance Avoid salt, tobacco, coffee Low salt diet (<3g/day) Alleviate anxiety Refer for neurological assessment Diuretic Surgery - for intractable cases |
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A young patient with a family history of migraines, presents with bouts of vertigo that are followed by a headache, without any aural symptoms, what is the likely diagnosis? |
Vestibular migraines Relatively common cause of vertigo Suspect if past/family hx of migraines OR Hx recurrent bouts of spontaneous vertigo or ataxia that persist for hrs-days Vertigo can take place of aura that precedes headache or may be the migraine equivalent. N/V may be present. Rx: pizotifen or propranolol prophylaxis. |
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What are the indications for referring patients presenting with vertigo? |
Uncertain dx, especially in children Possibility tumour or bacterial infection Vertigo in prevent of suppurative OM despite antibiotic therapy Vertigo post trauma Meniere syndrome Vertebrobasilar insufficiency BPPV persisting for >12mths despite Rx with particle repositioning exercises |
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A 60yr old patient presents with reading difficulty, difficulty recognising faces, problems driving at night, reduced ability to see in bright lights, and is seeing haloes around lights, what is the MOST likely diagnosis? |
Cataract - lens opacity Symptoms depend on degree/site opacity Causes gradual visual loss, normal direct pupillary light reflex Prevalence increases with age |
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What are the common causes of cataracts? |
Age DM Steroids - topical or oral Radiation - long exposure to UV light TORCH organisms - congenital cataracts Trauma Uveitis Dystrophia myotonica Galactosaemia |
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In a patient with cataracts what will be found on examination? |
Reduced visual acuity Diminished red reflex on ophthalmoscopy Change in appearance of the lens |
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What is the management of cataracts? |
Advise extraction when the patient cannot cope CI for extraction - intraocular inflammation and severe diabetic retinopathy The removal of lens is replaced by an intraocular lens implant, full visual recovery can be 2-3/12 Cx - opacities behind the lens implant Postoperative advice - avoid bending for a few wks, avoid strenuous exercise, may be prescribed drops - steroids (reduce inflammation), antibiotics, dilators (prevent adhesions) |
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What advice can we give our patients to prevent cataracts? |
Sunglasses - especially that wrap around and filter UV light, offer protection against cataract formation. |
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What is the commonest cause of irreversible blindness in middle age? |
Chronic glaucoma - at a very large stage it presents as difficulty in seeing because of loss of the outer fields of vision due to optic atrophy. |
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What are the clinical features of chronic glaucoma? |
Familial tendency No early signs or symptoms Central vision usually normal Progressive restriction of visual field |
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What investigations are used to detect glaucoma? |
Tonometry - upper limit normal is 22mmHg Opthalmoscopy - optic disc cupping >30% of total disc area |
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What is the management of glaucoma? |
Treatment can prevent visual field loss Medication (for life) usually selected from: - Timolol or betaxolol drops BD - Latanoprost drops, daily - Pilocarpine drops QID - Dipivefrine drops BD - Acetazolamide (oral diuretics) Surgery/laser therapy if failed medication |
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A patient presents with unrelenting pain in their eye, the eye appears reddened, with corneal clouding and a fixed dilated pupil. What is the diagnosis? |
Acute glaucoma. Patients require urgent referral to ophthalmologist. |
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A patient presents after being on holidays in the tropics and swimming everyday with an itchy, painful, fullness in the ear, that is making it hard to hear, what is the MOST likely diagnosis? |
Acute diffuse otitis externa (swimmer's ear) Follows skin maceration of the external ear canal from water exposure. Common cause: Pseudomonas aeruginosa Staphylococcus aureus Other bacterial or fungal causes are much less common, though Candida or Aspergillus species may be isolated from cultures, particularly following prolonged antibiotic use. |
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What is the management of otitis externa? |
1. Keep ear canal as dry as possible. Remove discharge from the ear canal by dry aural toilet, not by syringing with water. Dry aural toilet involves dry mopping the ear with rolled tissue spears or similar, 6-hourly until the external canal is dry. 2. Adequate analgesia 3. Instil combination corticosteroid and antibiotic ear drops after performing aural toilet; use: Sofradex 3 drops, TDS for 3-7 days OR Locacorten 3 drops, TDS for 3-7 days 4. If suspect a fungal infection use locacorten OR Kenacomb 3 drops, TDS for 3-7 days Pump the tragus for 30 secs after instilling ear drops. |
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What additional management can be used for severe cases of acute otitis externa where the ear canal is particularly swollen? |
Severe cases of acute diffuse bacterial otitis externa can be treated by inserting into the ear a wick that has been soaked in the combination corticosteroid and antibiotic ear drop preparation. |
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Is there any use for systemic antibiotic therapy in acute otitis externa? |
Systemic antibiotic therapy provides no additional benefit to topical therapy, unless there is fever, spread of inflammation to the pinna, or folliculitis, then use: - di/flucloxacillin 500 mg (child: 12.5 mg/kg up to 500 mg) QID for 5 days. |
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How can recurrent otitis externa be prevented? |
Recurrence of diffuse otitis externa can be prevented by keeping the external ear canal free of water. This can be achieved by using: Acetic acid plus isopropyl alcohol ear drops following exposure to water; instil 4 to 6 drops into each ear after shaking the water out OR Earplugs during showering and swimming. |
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What is a rare complication of acute diffuse otitis externa, characterised by the spread of infection to cartilage and bone in the external canal and base of the skull, that cannot be missed? |
Necrotising (malignant) otitis externa It mostly occurs in patients with diabetes, or in immunocompromised or elderly patients. It is almost always caused by Pseudomonas aeruginosa. Patients present with apparent treatment failure, fever, severe persistent pain, visible granulation tissue and progressive cranial neuropathies. Urgent referral to an infectious diseases physician and otolaryngologist is necessary. Systemic therapy is indicated; initially use an antipseudomonal regimen. |
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Why is the diagnosis of AOM difficult? |
Diagnosis of AOM is difficult because many children with a viral URTIs have mild inflammation of the middle ear, with visible reddening and dullness of the tympanic membrane. |
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What causes AOM? |
AOM can be either viral or bacterial (or mixed) in origin, but regardless of cause, it is usually self-limiting. Bacteria cause 2/3s cases. Commonest organisms: Streptococcus pneumoniae Non-typeable Haemophilus influenzae Moraxella catarrhalis. |
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What makes a diagnosis of AOM likely? |
1) Acute onset of signs and symptoms 2) A demonstrable middle ear effusion (MEE) characterised by any of the following: – bulging TM – limited/absent movement TM in response to changes in air pressure from a pneumatic otoscope – air–fluid level behind the TM – perforation TM with otorrhoea 3) Signs and symptoms of middle ear inflammation, characterised by redness of the tympanic membrane. |
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What is the treatment of AOM? |
The mainstay is NOT routine antibiotics. Adequate and regular analgesia is essential. Close follow up, if worsening = antibiotics. Controlled trials have not demonstrated a benefit with the use of decongestants or antihistamines in AOM. |
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In which situations of AOM are antibiotics indicated? |
If symptoms don't settle/worsen while doing watchful waiting, within 2-3/7 All children with systemic features - high fever, vomiting, lethargy Children <6/12 ATSI population |
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If antibiotics are being used for AOM what dose is recommended? |
Amoxycillin 15 mg/kg (max 500 mg) TDS for 5 daysOR (for patients suspected to be nonadherent) Amoxycillin 30 mg/kg (maxi 1g) BD for 5 days. |
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If patients have an inadequate response to amoxycillin therapy after 48-72hours what should be added? |
Patients who have an inadequate response to amoxycillin therapy within 48 to 72 hours may have infection caused by a beta-lactamase–producing strain of H. influenzae or M. catarrhalis; adding clavulanate provides increased activity against these pathogens. Use: Amoxycillin+clavulanate 22.5+3.2 mg/kg up to 500+125 mg orally, TDS for 5-7 days. If they still have an inadequate response - consider admission to hospital. |
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What are the rare complications of otitis media that require urgent referral? |
Mastoiditis Facial palsy |
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Should antibiotics be used if the patient has persistent middle ear fluid once recovered from AOM? |
Antibiotic treatment is not required for patients who have persistent middle ear fluid (for up to 3 months), unless other acute symptoms are present. By 3 months, 90% of effusions will have resolved spontaneously - check the patient's hearing. Persistence of effusion >3/12 is called persistent otitis media with effusion. |
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What are the risk factors for recurrent bacterial otitis media? What is the management of recurrent bacterial otitis media? |
Exposure to smoke (cigarettes, wood fires) Group child care Allergic rhinitis Adenoid disease Various structural anomalies, such as cleft palate and Down syndrome. Antibiotic prophylaxis has limited impact on the rate of recurrence. Frequent recurrence may require myringotomy and insertion of ventilation tubes (grommets).If recurrent infection occurs, manage as for acute otitis media. |
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What is persistent otitis media with effusion? |
Persistent OME (or glue ear) is the presence of a middle ear effusion for >3 months. Diagnosis is very difficult. Patients can present with behavioural problems due to undetected hearing loss; very rarely, patients present with conductive hearing loss, imbalance, or dull aching otalgia. |
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What are the clinical signs of persistent OME? |
Visible loss of lucency TM Visible grey-white or blue fluid Immobile TM with dilated blood vessels on pneumatoscopy, without signs of acute inflammation. |
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In persistent OME should antibiotic treatment be used? |
Some children with persistent OME, especially ATIS and children with risk factors for recurrent bacterial AOM, are at high risk of developing chronic suppurative otitis media and may benefit from a 3-6/12 course of amoxycillin (same as AOM dose). It is unclear whether longer courses are beneficial. |
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What is another treatment option for persistent OME? |
Traditional treatment is the insertion of a ventilation tube (grommets) through the TM, which restores hearing in the short term. Long-term improvements in learning have not been demonstrated. Modify risk factors for AOM. |
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When should referral to an ENT be made? |
Effusion lasting <3/12 associated with speech delay or educational handicap. Effusion lasting >3/12 and audiometry that shows bilateral hearing loss. Structural damage to the TM (significant retraction, cholesteatoma). |
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What is chronic suppurative otitis media? |
CSOM is an infection of the middle ear with a perforated eardrum and discharge for >6 wks. CSOM can cause hearing impairment and disability. Occasionally it can lead to serious complications, such as intracranial infections and acute mastoiditis, especially in developing countries. |
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How is CSOM managed? |
1. Cleaning the external ear canal by dry aural toilet should be performed before instilling ear drops. Dry aural toilet involves dry mopping the ear with rolled tissue spears, 6-hourly until the external canal is dry. 2. Ciprofloxacin 0.3% ear drops 5 drops instilled into the affected ear, BD until the middle ear has been free of discharge for at least 3 days. 3. Persistent discharge may require prolonged courses of treatment. Referral to an otolaryngologist is recommended to exclude cholesteatoma or chronic osteitis. |
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If there is a recent perforation (within the last 6/52) causing ear discharge, what is the treatment? |
Treat with both oral antibiotic therapy (dose for AOM) and topical antibiotic therapy (dose for CSOM). |
