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81 Cards in this Set

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How long does clinical vertigo last?
Greater than a year.
What type of history do patients with clinical vertigo present with?
Vague history
What physical exam finding to patients with clinical vertigo have?
Nystagmus on exam
What type of nystagmus does a central vestibular lesion show?
Vertical nystagmus.
-Vertical nystagmus
-Nystagmus will have a downward beat
-Due to a lesion in the brain
Central vestibular lesion
What type of nystagmus does a peripheral vestibular lesion have?
Mixed torsional horizontal (or downward) pattern of nystabmus
-Mixed torsional horizontal (or downward) pattern of lesioning
-Seen best when the patient is not fixing
-Lesion in the nerve or ear
Peripheral vestibular lesion
What is the #1 cause of vertigo in the vestibular clinic?
BPPV
What are the characteristics of vertigo?
1.Motion/spinning element
2.It's ALWAYS episodic
3.Linked to head movements
4.Nausea (often)
5.Oscillopsia
1.What is oscillopsia?
2.What is oscillopsia a symptom of?
1.A sense of the world moving
2.Nystagmus
What is the first part of the physical exam?
Differentially diagnose, to determine if patient actually has vertigo
What is the second part of the physical exam?
Determine the time course
What is the time frame of vertigo?
Vertigo is always episodic.
What is the #1 cause of vertigo that often only lasts seconds to minutes?
BPPV
Based on the following symptoms,what type of vertigo does the patient have?
1.Short isolated episodes of vertigo
2.Usually precipitated by any head movements
3.Usually worse in the morning
BPPV
Why does BPPV usually occur in the morning?
B/c of debris in the semicircular canals, due to head trauma.
What is the "garbage bag" of the ear since it is the lowest (most caudal) and is where all of the debris settles as these patients sleep at night?
Posterior semicircular canal
What is the ipsilateral posterior semicircular canal hooked up to?
1.Ipsilateral Superior Oblique
2.Contralateral Inferior Rectus
What canal is involved in driving the slow phase of BPPV?
Posterior semicircular canal
What is the posterior semiciruclar canal oreinted in the same plane as?
External Ear
How does one orient their head in the same plane as the posterior semicircular canal?
Turn head 45 degrees and then backward.
When the head is in the same plane as the posterior semicircular canal, what do the eyes do?
They move to the other side and downward.
When the head is in the same plane as the posterior semicircular canal, what moves the eyes?
1.Ipsilateral Superior Oblique
2.Contralateral Inferior Rectus
What does BPPV cause?
Peripheral Vestibular Nystagmus
When diagnosing vertigo, timing of what specific symptom should be the main concern?
How long the vertigo lasts-->ONLY the vertigo. Patient may feel lousy for a while but only want to know how long the vertigo lasts.
What test is used to diagnose BPPV?
Dix-Hallpike test.
When using the Dix-Hallpike test, what is one looking for?
Latency
In the Dix-Hallpike test why does latency occur?
B/c the debris in the bottom of the posterior semicircular canal will begin to resettle due to gravity.
When using the Dix-Hallpike test, when does the nystagmus start?
When resettling of debri in the posterior semicircular canal occurs.
What type of nystagmus does the Dix-Hallpike test induce?
Torsional nystagmus (peripheral vestibular nystagmus)
How long should the nystagmus induced by the Dix-Hallpike test last?
Less than 45 seconds.
The Dix-Hallpike test induces a reversible nystagmus, what does this mean?
1.When you lay the patient down the nystagmus is in one direction.
2.When you sit them up the nystagmus is in the opposite direction.
The nystagmus induced by the Dix-Hallpike test is fatiguable. What does this mean?
The nystagmus will STOP when you've "shaken up" the debris enough.
Is BPPV unilateral or bilateral?
Both-->pt's can usually tell you which ear is the problem
What other diagnostic tool is used to diagnose peripheral vestibular vertigo?
Electronystagmogram
What does an electronystagmogram involve?
Involves squirting warm and cold water or air into each ear and measure the slow phase velocity in each ear for comparison.
In what diagnostic test is BPPV normal?
Electronystagmogram.
What is an important test for fluctuating low frequency hearing loss, accompanied by tinnitus, and if positive is a sign for Menieres?
Rotary chair or audiogram.
What disorders seen on a lab report can cause peripheral vestibular vertigo?
Syphilis or thyroid disorders.
Will an MRI help in an isolated vertigo case?
No
In an isolated vertigo case, what will MRI rule out?
Acoustic Neuroma (vestibular schwannoma)
When should an MRI be considered?
If the patient has asymmetric hearing problems-->due to vestibular schwannoma
What maneuver is used to treat BPPV?
The Epply or Somant Repositioning Maneuver
What is the goal with the Epply or Somant Repositioning maneuver?
To move the debris from the bottom of the posterior semicircular canal all the way to the top of the common arm it shares with the anterior canal, and then dump the debris back into the urticle (where it probably came from to begin with)
Descirbe the steps involved in the Epply or Somant Repositioning maneuver.
1.Turn the head 45 degrees toward affected side
2.Lay the patient back
3.Extend head
4.Slowly roll their body towards the unaffected side, making sure you keep the head down and back
5.The head should finish down and looking towards the unaffected side.
6.Sit the patient up to dump the debris into the utricle.
If the Epply or Somant Repositioning Maneuver is done correctly, what should the patient experience?
A short burst of nystagmus (in the same direction as when you first layed them down). This will occur as the debris falls into the utricle.
What happens if the nystagmus is in the opposite direction when the patient is sat back up after performing the Epply or Somant Repositioning Maneuver?
This means that the debris fell backward (in the wrong direction--back into the posterior semicircular canal)-->patient can be re-treated with the same maneuver.
What meds help BPPV?
NONE
What other symptoms does a TIA present with besides dizziness that lasts seconds to minutes?
Dysphagia, dysarthria, numbness, double vision
Besides a TIA, if the dizziness lasts minutes, what else must be included in the differential diagnosis?
Migraines
If the dizziness lasts for hours, what other differential diagnosis should be taken into account?
Meniere's Disease.
What disease is precipated by high salty foods, and presents with tinnitus, hearing changes, and vertigo developed later on?
Meniere's Disease
If the dizziness lasts for days, what could the patient have?
Vestibular Neuritis
99% of the time, will the patient have pure vertigo?
No, it will be vertigo mixed with other symptoms.
What are the 4 steps involved in a patient with vertigo?
1.Diagnose it
2.Determine the time course
3.Localize the vertigo (Central or Peripheral)
4.Treat it!
If a patient has central vestibular nystagmus related to the brainstem, what other symptoms will they have?
Double vision, dysarthria, dysphasia, weakness, etc. Not as much nausea or vomiting
What clearly signifies a central vestibular nystagmus?
Down beating nystagmus, unaffected by visual fixation.
How is down beating nystagmus unaffected by visual fixation best seen?
Have the patient look down and to the side.
What is the most common brain stroke syndrome often missed in the ER b/c the patient does NOT present with weakness?
Wallenberg's (Lateral Medullary Syndrome)
What will a patient with Wallenberg's Lateral Medullary Syndrome present with?
1.Vertigo
2.Horner's Sign
3.CN V, IX, & X deficiencies
4.Ataxia
5.STT is often involved
What does Wallenburg's Syndrome affect?
1.Descencing tracts of CN5 (ipsilateral facial numbness), sympathetics (Horner's sign), restiform body (ipsilateral ataxia), and vestibular nucleus (vertigo)
What type of nystagmus causes hearing loss, tinnitus, lots of nause & vomiting? Also fixation must be removed to see this one the best.
Peripheral vestibular nystabmus.
What is peripheral vestibular nystagmus due to?
Ear disease-->broken vestibular nerve
What does a broken vestibular nerve cause in peripheral vestibular nystagmus?
A slow torsional drift of the eye toward the side of the vestibular nerve lesion.
To prevent fixation when examining a patient with peripheral vestibular nystagmus, what do physicians use?
Frenzel lenses/opthalamoscope
How is non-BPPV vertigo treated?
Treat vertigo acutely for all of the miserable symptoms (nausea, vomiting,etc)--use a vestibular suppressant or anti-emetic.
What should NOT be done to treat non-BPPV vertigo?
1.Don't treat isolated brief attacks
2.Don't suppress chronically
3.Don't treat non-vestibular etiologies
What does the vestibular ocular reflex do?
It allow us to keep our eyes fixed on a target while moving our head. It MUST be fast.
What are the symptoms for a patient that doesn't have a vestibular reflex?
Everything will be moving a little bit 24 hours a day.
How does the vestibular ocular reflex work?
Semicircular Canal & Vestibular Nerve-->Vestibular Nucleus-->Ocular Motor Nuclei
Does the vestibular ocular reflex work fast or slow?
It MUST be fast!
What are the balance organs in the ear?
Labyrinth
What does the labyrinth consist of?
Utricle + semi-circular canals + otolith organ
What is the purpose of the 3 semicircular canals on each side of the ear?
They are angled in such a way that they allow you to sense acceleration in any plane of motion. They work as a "push-pull" mechanism. The brain will get a message from each side about the direction the head is accelerating in.
What is the purpose of the otolith organ?
Concerned with translational movement and gravity.
How does the vestibular-ocular reflex cause your eyes to move?
Semicircular canal & vestibular nerve-->vestibular nucleus-->ocularmotor nuclei-->cranial nerves involved with sight
What cranial nerves move the eyes vertically and torsionally?
CN III and IV
What cranial nerves move the eyes horizontally?
CN VI and III
If your vestibular-ocular reflex is NOT precise--if your eyes move even 1/2 degree or less different than the amount you move your head, what symptoms will you have?
Blurry vision.
How should the vestibular ocular reflex be tested in a patient?
1.Have pt."fix" at a distant object
2.Quickly turn pt.'s head from side to side
3.If there is damage to the vestibular ocular reflex the eyes will not be able to stay fixed on the target and there will be a brief period of "catch-up" as the eyes refocus back on the target.
Should long-term vestibular suppressants be used?
NO!