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ENT: Vertigo and Tinnitus
Vertigo and Tinnitus ENT
73
Anatomy
Graduate
10/04/2011

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Term
Vertigo is caused by issues with the __ and __ systems.
Definition
auditory and vestibular
Term
Near-faint dizziness suggests problems with the ___ system.
Definition
cardiovascular
Term
Psychophysiological dizziness has a __ origin.
Definition
psychiatric
Term
Hypoglycemic index needs __ __.
Definition
metabolic assessment
Term
Disequillibrium is caused by issues with the __ __, __ __, __ __, __, and __.
Definition
- peripheral nerves
- spinal cord
- inner ear
- vision
- CNS
Term
40% Peripheral vestibular dysfunction
10% Central brainstem vestibular lesion
25% Presyncope or disequilibrium
15% Psychiatric disorder
10% Unknown cause
Definition
Term
Vertigo is the illusion of __, usually __. The patient may perceive that he is moving while the environment is still, or vice versa.
Definition
- movement
- spinning
Term
Vertigo is caused by a defect in 1 of 3 systems:
Definition
- Vestibular system (most common)
- Visual system
- Somatosensory system
Term
Most common system disorder responsible for vertigo?
Definition
vestibular system dysfunction
Term
With vertigo it is important to distinguish between __ and __ vertigo. __ vertigo has a poorer prognosis than __ vertigo.
Definition
- central and peripheral vertigo
- Central vertigo has a poorer prognosis than peripheral vertigo.
Term
Central vertigo means tumor/cns problem until proven otherwise.
Peripheral is usually self limiting in most cases.
Definition
Term
History of dizzy patient:
Definition
Detailed description of dizziness
Differentiate vertigo from non-vertigo
Determine onset, length, and if recurrent
Associated neurological or systemic signs
Any hearing loss?
Current medications
Differentiate Peripheral vs. Central cause
Term
3 classes of medications that may cause dizziness:
Definition
- Anti-cholinergics
- Diuretics
- Anti-HTN meds
Term
Peripheral vertigo has __ or __ __ __, while central vertigo has __ or __ __ __.
Definition
- labyrinth or vestibular nerve dysfunction
- cerebellum or brain stem dysfunction
Term
Peripheral vertigo is __, while central vertigo is ___.
Definition
- recurrent
- continuous
Term
Peripheral vertigo shows __ nystagmus, while central vertigo shows ___ nystagmus.
Definition
- horizontal
- vertical
Term
Peripheral vertigo tends to be __, while central vertigo is __.
Definition
positional
nonpositional
Term
Peripheral vertigo tends to __ to __, while central vertigo is __.
Definition
- moderate to severe
- mild
Term
Peripheral
Labyrinth or vestibular nerve dysfunction
Recurrent
Nystagmus-horizontal
Position change
Moderate to severe vertigo
Definition
Central
Cerebellum or brain stem dysfunction
Continuous
Nystagmus-vertical
Mild vertigo
Non-positional
Term
does peripheral or central vertigo cause more patient distress?
Definition
peripheral

Peripheral vertigo causes more pt distress even though the episodes are shorter
Term
Peripheral vertigo
Definition
Tends to cause more patient distress, although the episodes are briefer. [The central nervous system (CNS) tends to adapt, shortening episodes in patients with peripheral vertigo.]
There are no brain stem, cerebellar, or cerebral hemispheric signs.
Term
Peripheral horizontal nystagmus is inhibited by __ __, central vertigo is not.
Definition
visual fixation
Term
Peripheral vertigo has ___, __, and has its fast component towards the the side of the __ ear.
Definition
- unidirectional, horizontal
- normal
Term
Tinnitus or hearing loss are often associated with __ vertigo.
Definition
peripheral
Term
Brain stem, cerebellar/cerebral hemispheric signs that occur with central vertigo:
Definition
- headache
- limb ataxia
- true weakness
- paresthesias
- dysarthria
- diplopia
Term
__ or __ __ are NOT associated with central vertigo.
Definition
Tinnitus or hearing loss are NOT associated with central vertigo
Term
Peripheral Vestibular Disorders:
Definition
- BPPV
- Labrynthitis
- Meniere's disease
- Acoustic neuroma
- Motion sickness
- Cervicogenic
- Perilymphatic fistula
- Vestibular neuronitis
- Semicircular canal infection
- Semicircular canal water penetration
Term
Pneumonic to remember most common causes of Peripheral vertigo:
Definition
AMPLITUDE

- Acoustic neuroma
- Meniere's disease
- Positional vertigo
- Labrynthitis
- Infection of the middle or inner ear
- Trauma
- Unconventional-psycogenic (consider when normal neuro exam)
- Drugs
- Endocrine disorders
Term
Central Vestibular Disorders:
Definition
- Brain stem lesion
- Basilar artery migraine
- TIA
- Stroke
- MS
- Cerebellar lesions
- Metastatic tumor
- Meningioma
Term
Mneumonic to remember causes of central vertigo:
Definition
SPIN
- Sclerosis (MS)
- Pretty bad migraine (especially basilar)
- Ischemia or CNS lesion (especially basilar transient ischemic attack )
- Neuroma (acoustic neuroma)
Term
3 physiologic components of balance:
Definition
- Vestibular: labyrinth, vestibular nuclei
- Visual- CN III, IV, and VI
- Proprioceptive: upper cervical ms and joints
Term
Subjective vertigo:
Definition
patient feels that they are spinning
Term
Objective vertigo:
Definition
- patient feels still but objects around them seem to be spinning
Term
Causes of vertigo:
Definition
- Ear disease
- Toxic conditions (alcohol, food poisoning)
- Postural hypotension
- Infectious disease
- Cervicogenic
- Disease of the eye or brain
- Psychological
Term
BPPV (Benign Paroxysmal Positional Vertigo):
Definition
- BRIEF EPISODES
- RECURRENT
- ASSOCIATED WITH HEAD POSITION
- NO HEARING LOSS
- POSITIVE NYLEN-BARANY MANEUVER
- CAUSED BY OTOCONIA DEBRIS FLOATING IN PSC
- moderate to severe
- gradually diminishes over a month or two
- latency or delayed onset of s/s
Term
Nylen Barany maneuver aka __ __ maneuver.
Definition
Dix-Hallpike
Patient seated, head turned 45 degrees
Patient quickly lays supine
Latency period, then horizontal or rotational nystagmus
Nystagmus decreases after 10-20 seconds
Affected ear is the side head is turned toward when nystagmus and vertigo occurs
Term
With the Dix-Hallpike maneuver, the affected ear which one?
Definition
the affected ear is the side the head is turned towards when nystagmus occurs
Term
Treatment options for BPPV:
Definition
- Epley's
- Sermont's
- Habituation exercises (Brandt-Daroff)
- Cervical adjusting
Term
Modified Epley Maneuver;
Definition
Patient placed supine with head turned 45 degrees toward the affected ear (30 sec.)
Dr. turns head 90 degrees so affected ear is up. (30 sec.)
Patient rolls on to side, head looking toward the floor (30 sec.)
Patient is lifted into sitting position
Procedure is repeated until no nystagmus
Term
Sermont's maneuver can be done at home. Explain how to do this:
Definition
Patient turns head 45 degrees away from the affected side
Quickly lays down maintaining head position (4 minutes)
Brought up and placed on other side with same head position. (4 min) Sit up normal
Term
Post Maneuver Instructions:
Definition
Patient waits 10 min. before leaving office.
Other person drives them home.
Sleep half-reclined 2-3 days.
Avoid laying on bad side.
Avoid extreme head extension for 2-3 days
Term
DOC for BPPV:
Definition
Meclizine (Antivert) 12.5 to 50 mg orally every 4-8 hours
Term
Common medications used for BPPV and vertigo:
Definition
Meclizine* (Antivert) 12.5 to 50 mg orally every 4 to 8 hour
Dimenhydrinate* (Dramamine) 25 to 100 mg orally, IM, or IV every 4 to 8 hours
Diazepam (Valium) 2 to 10 mg orally or IV every 4 to 8 hours
Lorazepam (Ativan) 0.5 to 2 mg orally, IM, or IV every 4 to 8 hours
Metoclopramide (Reglan) 5 to 10 mg orally every 6 hours
5 to 10 mg by slow IV every 6 hours
Prochlorperazine (Compazine) 5 to 10 mg orally or IM every 6 to 8 hours 25 mg rectally every 12 hours (nausea and vomiting)
5 to 10 mg by slow IV over 2 minutes
Promethazine (Phenergan) 12.5 to 25 mg orally, IM, or rectally every 4 to 12 hours

also can do scopalamine
Term
Cervicogenic vertigo:
Definition
- hx of neck trauma/muscle spasm
- limited cervical ROM
- positive chair rotation test (Fitz-Ritson)
- complain more of dysequilibrium (tilt) more than rotational vertigo
- overstimulation of upper cervical proprioceptors
- may overlap with BPPV or Meneire's disease
Term
Vertebrobasilar Insufficiency TIAs:
Definition
- vertigo with associated neurological signs
- diplopia
- ataxia
- drop attacks
- dysarthria
- paralysis/weakness/numbness
- headache
- risk factors (HTN, Diabetes, Coronary Disease)
Term
Meniere's Disease presenting symptoms:
Definition
- SUDDEN AND RECURRENT (PAROXYSMAL) ATTACK OF SEVERE VERTIGO
- LOW TONE HEARING LOSS
- LOW TONE TINNITUS
- SENSE OF FULLNESS IN THE EAR
- VERTIGO LASTS FOR HOURS TO DAYS AND THEN BURNS OUT
- HEARING LOSS MAY PROGRESS
Term
4th leading cause vertigo:
Definition
Meniere's Disease
Term
Meniere's disease is caused by __ or __ of __, possible __ etiology, __ __, __ __. ___ __ are more prone.
Definition
- overproduction or retention of endolymph
- autoimmune etiology
- head trauma
- previous infection
- Pregnant females
Term
Management of Meniere's:
Definition
- salt-restriction diet
- diuretic therapy
- cervical adjusting (overlaps with cervicogenic vertigo)
Term
Perilymphatic fistula pts usually have a history of __ __ __ like an __ or __ __.
Definition
- barometric pressure changes
- airplane
- weight lifting
Term
With a perilymphatic fistula an __ develops between the __ and __ ear, called an __ __ __. This is a rare cause of __. __ __ reproduces signs and symptoms. Treatment is __.
Definition
- opening
- middle and inner ear
- oval window rupture
- rare cause of vertigo
- Bearing down
- surgery
Term
Labrynthitis is __ __ vertigo that lasts __ to __. Pts may have __ and __. If the cause is viral, there is __ __ __. If the cause is __ there is __ __.
Definition
- sudden severe
- days to weeks
- nausea and vomiting
- viral> no hearing loss
- bacterial> hearing loss
Term
Acoustic Neuroma has __ but __ hearing loss. Pts will have __ and possible __. The onset is __.
Definition
- mild but constant hearing loss
- dizziness with possible tinnitus
- gradual
Term
Common acoustic neuroma:
Definition
Benign schwannoma of 8th CN
Term
tmt of acoustic neuroma:
Definition
surgery
Term
Cerebral hemorrhage presents with __ vertigo and ___. Often there is __ associated with a __. List more symptoms.
Definition
- sudden vertigo
- nausea
- vomiting associated with headache
- nystagmus
- nuchal rigidity
- facial paralysis
- ataxia
- dysrhythmia
- small reactive pupils
Term
There is a history of __ in 2/3 of pts with cerebral hemorrhage.
Definition
hypertension
Term
When to refer:
Definition
Serious vertigo that is disabling
Ataxia out of proportion to vertigo
Vertigo longer than 4 weeks
Changes in hearing
Vertical nystagmus
Focal neurological signs
Systemic disease or psychological origin
Term
Tinnitus:
Definition
- perception of sound produced involuntarily within the body
- symptom of life threatening disease or benign annoyance
- psychological effects can be severe
Term
Objective tinnitus is __ to the __ or __. This encompasses all ___ causes. It can be __ or ____.
Definition
- audible to the physician or observer
- parauditory
- pulsatile or non-pulsatile
Term
Vascular abnormalities that may cause objective tinnitus:
Definition
- neoplasm
- Arteriovenous malformations (AVM)
- arterial bruit
- venous hum
Term
____ is a fast spasm/contraction of the muscles of the roof of the mouth that may cause tinnitus.
Definition
Palatomyoclonus
Term
H&P of objective tinnitus:
Definition
Relation to the heart rate, light exercise
Thorough ENT exam, particulary otoscopy
Exam for retrotympanic mass
Auscultate ext. canal, orbit, mastoid, skull, and neck
Audiogram
Term
Subjective tinnitus originates in the __ system.
Definition
auditory
Term
Is subjective or objective tinnitus more common?
Definition
subjective
Term
There is little known about the physiologic cause of subjective tinnitus, proposed theories suggest the following 3 causes:
Definition
- hyperactive hair cells/nerve fibers
- chemical imbalance
- reduced suppressive influence of CNS
Etiologic factors - otologic, cardiovascular, metabolic, neurologic, pharmacologic, dental, psychological
H/O noise exposure and related symptoms - hearing loss, vertigo
Exact characterization of tinnitus quality
Perceptual location
Term
More possible causes of subjective tinnitus:
Definition
Head injury, whiplash injury, meningitis, multiple sclerosis
Medications - aspirin, aspirin compounds, aminoglycoside antbiotics, NSAIDS, heterocycline antidepressants
TMJ, dental abnormalities prevalent
Psychologic factors, somatoform disorder, Depression
Term
Medications that may cause subjective tinnitus:
Definition
- Aspirin
- Aminoglycoside antibiotics
- NSAIDS
- Heterocycline antidepressants
Term
Overdose of ASA> ringing of the ears. ASA is a huge culprit. BC powder= buffered ASA- causes this too.
Definition
Term
tinnitus treatment counseling:
Definition
Etiologic factors
After work-up, unlikelihood of tumor or life-endangering disease
25% improve or go away, 50% decrease, 25% persist, very small portion increase
Avoid loud noise, wear ear protection
Avoid caffeinated beverages, stimulants (coffee, tea, colas, chocolate)
Stop smoking
Term
environmental masking of tinnitus;
Definition
For mild tinnitus esp. bothersome in quiet
Home environmental maskers
Broad-band noise, between FM stations
Particularly useful at night
Required noise soft usually does not disturb family members
Term
Hearing aids and maskers for tinnitus:
Definition
Saltzmann and Ersner (1947) - hearing aids amplified background noise, mask tinnitus
If hearing loss try HA, less interference with speech, no noise to produce damage, improve speech understanding
Commercial tinnitus maskers with or without HA
Complete or partial mask
No clear guidelines for use
Term
Surgery can be effective if cause of tinnitus is __, __ __, or __ __. Literature discusses __ __ and __ __ of the cochlear nerve. BUT RESULTS ARE NOT CONSISTENT AND FEW OTOLOGISTS ADVOCATE FOR SURGERY.
Definition
- otosclerosis
- acoustic neuroma
- glomus jugulare
- cochlear neurectomy
- microvascular decompression of the cochlear nerve
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