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13.04.10 Vestibular pathologies

Acute vestibular neuritis (labyrinthitis)
  • Symptoms
    • Acute onset of vertigo
    • N + V
    • No hearing loss or tinnitus (doesn't affect cochlea)
    • Non-recurring
  • Signs
    • Nystagmus
      • Unidirectional
        • Direction of nystagmus is to the opposite side of the lesion (c.f. irritative)
      • Horizontal
      • Conjugate
      • Enhanced by removal of optic fixation
        • Frenzel glasses
      • Obeys Alexander's law
        • Frequency increases if you look in the direction of the fast component
    • Positive rightwards horizontal head impulse test
      • Ask patient to focus on your nose and rapidly move head to the right => Eyes follow head and must jump back to your nose
    • Rightwards rotation on Unterberger test
  • Aetiology
    • Caused by viral infection
  • Management
    • Symptomatic treatment with antiemetics
    • Symptoms resolve in 6-12 weeks (vestibular compensation)
    • Can use vestibular rehabilitation (Cawthorn-Cooksey)


Ménière's

  • Incidence
    • 1-2/10,000
  • Symptoms
    • Sudden onset severe vertigo
    • Nausea
    • Unilateral aural fullness
    • Unilateral tinnitus
    • Fluctuating unilateral hearing loss
  • Diagnostic criteria
    • Two or more episodes of vertigo lasting 20 mins or longer
    • Documented low-frequency hearing loss on at least one occasion
    • Tinnitus or aural fullness
  • Mangement
    • Reduce fluids:
      • Strict low-salt diet
      • Restrict fluid intake
      • Diuretic (Bendroflumethiazide 2.5-10 mg OD)
  • Aetiology
    • Endolymphatic hydrops?


Benign paroxysmal positional vertigo

  • Symptoms
    • Sudden onset brief attacks of severe vertigo, lasting seconds-minutes (may think they've had a stroke)
    • Triggered by head position
    • More common in elderly or following head trauma
  • Aetiology
    • Dislocation of otoliths, which float around semi-circular canals
  • Diagnosis
    • Dix-Hallpike manoeuvre
      • Rapidly lie patient down and tilt head to the side
      • Observe nystagmus - If it beats towards the ground, the lesion is on that side
  • Management
    • Epley manoeuvre to empty semicircular canals


Migraine associated vertigo

  • Symptoms
    • Episodic vestibular symptoms
    • At least two migrainous symptoms during at least two vertiginous attacks
      • Migrainous headache
      • Photophobia
      • Phonophobia
      • Visual or other aurae
    • Attacks of migraine (by IHS criteria) outside episodes of vertigo
  • Management
    • Behavioural / non-pharmacological interventions
    • Preventative medication
      • Topiramate, divalproex/sodium valproate, propranolol, metoprolol
    • Symptomatic medication
      • Paracetamol, aspirin, NSAIDs, sumatriptan

Other rare causes
  • Vestibulotoxicity
  • Central pathology


Key history questions:
  • Onset
    • One acute (labyrinthitis)
    • Recurrent (Ménière's)
  • Auditory symptoms
    • Yes (Ménière's)
    • No (labyrinthitis)
  • Trigger
    • Yes (BPPV)
    • No (Ménière's / labyrinthitis)
  • Associated symptoms
    • Yes (Central problem)


Notes
  • Otoliths
    • In saccule + utricle
    • Shouldn't ever be in semicircular canals
  • Supratentorial region contains the cerebrum; infratentorial region contains the cerebellum
  • Oscillopsia: Visual disturbance in which objects in the visual field appear to oscillate (can be from vestibular dysfunction)
  • Criteria for adult migraine without aura:
    • A) 5 or more attacks fullfilling B-D
    • B) Headache lasting 4-72 hours
    • C) Headache has at least two of:
      • Unilateral 
      • Pulsating
      • Moderate to severe
      • Aggravated by physical activities
    • D) At least one of:
      • N and/or V
      • Photophobia and phonophobia
    • E) Not attributed to another disorder
  • Caloric test (warm water) for horizontal semicircular canal (good as can test each side independently)

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