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
- 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
- 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
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
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)
|
|
