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)