PANCE Blueprint EENT (6%)

55 y/o male with dizziness

Patient will present as → a 29-year-old male with intense nausea and vomiting that began yesterday. He states that he ran a 5K race in the morning and felt well while resting afterward. However, when he arose, he experienced two episodes of emesis accompanied by a sensation that the world was spinning around him. This lasted about one minute and subsided. He denies tinnitus or hearing changes but feels imbalanced. He has a PMH of migraines, but he typically does not have nausea or vomiting with migraine episodes. His temperature is 98.7°F, blood pressure is 132/82 mmHg, pulse is 75/min, and respirations are 13/min. The cardiopulmonary exam is unremarkable. Cranial nerves are intact, and gross motor function and sensation are within normal limits. When the patient’s head is turned to the right side and lowered quickly to the supine position, he claims that he feels “dizzy and nauseous.” Nystagmus is noted in both eyes.

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Vertigo is the sensation of movement (spinning, tumbling, or falling) in the absence of any actual movement or an over-response to movement.

• Peripheral (inner ear) causes of vestibular dysfunction include labyrinthitis, benign paroxysmal positional vertigo, Ménière syndrome, vestibular neuritis, and head injury
• Central (neurologic) causes of vertigo include brainstem vascular disease, arteriovenous malformations, tumors, multiple sclerosis, and vertebrobasilar migraine

Duration and presence of hearing loss/nystagmus can help with the diagnosis

• Peripheral vertigo is associated with sudden onset, nausea/vomiting, tinnitus, hearing loss, and nystagmus (typically horizontal with a rotatory component)
• Central vertigo is associated with a more gradual onset and vertical nystagmus. Unlike peripheral vertigo, it does not present with auditory symptoms. Central vertigo is commonly associated with motor, sensory, or cerebellar deficits.

Vertigo and syncope = vertebrobasilar insufficiency

Overview

Clinical features of peripheral versus central vertigo

• With benign positional vertigo, the Dix–Hallpike maneuver (i.e., quickly turning the patient’s head 90 degrees while the patient is in the supine position) will produce delayed fatigable nystagmus (nystagmus abates when the provocative position is held for a long time)
• If the nystagmus is non-fatigable (not inhibited by fixation of gaze), a central cause for the vertigo is more likely
• Other testing, such as audiometry, caloric stimulation, electronystagmography (ENG), MRI, and evoked potentials, are indicated with persistent vertigo or with suspected central nervous system (CNS) involvement
• + Romberg Sign = central vertigo

Therapy is based on the underlying etiology

• Vestibular suppressants (i.e., diazepam, meclizine) may help with acute symptoms
• Benign paroxysmal positional vertigo may respond to physical therapy maneuvers (Epley Maneuver)
• Some cases may require interventional/surgical therapies