PANCE Blueprint EENT (9%)

Vertigo (ReelDx)

VIDEO-CASE-PRESENTATION-REEL-DX

Vertigo

Patient will present as → a 27-year-old male with intense nausea and vomiting that began yesterday. He states that he ran a 15-kilometer race in the morning and felt well while resting in a hammock afterward. However, when he rose from the hammock, he experienced two episodes of emesis accompanied by a sensation that the world was spinning around him. This lasted about one minute and self-resolved. He denies tinnitus or hearing changes, but he notes that he still feels slightly imbalanced. He has a past medical history of migraines, but he typically does not have nausea or vomiting with the headaches. At this visit, the patient’s temperature is 98.5°F (36.9°C), blood pressure is 126/81 mmHg, pulse is 75/min, and respirations are 13/min. 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 he is lowered quickly to the supine position, he claims that he feels “dizzy and nauseous.” Nystagmus is noted in both eyes

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, endolymphatic hydrops (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 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 = vertebral basilar insufficiency

Overview

Disease Characteristics Symptoms Diagnostic Test Treatment
Benign positional vertigo Changes with position Vertigo without hearing loss, tinnitus, or ataxia MRI of internal auditory canal Diagnosis: Dix-Hallpike maneuver

Treatment: Epley maneuver

Meclizine

Vestibular neuritis Vertigo without postion changes Vertigo but no hearing loss or tinnitus(inflammation of vestibular portion of CN VIII) Meclizine
Labyrinthitis Acute, self-resolving episode Vertigo

Hearing loss

Tinnitus

Self-limited

Meclizine + steroids
Meniere's disease Chronic remitting and relapsing episodes Vertigo

Hearing loss

Tinnitus in achronic remitting and relapsing manner

Diuretics

Salt restriction

Unilateral CN VIII ablation (severe cases)

Perilymph fistula History of trauma Vertigo from Trauma Fix damage surgically
Acoustic neuroma Ataxia

Neurofibromatosis type II

MRI findings

Vertigo

Hearing loss

Tinnitus ANDataxia

Surgical intervention

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 a delayed fatigable nystagmus.

  • If the nystagmus is nonfatigable, 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

Question 1
A 23 year-old graduate student presents with sudden onset of severe dizziness, with nausea and vomiting for the past couple of hours. She denies hearing loss or tinnitus. She has had a recent cold. Which of the following is the most likely diagnosis?
A
Ménière's disease
Hint:
Ménière's disease is associated with hearing loss, tinnitus, and vertigo that lasts from seconds to hours.
B
Vestibular neuronitis
C
Benign positional vertigo
Hint:
Benign positional vertigo occurs with changes in position, especially rapid movements of the head. Nausea may occur, but vomiting is not significant.
D
Vertebrobasilar insufficiency
Hint:
Vertebrobasilar insufficiency is usually accompanied by brain stem findings, such as diplopia, dysarthria, or dysphagia, and is not common in this age group.
Question 1 Explanation: 
Vestibular neuronitis or labyrinthitis presents with vertigo, nausea, and vomiting, but not hearing loss or tinnitus. It is related to viral URIs, and develops over several hours, with symptoms worse in the first day, with gradual recovery over several days.
Question 2
A patient presents with complaint of sudden onset of recurrent episodic vertigo for one week that happens when rolling onto the left side. The patient states that this sensation lasts approximately 30 seconds and then goes away. The patient admits to associated nausea. The patient denies associated hearing difficulties or tinnitus. Which of the following is the most likely diagnosis?
A
Benign positional vertigo
B
Ménière's disease
Hint:
Ménière's disease is characterized by a sudden onset of vertigo that lasts several hours to more than a day. Patients typically have sensorineural hearing loss and tinnitus.
C
Acoustic neuroma
Hint:
Acoustic neuroma is characterized by an insidious onset of vertigo with impaired unilateral hearing and the presence of tinnitus.
D
Vestibular neuronitis
Hint:
Vestibular neuronitis (acute labyrinthitis) has a sudden onset of vertigo lasting hours to two weeks. There is no hearing impairment or tinnitus.
Question 2 Explanation: 
Benign positional vertigo is characterized by the sudden onset of vertigo when rolling onto the affected side or tilting the head up. The typical duration is less than a minute. There can be associated nausea and vomiting. There is n
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