Vertigo and Tinnitus

History

- As above, ensure you understand exactly which symptomatic entity the patient is describing i.e. is the patient truly describing vertigo?
- Timing: how long does it last?
- Onset: is it sudden?
- Vertigo association: do certain postures bring it about?
- Presence of tinnitus, hearing loss, otalgia, otorrhoea, aural fullness
- Preceding URTI
- Smoking and other medications or herbal remedies 

- Review of systems:
  - associated gait problems or ataxia (suggest a neurological cause)
  - head trauma
  - other medical problems
  - other ENT diseases

Examination

- Vital signs including orthostatic BP
- Full ENT exam (particularly for signs of infection, hearing loss etc.)
- Thorough neurological exam is mandatory with specific focus on cranial nerves, gait and cerebellar function

Special tests:
- Dix Hallpike test
- Romberg and tandem gait
- Head thrust
- Caloric testing

Investigations

A range of specialist vestibular reflex testing exist

Imaging with MRI is indicated where there is asymmetric hearing loss an (acoustic neuroma may be suspected)

Baseline bloods should be performed e.g. FBC, U+E, Glucose

Aetiology

BPPV is defined as vertigo that is elicted by certain head positions. The positions trigger nystagmus.
The cause of this is unknown but is postulated to be due to 2 pathological mechanisms:

1. Canalithiasis: This is due to otoliths that have become detached from the otolithic organs and are free-floating; exerting a force on the cupula mechanism within the semicircular canals 
(analogy is: pebbles in a tyre - when the tyre turns the pebbles tumble down due to gravity; this tumbling triggers the nerves inappropriately)

2. Cupulolithiasis: This is due to deposits of otoliths on the cupula themselves; rendering the cupula more sensitive to gravitational force with certain head positions
(analogy is: heavy object placed on a skinny pole; extra weight makes pole unstable and harder to keep in upright position - pole easily clunks from one side to another and tends to keep tilted position)

History

Onset of vertigo is sudden and severe - lasting ~30 seconds
Typically occur when moving the head in certain positions e.g. from lying to sitting
May be associated with nausea and vomiting

Examination

Diagnosis is made by Dix-Hallpike test
Remainder of examination should be normal

Management

1. Canalith repositioning via Modified Epley Maneuver 

2. In the acute setting vestibulosuppresants can be tried for symptomatic relief:
- Promethazine
- Benzodiazepines e.g. lorazepam
- Scopolamine

Surgery reserved for severe intractable cases

Aetiology

Also known as endolymphatic hydrops (hydrops is another term for oedema)

The cause is thought to be due to impaired reabsorption of the endolymphatic fluid
The precipitent factors is still unknown but postulated to be infectious, immunologic or allergic

History

Meniere disease occurs as attacks lasting for hours. The four symptoms are:

1. Unilateral fluctuating SNHL
2. Vertigo lasting minutes to hours
3. Constant or intermittent tinnitus - typically increasing in intensity during vertiginous attack
4. Aural fullness

The attack is associated with nausea and vomiting - followed by feeling lethargic for a few days

Investigation

Meniere disease is a clinical diagnosis - based on history and normal examination
Audiometry is used to confirm SNHL

The following are performed to help rule out differential diagnoses:
- Syphilis as this can perfectly mimic Meniere disease
- As noted before if hearing loss is asymmetric then MRI needs to be performed

Management

Acutely:
1. Vestibular suppresants - promethazine, benzodiazepines, scopolamine
2. Betahistine

Long term suppression
1. Dietary restriction of salt
2. Thiazide diuretic
3. Betahistine
4. Aminoglycoside injection into middle ear
5. Surgery reserved for severe and intractable cases

Aetiology

This is an acute, sustained dysfunction of the peripheral vestibular system causing vertigo, nausea and vomiting

The most likely cause is reactivation of HSV in the vestibular ganglion and nerve - other viruses e.g. adenovirus are also potential pathogens (note: do not confuse this with Herpes Zoster Oticus - which is a Varicella Zoster virus mediated disease)

Epidemiology

Commonly in 4th to 6th decades

History

Commonly have preceding URTI
Sudden and acute vertigo, nausea and vomiting without hearing loss
Lasts for days -> cannot work or do usual activities

Examination

Should have normal hearing and neurological exam (otherwise suspect something more sinister)

Nystagmus will be present with slow phase towards injured ear

Management

1. Vestibular suppressants
2. Corticosteroids for 3 weeks (decreases chances of long term vestibular function loss)

The presence of SNHL indicates that the diagnosis is labyrinthitis. These patients need to be admitted for IV antibiotics