Download Case #1 - VCOMcc

Vestibulitis, Labrynthitis, Meniere’s
Disease, and Tinnitis
Case Study
Todd Zusmer, D.O.
Clinical Medicine - EENT
Case #1
Chief Complaint: Dizziness
Mrs. White is a 67 yo retired psychologist who complains of a
sensation of room spinning for the past 4-5 days. She denies any
trauma, head injury, syncopal episode, chest pain, or new
medications. She states the episodes last approximately 30 seconds
to two minutes in duration during which time she feels nauseated
What is your working differential diagnosis at this time?
List all potential causes.
Case#1 - Peripheral Causes
Acute labyrinthitis
Inflammation of the labyrinthine organs caused by viral or bacterial infection
Acute vestibular neuronitis (vestibularneuritis)
Inflammation of the vestibular nerve, usually caused by viral infection
Benign positional paroxysmal vertigo (benign positionalvertigo)
Transient episodes of vertigo caused by stimulation of vestibular sense organs by canalith; affects middle-age and older
patients; affects twice as many women as men
Cholesteatoma
Cyst-like lesion filled with keratin debris, most often involving the middle ear and mastoid
Herpes zoster oticus (RamsayHunt syndrome)
Vesicular eruption affecting the ear; caused by reactivation of the varicella-zoster virus
Ménière’s disease (Ménière’s syndrome, endolymphatic hydrops)
Recurrent episodes of vertigo, hearing loss, tinnitus, or aural fullness caused by increased volume of endolymph in the
semicircular canals
Otosclerosis
Hardening or thickening of the tympanic membrane caused by age or recurrent infections of the ear
Perilymphatic fistula
Breach between middle and inner ear often caused by trauma or excessive straining
Case #1 – Central Causes
Neoplastic
Cerebellopontine angle tumor Vestibular schwannoma (i.e., acoustic neuroma) as well as infratentorial ependymoma,
brainstem glioma, medulloblastoma, or neurofibromatosis
Cerebrovascular disease
Such as transient ischemic attack or stroke Arterial occlusion causing cerebral ischemia or infarction, especially if
affecting the vertebrobasilar system
Migraine Episodic headaches
Usually unilateral, with throbbing accompanied by other symptoms such as nausea, vomiting, photophobia, or
phonophobia; may be preceded by aura
Multiple sclerosis
Demyelinization of white matter in the central nervous system
Other Causes
Cervical vertigo
Vertigo triggered by somatosensory input from head and neck movements
Drug-induced Vertigo
Adverse reaction to medications, Psychological Mood, anxiety, somatization
Central vs. Peripheral Disease
Inner ear disease (peripheral):
Central “CNS” Disease:
•
•
•
•
•
Sudden onset of vertigo episodes
Hearing loss, ear pressure, or tinnitus
Lasts for seconds and is associated
with position changes (suggests
benign positional vertigo)
Vertigo that lasts for hours or days is
probably caused by Ménière disease
or vestibular neuronitis
•
•
Gradual and ill-defined symptoms are
more common in CNS, cardiac, and
systemic diseases.
Vertigo of sudden onset that lasts for
minutes can be due to vascular
disease
Central vertigo secondary to
brainstem ischemia is often
associated with other brainstem
characteristics, including diplopia,
autonomic symptoms, nausea,
dysarthria, dysphagia, or focal
weakness
5
Central vs. Peripheral Disease
Inner Ear Disease:
Central “CNS” Disease:
• Prior viral illness, cold sores, or
sensory changes in the cervical
C2-C3 or trigeminal distributions
usually indicate vestibular
neuronitis or recurrent episodes
of Ménière disease.
• Patients with peripheral vertigo
are usually able to ambulate
during attacks and are
consciously aware of their
environment.
• Dysdiadochokinesis and gait
ataxia during episodes are more
likely due to cerebellar diseases
• Sensory and motor symptoms
and signs are usually associated
with CNS diseases
• Common causes of central
dizziness are migraine
syndromes. Other central causes
include demyelination, acoustic
tumors, or cerebellar lesions.
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Case #1 – Medical History
After repeated questioning Mrs. White states she has had no headaches, vision changes, hearing
loss, or tinnitus. She denies any recent illness but now seems to think the episodes occur with
changes in head position. She has had no spontaneous episodes.
Medical History
• PMHx – She has no hx of Diabetes, hypertension, or CAD, menopause at age 52
• PSugHx – cholecystectomy, age 47
• FamHx – There is no family hx of migraines or head and neck cancer. She is a retired
psychologist.
–
–
–
–
•
•
Father deceased at age 84 of MI
Mother decease at age 82 pneumonia
Brother alive age 64 - HTN
Sister alive age 65 - obese
Meds – She again states she takes no medications other than OTC vitamin D and calcium.
SocHx – married , social ETOH < 2x/month, non smoker
OccHx – psychologist, retired
Case #1 – Physical Examination
Objective Parameters
–
Ht 5'2" wt 140lbs BP 124/81 P 76 reg R 16
HEENT
–
–
E – atraumatic, normocephalic, TM’s clear with effusion or exudate, external ear canal clear
E - PERRLA, EOMI, nonystagmus fundoscopic exam reveals sharp disc margins and no vessel nicking
Vascular Exam
–
Carotid pulses are strong, equal and no bruits
Neuro Exam
–
–
Cranial Nerves – no palsies, weakness or sensorineural hearing loss is noted
Gait is normal, mental status appears normal
Cardio Exam
–
Cardiac regular rate and rhythm without rubs, clicks or murmurs
Diagnostic Maneuvers
–
You perform a Dix- Hallpike maneuver and note the patient develops torsional upbeat and horizontal
nystagmus.
Could you refine your diagnosis at this time? List your most probable cause.
Case #1 – Diagnosis
Dx. Benign Positional Paroxysmal Vertigo
•
Obtain history, especially of timing and
duration, provoking and aggravating
factors, associated symptoms, and risk
factors for cerebrovascular disease.
•
No
Continue diagnostic work-up as
appropriate for lightheadedness,
presyncope, or dysequilibrium.
Perform physical examination with
special attention to head and neck,
cardiovascular, neurologic systems, and
provocative diagnostic tests such as
Dix-Hallpike.
•
Consider brain MRI in patients with focal
neurologic findings, risk factors for
cerebrovascular disease, or other
findings suggesting a central cause of
vertigo.
No
Proceed as outlined right.
•
Consider other laboratory and radiologic
studies as indicated (e.g., cervical spine
series in patients with findings
suggesting cervical vertigo).
Considerations on Diagnosing Vertigo
Patient complains of dizziness
Does the patient have vertigo?
Yes
Is the patient taking a drug
that can cause vertigo?
Yes
Consider stopping medication,
if possible.
Case #1 – Treatment
You decide to treat the patient with physical therapy (Epley maneuver) and
modified home Epley maneuver.
This patient does not have: severe carotid stenosis, unstable heart disease,
cervical spondylosis, or advanced rheumatoid arthritis which are
contraindications to treatment.
Older patients are at risk with use of vestibular suppressant medications
(sedation, falls, and urinary retention).
Now that you have made your diagnosis what signs and symptoms would
prompt you to order laboratory or imaging studies?
Case #1 – Additional Plans
• With current diagnosis no labs or imaging are needed.
• Consider labs if a an underlying illness is suspected.
Considerations of underlying illness for imaging:
1. Neurologic symptoms and signs are present.
2. The patient has risks for CVA.
3. There is progressive unilateral hearing loss.
Case #1 – Learning Outcomes
Associated progressive hearing loss is not present in this case but can refine
your diagnosis. Name causes of vertigo associated with hearing loss.
Associated hearing loss is found in:
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•
•
•
•
•
•
Ménière’s disease
perilymphatic fistula
acoustic neuroma
cholesteatoma
otosclerosis
transient ischemic attack or stroke involving anterior inferior cerebellar artery
herpes zoster oticus
Case #1 – Follow Up
Your patient returns three weeks later and has noticed
improvement of symptoms with physical therapy. She
denies any headaches, hearing loss, or tinnitus.
What are the characteristics of peripheral vs. central
vertigo?
Diagnostic Characteristics
Central vs. Peripheral Vertigo
Peripheral
Central
Nystagmus
Combined horizontal and torsional;
inhibited by fixation of eyes onto
object; fades after a few days; does
not change direction with gaze to
either side.
Purely vertical, horizontal, or
torsional; not inhibited by fixation of
eyes onto object; may last weeks
to months; may change direction
with gaze towards fast phase of
nystagmus.
Imbalance
Mild to moderate; able to walk.
Severe; unable to stand still or walk.
Nausea
Vomiting; may be severe
Variable
Hearing Loss
Common
Rare
Non-Auditory Neurologic
Symptoms
Rare
Common
Latency Following VertigoProvocative Diagnostic Maneuver
Longer; up to 20 seconds
Shorter; up to 5 seconds
Case #1 – Special Considerations
Specialty referral when diagnosis is unclear, if
diagnosis is in doubt or indicated by findings.
Medical diagnosis is made requiring specialty
input.