EENT

11/11/99

 

Vertigo

Peripheral	Central
Labyrinth/vestibular branch of 8th nerve, eye, ear, joint (includes cardiovascular, ototoxicity, MVA, BPPV, etc.)	Brainstem, cerebellar (trauma, MS, TIA, etc.)
Vague Sx, positional vertigo, abrupt onset exc. Stroke intermittent, limbs are coordinated	Persistent vertigo, Nystagmus, gait disturbances, slurred speech, double vision or loss, no hearing loss
If CNS dysfunction does not appear in 7-14 days then it is probably peripheral	Sensory impairment
Dizziness not true vertigo	Cerebellar loss of coordination

 

• Do a complete EENT and neuro work up
• Hx
• Ears—tinnitus
• Pulsing = bruit, if time w/pulse
• Auscultate over mastoid-arteriovenous malformation
• Carotid or other cervical vessel bruit
• Fullness
• Pain
• Discharge
• Hearing loss
• Sensation of imbalance-increasing Sx when riding in a car leaning, veering when walking
• Sympathetic Sx—nausea, perspiration, sense of fear
• Length of episode
• Seconds—cervical Spondylosis, BPPV, Postural hypotension
• Minutes to hours—Meniere's ds, labyrinthitis
• Hours to days—layrinthe failure, ototoxicity, tumor; central vestibular ds (brainstem)     
• Increasing severity w/position, darkness or eyes closed
• Medication/chemical exposure
• Trauma

 

Vertigo Testing

1. Observation—while going into room—gait-unsteadiness or leaning-mood-anxiety, moodiness, confusion
2. Cranial nerves—while testing, observe facial movements-could be indicative of acoustic neuroma, stroke checking peripheral vision, vision loss, blurring-tumor, trauma, MVA
3. Ear—otitis externa, otitis media, cholestoma
4. Palpation—cervical lymph nodes, trigger points
5. Auscultation—posterior to mastoid if tinnitus timed w/pulse-arteriovenous aneurysm cervical vessels-bruit
6. Blood pressure—positional, antihypertensives
7. Neurologic testing—DTR (increased w/UMNL), dermatomes (checking for numbness), myotomes—Nylen-Barany or Hallpike or Dix-Hallpike test for Dx of BPPV—pt seated then lie the pt down w/head in extension 30-45°
1. BPPV-vertigo and Nystagmus appear after 3-4 sec and will decrease and stop after a few seconds—slow phase of nystagmus goes down toward the downward ear (R ear down=eyes R)

                                                               i.      Peripheral cause—decrease w/repetition

                                                             ii.      Central cause—no decrease in vertigo or nausea

2. Have tp stand on one foot w/eyes closed, then other foot—if can do then E/N (uermura)
3. Have pt hop on one foot-difficulty hopping if cerebellar dysfunction on the same side as being hopped on
4. Tandem Romberg—have the pt read a sign over the shoulder while walking the other way—see if they can hit the spot they are aiming for
5. Sharpened Romberg—have the pt stand w/arms across chest w/eyes closed and head as if reading over the shoulder—normal can maintain position >30 sec—purpose—vestibular systems screen
6. Stepping test—marching in place 50´ at same speed as in walking watch for turning of head, position of arm/body or sway-ABN=>30 body rotation or 1 meter of body movement from the starting place

 

Positional vertigo

• Commonly seen in whiplash injuries, discogenic, Spondylosis, cervical disc injuries and Myofascitis
• Proprioceptors orient the head to the body whereas the vestibular apparatus orients the body to space

 

Myofascial proprioceptive vertigo

• Typically the clavicular division of the SCM

• The pt will have the illusion of disagreeable motion that occur w/a sudden turning of the head or other motions
• The pt may fall when bending forward, stooping or be ataxic
• The pt may simply feel like falling backwards when looking up and visa versa
• These attacks can last just a few seconds (or last for hours)
• Nausea is common
• Other symptoms include:  carsickness, frontal headaches, dizziness turning in bed, holding the pone w/the shoulder
• Activated by painting, sleeping on two pillows, sports, scoliosis, emphysema,

 

The key is: DRAMATINE RELIVES NAUSEA BUT NOT DIZZINESS       

 

Another myofascial proprioceptive vertigo is EAGLE Syndrome:

The styloid process is elongated by calcification of the stylohyoid ligament

There are trigger points in the posterior belly of the digastrics and medial pterygoid muscles

Note: There are typically concurrent trigger points in the SCM

S&S:  dizziness

 

Hypoglycemia:  mostly the complaints are of a lightheadedness nature. 

• The complaints will typically be in the morning or 3-4 hrs post-prandial.
• A serum glucose test should be preformed while the pt is symptomatic
• If the results are positive, then, you order a glucose tolerance test.

 

Vestibular neuronitis—a viral infection of the vestibular nerve

• There is of a Hx of an upper respiratory infection 2-3 wks prior in the onset of Sx
• There is a sudden onset of dizziness and sometimes nausea
• The pt may complain of feeling the earth move
• The episodes may be short and mild or long and severe
• The viral infection typically clears in 3 wks to 3 months

 

Demyelinating ds—nystagmus, sensorineural hearing loss, dizziness, etc. 

• What you see here is a global pattern that involves several systems
• MS

 

Meniere's Ds

• Tinnitus and vertigo that comes in episodes
• Tinnitus w/aura and then vertigo
• The tinnitus will remain after the vertigo has gone
• Semicircular canals—sudden increase w/in the chamber that messes w/the entire communicating system—look like they are drunk
• Episodes can be minutes to hours or longer
• Highly debilitating
• Burr hole in semicircular canal to drain—works about 6 months
• Decrease anything that will cause a ANS response—special diet
• Chocolate
• Caffeine
• Stimulants
• Hallpike exercises—improve proprioception
• Highly anxious
• Working on them may bring on an episode so warn the pt

 

Aging

• Loss of balance due to falling eyesight and hearing
• Cervical Spondylosis and vertebrobasilar ischemia and atherosclerosis or the cerebral arteries
• There may also be postural hypotension and cardiac arrhythmias
• A medication may also be at fault, i.e. antihypertensives

 

Migraine

• Only unsteadiness and imbalance

 

Equilibrium

1. Eyes
2. Proprioception
3. Vestibular apparatus (semicircular canals)

 

Vestibular apparatus—

Hair cells®neurons®

 

C1/C2 (lateral cervical nerve) nerves are monosynaptic and have direct connections to the spinal cord

• Stimulation of muscles innervated by these nerves can cause nystagmus (splenius capitus)
• C2 dorsal root ganglia—takes sensory information form the joints and muscles
1. Has direct connection w/the spinal cord and brainstem nuclei (medullary nuclei-increase vestibular nucleus, cuneatus)
2. Stimulation of traumatized cervical muscles can cause nystagmus
3. Watch for nystagmus by putting water in someone ears—do not do this in the office but it is on National Boards
• Cold water—see for nystagmus
• Warm water—see for nystagmus
• COWS—if positive w/cold water goes to opposite side, warm water goes to same side
• Cold water constricts and everything moves away
• Warm, everything expands and stays there

 

Eye

• Cornea—first thing you see
• Clear
• Fed by endothelial layer on inside—circulates in anterior chamber
• No efficient new growth—fluid backs up and gets blue haze
• Canal of Schelm—drainage system for the anterior chamber right behind the cornea
• Free radicals build up and block the system
• Myopia—area around the canal of Schelm is too small
• Iris is thicker making it smaller
• Glaucoma—make sure pt has it tests
• Narrowed angle—go into a movie theater—pain, headache, nausea, sweating—sympathetic episode—get them in the light
• 20-40 y/o is the most frequent group to develop glaucoma
• Should get eyes checked regularly
• Comes on w/no Sx until advanced
• Pressure increases w/in the eye
• After awhile the tissues w/in the eye give up and the retinal layers and optic nerve start to degrade
• Lens
• At as 45 y/o it becomes stiffer
• UV exposure develops cataracts
•