1. Vestibulitis, Labrynthitis, Meniere’s Disease, and Tinnitis Case Study
Todd Zusmer, D.O.
Clinical Medicine - EENT

2. 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.

3. 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

4. Case #1 – Central Causes Other 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

5. Central vs. Peripheral Disease
Inner ear disease (peripheral):
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
Central “CNS” Disease:
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

6. Central vs. Peripheral Disease
Inner Ear 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.
Central “CNS” Disease:
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.
inability to execute rapidly alternating movements, particularly of the limbs.

7. 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 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

8. 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.

9. Patient complains of dizziness
Case #1 – Diagnosis
Dx. Benign Positional Paroxysmal Vertigo
Considerations on Diagnosing Vertigo
Obtain history, especially of timing and duration, provoking and aggravating factors, associated symptoms, and risk factors for cerebrovascular disease.
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.
Consider other laboratory and radiologic studies as indicated (e.g., cervical spine series in patients with findings suggesting cervical vertigo).
Patient complains of dizziness
Does the patient have vertigo?
Yes
Is the patient taking a drug that can cause vertigo? No
Continue diagnostic work-up as appropriate for lightheadedness, presyncope, or dysequilibrium.
Yes
Consider stopping medication, if possible.
No Proceed as outlined right.

10. 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?

11. 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:
Neurologic symptoms and signs are present.
The patient has risks for CVA.
There is progressive unilateral hearing loss.

12. 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:
Ménière’s disease
perilymphatic fistula
acoustic neuroma
cholesteatoma
otosclerosis
transient ischemic attack or stroke involving anterior inferior cerebellar artery
herpes zoster oticus

13. 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?

14. Diagnostic Characteristics Central vs. Peripheral Vertigo
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
Latency Following Vertigo-Provocative Diagnostic Maneuver
Longer; up to 20 seconds
Shorter; up to 5 seconds

15. 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.