6. EVALUATION
HISTORY
Define symptom
Timing
Triggers
Otologic history
Drug history
Family history
Review systems
Previous studies
7. EVAL-PE
General
Balance
Otologic exam
Neurologic exam
Nystagmus-spontaneous,Dix –Hallpike ,head shake
test,neck vibration test,valsalva test,hyperventilation
test
VOR gain
8. dotted lines represent the planes containing the posterior semicircular canal (PSC) of the rightl abyrinth, the
superior and inferior recti of the left eye, and the superior and inferior oblique muscles of the right eye. This
corresponds to the main neuro anatomical connections of the vestibular ocular reflex . Activation of the PSC,
therefore, results in a mixed vertical and torsional nystagmus, with the contralateral eye having more upbeat, and
the ipsilateral eye more extorsional components.
11. Finding Peripheral Central
Latency Yes, typically 3-10 sec, rarely as long as 40 sec No
Fatigability* (habituation) Yes, individual episode typically lasts 10-30
sec, rarely as long as 1 min
No
Adaptability* (fatigability) Yes, maneuver done several times
consecutively provokes less of a response each
time
No
Nystagmus direction Direction fixed, typically mixed rotational
upbeating with small horizontal component;
quick phase of intorsion movement toward
the dependent ear, upbeat toward forehead
Direction changing, variable, often purely
vertical (either upbeating or downbeating) or
purely horizontal
Suppression of nystagmus by visual fixation Yes No
Severity Severe, marked vertigo, intense nystagmus,
nausea
Mild vertigo, less obvious nystagmus,
inconspicuous nausea
Consistency (reproducibility Less consistent More consistent
Past pointing In direction of nystagmus slow phase May be in direction of fast phase
21. In general the 7 most common
mistakes
1.Distinguishing vertigo from imbalance;
2.knowing how to do a positional test;
3.knowing how to do ahead impulse test;
4.Migraine is a frequent cause of vertigo without headache
5.Able to interpret an audiogram;
6.Arranging to review the patientduring a vertigo attack;
7. Ordering a magnetic resonanceimaging (MRI) instead of
examining the patient properly.
22. SUMMARY
In the patient with repeated attacks of isolated vertigo
(1) Always do a positional test.
(2) Learn to do the particle repositioning manoeuvre.
(3) Always order an audiogram.
(4) Try migraine treatment.
(5) Put vertebrobasilar insufficiency at the bottom of the list.
In the patient having the first ever attack of acute spontaneous
(1) Learn to do the head-impulse test.
(2) Always think of cerebellar infarction.
In the patient who is off-balance
(1) Think of vestibulotoxicity.
(2) Think of normal pressure hydrocephalus.
(3) Beware of the posterior fossa tumour or malformation.
(4) Think of orthostatic tremor.
(5) Consider spinal cord or peripheral nerve pathology and do a serum B12.
23. Q & A
1. A patient presents with vertigo, diplopia, dysarthria,
weakness and numbness. Which of the following is
the most likely location of the lesion?
A. brainstem
B. vestibulocochlear nerve
C. spinal cord
D. labyrinth
24. 2. A patient presents with vertigo, hearing loss, and
tinnitus. There are no other neurologic abnormalities.
Which is the following is the most likely location of
the lesion?
A. brainstem
B. vestibulocochlear nerve
C. spinal cord
D. cerebral cortex
25. 3. A patient describes short-lived episodes of vertigo
(rotary) precipitated by head movements, especially
when lying down (neck extension).
The vertigo usually lasts less than 45 seconds. There
are no other neurological symptoms except
nystagmus. What is the most likely diagnosis?
A. Meniere’s disease
B. Occlusion of the posterior inferior cerebellar artery
C. Multiple sclerosis
D. Benign paroxysmal positional vertigo (BPPV)
26. 4. A patient describes spells of vertigo lasting hrs,
preceded by ear fullness, tinnitus and hearing
dysfunction. No other neurological abnormalities.
What is the most likely diagnosis?
A. Meniere’s disease
B. Occlusion of the posterior inferior cerebellar artery
C. Multiple sclerosis
D. Benign paroxysmal positional vertigo (BPPV)
