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Questions and Answers
What condition can result from untreated labyrinthitis secondary to a middle ear infection?
What condition can result from untreated labyrinthitis secondary to a middle ear infection?
Which pathogen is most commonly associated with causing diffuse suppurative labyrinthitis?
Which pathogen is most commonly associated with causing diffuse suppurative labyrinthitis?
Which of the following is a typical feature of Ramsay Hunt syndrome?
Which of the following is a typical feature of Ramsay Hunt syndrome?
How can labyrinthitis spread from an acute otitis media (AOM) condition?
How can labyrinthitis spread from an acute otitis media (AOM) condition?
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What is the main treatment approach for preventing further bacterial invasion in diffuse suppurative labyrinthitis?
What is the main treatment approach for preventing further bacterial invasion in diffuse suppurative labyrinthitis?
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What is the duration criterion for tinnitus to be classified?
What is the duration criterion for tinnitus to be classified?
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Which type of tinnitus can be heard by the examiner?
Which type of tinnitus can be heard by the examiner?
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What percentage of individuals with tinnitus experience disturbing tinnitus?
What percentage of individuals with tinnitus experience disturbing tinnitus?
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Which of the following is a major cause of tinnitus?
Which of the following is a major cause of tinnitus?
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What type of investigation can reveal myoclonic activity in tinnitus patients?
What type of investigation can reveal myoclonic activity in tinnitus patients?
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How can palpation of the jugular vein affect tinnitus of venous origin?
How can palpation of the jugular vein affect tinnitus of venous origin?
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In which area of the ear is crackling sound associated with tinnitus generally located?
In which area of the ear is crackling sound associated with tinnitus generally located?
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What is a common symptom of subjective tinnitus?
What is a common symptom of subjective tinnitus?
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What is the first-line therapy for BPPV?
What is the first-line therapy for BPPV?
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Which symptom is commonly associated with Meniere's disease?
Which symptom is commonly associated with Meniere's disease?
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What is a characteristic feature of vestibular neuritis?
What is a characteristic feature of vestibular neuritis?
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What dietary approach is recommended for managing Meniere's disease?
What dietary approach is recommended for managing Meniere's disease?
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Which statement about labyrinthitis is true?
Which statement about labyrinthitis is true?
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Which of the following is NOT a proposed etiology of vestibular neuritis?
Which of the following is NOT a proposed etiology of vestibular neuritis?
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What is a common management strategy for Meniere's disease besides medication?
What is a common management strategy for Meniere's disease besides medication?
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What is the primary symptom experienced by a person with a patulous Eustachian tube?
What is the primary symptom experienced by a person with a patulous Eustachian tube?
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What is the outcome of repeated Epley manoeuvres?
What is the outcome of repeated Epley manoeuvres?
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What management technique is often used when no cause for tinnitus can be found?
What management technique is often used when no cause for tinnitus can be found?
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What is the most common complaint in patients with vestibular system injury?
What is the most common complaint in patients with vestibular system injury?
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Which of the following conditions is associated with vertigo lasting only for seconds?
Which of the following conditions is associated with vertigo lasting only for seconds?
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What is a technique used to temporarily mask tinnitus?
What is a technique used to temporarily mask tinnitus?
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Which symptom is indicative of Meniere's disease?
Which symptom is indicative of Meniere's disease?
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What is one of the relaxation techniques used for managing tinnitus?
What is one of the relaxation techniques used for managing tinnitus?
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In terms of duration, what condition can cause vertigo lasting for hours?
In terms of duration, what condition can cause vertigo lasting for hours?
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What indicates a positive Dix-Hallpike test?
What indicates a positive Dix-Hallpike test?
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Which condition is primarily characterized by sudden vertigo lasting seconds with certain head positions?
Which condition is primarily characterized by sudden vertigo lasting seconds with certain head positions?
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What is the expected average age of presentation for patients with BPPV?
What is the expected average age of presentation for patients with BPPV?
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What does the head thrust test primarily evaluate?
What does the head thrust test primarily evaluate?
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In BPPV, what is the typical recurrence rate per year?
In BPPV, what is the typical recurrence rate per year?
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Which test is performed when a perilymph fistula is suspected?
Which test is performed when a perilymph fistula is suspected?
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What characterizes nystagmus?
What characterizes nystagmus?
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What should be investigated if a brain injury is suspected?
What should be investigated if a brain injury is suspected?
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Which condition is NOT associated with hearing loss?
Which condition is NOT associated with hearing loss?
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What is the primary focus when diagnosing inner ear diseases?
What is the primary focus when diagnosing inner ear diseases?
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During a Romberg's test, which sensory input is primarily removed?
During a Romberg's test, which sensory input is primarily removed?
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What symptom can be associated with true vertigo?
What symptom can be associated with true vertigo?
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Which of the following is NOT a component assessed by the Romberg's test?
Which of the following is NOT a component assessed by the Romberg's test?
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What may indicate a labyrinthine lesion during the Unterberger test?
What may indicate a labyrinthine lesion during the Unterberger test?
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Which of the following symptoms is considered a neurological symptom?
Which of the following symptoms is considered a neurological symptom?
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What does a positive Romberg's test suggest about the patient's proprioception?
What does a positive Romberg's test suggest about the patient's proprioception?
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Study Notes
Inner Ear (Tinnitus & Vertigo)
- Tinnitus is any sound perceived by a listener that is not from an external source for more than five minutes, absent external stimulation, and not immediately following loud noise exposure.
- Disturbing tinnitus affects 3-5% of individuals experiencing tinnitus.
- Two tinnitus types:
- Subjective: only heard by the patient (95%)
- Objective: detectable by an examiner with a stethoscope, often pulsatile (synced with heartbeat).
- Subjective tinnitus is more common than objective.
- Tinnitus causes can be:
- Unilateral: Non-pulsatile causes include idiopathic, noise-induced, and intracranial tumors. With hearing loss causes include idiopathic, presbycusis & noise-induced, drugs, and Meniere's disease. Pulsatile causes include aneurysm, vascular malformation, and glomus tumor.
- Bilateral: Non-pulsatile causes include idiopathic and drugs. With normal hearing causes include idiopathic and drugs. Pulsatile/objective causes include idiopathic, anaemia, and hypertension.
- 80% of patients with sensorineural hearing loss (SNHL) experience tinnitus.
- Hearing loss causes changes in auditory system neural activity, interpreted as sound by the brain; this resembles phantom limb syndrome.
- Areas of damaged cochlea hair cells cannot amplify sounds, creating a perceived phantom sound.
History
- Important features include sound quality (tonal, hissing, buzzing, clicking, ringing), localization (unilateral vs. bilateral, position), temporal features (episodic, fluctuating, constant, pulsatile), interaction with external sounds/ masking/inhibition/exacerbation, pitch (high—inner ear; cracking—middle ear; pulsating—vascular), and loudness.
Physical Examination
- Palpation/light compression of the jugular vein can lessen venous-origin tinnitus. Valsalva manoeuvre can achieve a similar effect.
- Auscultation of the neck/cranium can detect carotid bruit/blood turbulence from arteriovenous malformation.
- Otoscopy/Otomicroscopy can reveal glomus tumors or tympanic hemangiomas.
- Oropharyngeal exam can show soft palate contraction in palatal myoclonus.
Investigations
- Tympanometry may show myoclonic activity and patulous Eustachian tube.
- Pure-tone audiometry can detect conductive hearing loss secondary to vascular lesions affecting the middle ear.
- Gadolinium-enhanced CT or MRI imaging is frequently necessary.
- Patulous Eustachian tube (PET) is where the Eustachian tube remains intermittently open, causing autophony (hearing self-generated sounds).
Management
- Tinnitus is a symptom, not a disease. Seek treatment for the cause.
- Reassurance/psychotherapy may be needed. Relaxation techniques/biofeedback may be useful.
- Sedation/tranquilizers may be needed initially for symptom adjustment.
- Masking, using noise to cover up the tinnitus, is often effective. Traditional/newer hearing aids with tinnitus masking.
- Sound machines/environmental noise can mask at night.
Vertigo
- Vertigo is the illusion of motion of oneself or the surroundings.
- Chief complaint is often dizziness, not vertigo in vestibular system injury.
- Vertigo is typically not permanent or continuous; the central nervous system adapts to the vestibular lesion.
- Constant dizziness lasting months is not usually vestibular in origin, often due to episodic dizziness.
- Vertigo duration-based causes:
- Seconds: Benign Paroxysmal Positional Vertigo (BPPV)
- Minutes: Migraine-associated vertigo, Vertebrobasilar insufficiency
- Hours: Meniere's disease (endolymphatic hydrops), Otic syphilis
- Weeks: CNS disorders, Multiple sclerosis, Acoustic neuromas, autoimmune diseases
- Variable duration: Inner ear fistula, Lyme disease, Labyrinthine concussion, blast trauma, barotrauma, superior semicircular canal dehiscence syndrome.
- Days: Vestibular neuritis, Labyrinthitis
Vertigo Types
- Peripheral: more severe, short-lived, associated with peripheral symptoms (tinnitus, hearing loss, ear discharge, otalgia), associated with peripheral nystagmus
- Central: milder, long-lived and chronic, associated with central symptoms (diplopia, slurred speech, dysarthria, dysphoria), associated with central nystagmus
Diagnosis
- Diagnosis relies primarily on history (onset, character, duration, relation to head movements, associated symptoms like tinnitus/hearing loss) and physical examination, with limited need for investigative procedures.
- Neurological symptoms (loss of consciousness, weakness, numbness, dysarthria, diplopia) are relevant to the diagnosis.
BPPV
- Sudden vertigo lasting seconds associated with specific head positions.
- No associated hearing loss.
- Characteristic nystagmus (latent, geotropic, fatigable) evident in the Dix-Hallpike test.
- Posterior semicircular canal (PSC) most commonly affected (93% unilateral, 8% bilateral).
- Presentation typically in the 5th decade, with approximately 20% of vertigo clinic patients diagnosed with BPPV.
- Recurrence rate of about 10-15% per year likely due to canalithiasis.
Predisposing Factors for BPPV
- Circumstances placing the head in inverted orientations (e.g., dental procedures, hairdressing).
- Age, inactivity, and family history
- Trauma, vestibular neuritis, other ear diseases, Meniere's syndrome
- Triggering positions (e.g., rolling over, getting out of bed, looking up/back, bending over).
- Dix Hallpike Test: latent period (1-5 seconds) is followed by acute vertigo/nystagmus towards affected side (typically 10-40 seconds), repeated testing.
Treatment of PSC BPPV
- Treatment Repositioning, using gravity to move canalith debris out of the affected semi-circular canal and into the vestibule using maneuvers (e.g., Epley maneuver).
- Epley maneuver repeated until no nystagmus occurs (effective in >90% of cases for BPPV elimination).
- Epley maneuver steps (illustrated on page 23).
Meniere's Disease
- Endolymphatic hydrops (excessive endolymph build-up). Etiology unknown.
- Secondary hydrops from head trauma or surgery, or due to inner ear disorders, allergies, or systemic conditions (e.g., diabetes, autoimmune).
- Episodic vertigo (hours), fluctuating hearing loss, tinnitus, pulsatile aural pressure are diagnostic features (unilateral onset but in 25% of cases is bilateral).
Vestibular Neuritis
- Vertigo lasting days after upper respiratory infection.
- No hearing loss.
- No other neurological signs/symptoms.
- Viral infections, vascular occlusion, and immunologic mechanisms are potential causes.
- Postural instability toward injured ear but patient can typically walk normally.
Labyrinthitis
- Viral induced Endolabyrinthitis; not fatal unless it causes suppurative labyrinthitis which can lead to meningitis and fatal.
- Suppurative Labyrinthitis: vertigo + permanent SNHL.
- Routes of spreading into labyrinth:
- Acute otitis media (AOM)
- Weakened oval window membrane (post stapes surgery)
- Dehiscent oval window (congenital labyrinthine deformities)
- Cholesteatomatous lateral semi-circular canal fistula.
Diffuse Suppurative Labyrinthitis
- Caused by S. pneumoniae; H. influenzae; Neisseria meningitides
- Management includes admission and i.v antibiotics to prevent further bacterial invasion.
- Other related ear disorders include Ramsay Hunt syndrome (herpes zoster oticus) that can cause vertigo, hearing loss, facial paralysis, ear pain, and vesicles in auditory canal/auricle. Acoustic neuroma is caused by a tumor of the nerve tissue. Typical symptoms are ringing, vertigo, and hearing loss in one ear.
General Management
- Stabilize body's fluid/electrolyte balance including a hydrops diet (minimize solutes, adequate fluid, limit caffeine/alcohol).
- Physicians can prescribe diuretics along with environment modifications
- Manage persistent symptoms including aminoglycoside therapy like intratympanic gentamicin (10% risk of worsening hearing loss, but is used for secondary issues).
- Other surgical measures include endolymphatic sac decompression, vestibular neurectomy, and labyrinthectomy.
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Description
Test your knowledge on the conditions associated with tinnitus and labyrinthitis, including causes, symptoms, and treatment approaches. This quiz covers important aspects of diffuse suppurative labyrinthitis and Ramsay Hunt syndrome. Get ready to explore the intricate connections between ear infections and tinnitus.
