Whilst most cases resolve fully within a week long-term vestibular deficit after the acute episode can lead to unsteadiness over a period of weeks whilst the brain compensates for this. Neurological examination will be unremarkable and the hearing for these patients will be normal. On otoscopy, the ear drum will be normal and a horizontal nystagmus will be present when examining the eyes. Symptoms will be sudden onset and severely incapacitating, nearly always associated with nausea and vomiting. Vestibular neuronitis is inflammation of the vestibular nerve, resulting in vertigo that lasts for days. Most cases are due to a viral infection, therefore a URTI precedes around half of the cases. This can include intratympanic gentamicin injections, intratympanic steroid injections, endolymphatic sac destruction, or labyrinthectomy (now rarely performed).
If attacks persist despite prophylaxis, surgical intervention may be warranted. Patients should be advised suitable lifestyle advice (reducing salt or avoiding chocolate and caffeine) and regular betahistine medication. Most importantly however, management requires sufficient prophylaxis between attacks. In acute attacks, the vertigo and nausea symptoms can be reduced by a short course of prochlorperazine (a vestibular sedative), given either buccal or intramuscular. Otoscopy will show a normal looking ear drum, audiometry will typically show a sensorineural hearing loss, and tympanometry will be type A (normal). Whilst the disease will burn out eventually with time, permanent sensorineural hearing loss can remain. During remission between attacks, the symptoms will improve yet repeated attacks result in a sensorineural hearing loss that worsens over time. Symptoms are predominantly unilateral, lasting for minutes to hours, and usually resolve within 24 hours.
Meniere’s disease presents with attacks comprised of a triad of severe paroxysmal vertigo, sensorineural hearing loss, and tinnitus. *Most commonly crystals form in the posterior canal, resulting in a rotatory nystagmus to be present if in the horizontal canal then result in a horizontal nystagmus.įigure 3 – The components of the membranous labyrinth Clinical Features Patients can also be advised to perform Brandt-Daroff exercises, positions they can practice at home that are beneficial in reducing symptom intensity. Resolution is not always complete, with some patients requiring repeated Epley’s as symptoms persist, and BPPV can also recur. Patients post-Epley’s manoeuvre are advised not to drive, to keep sleep upright, not to bend down or look upwards for 48 hours. A common manoeuvre is Epley’s Manoeuvre, performed if the canalith are in the posterior canal. Once the condition is diagnosed, specific manoeuvres can be employed to remove the crystals from the canal and resolve the symptoms. The nystagmus fatigues in less than a minute. The diagnostic examination for BPPV is the Dix-Hallpike manoeuvre, with a positive test invoking the symptoms and nystagmus* will be present. By Francesca Leone, TeachMeSurgery įigure 2 – Formation of crystals and their migration into the semi-circular canals in BPPV Management
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