Margaret Davenport; 60 yo 8/8/1950
Author: Teresa S. Wu, MD
Reviewer:
Thomas Payton, MD
“I think I’m having a stroke!”
Case Title:
Target Audience: medical students, physicians’ assistants, nurse practitioners, residents
Primary Learning Objectives: key learning objectives of the scenario
1.
The participant will obtain a detailed history and perform a comprehensive
neurological exam.
2.
The participant will formulate a broad & comprehensive differential diagnosis for
patients presenting with vertigo.
3.
The participant will avoid anchoring into a diagnosis and will carefully consider
the data presented in the case.
4.
The participant will explain the pathophysiology of Meniere’s Disease and offer
options for symptomatic control and surgical treatment.
Secondary Learning Objectives:
1.
The participant will actively manage and reassess the patient’s symptoms (IV
antiemetics, benzodiazepines, IVF’s, etc.)
2.
The participant will order the correct tests to rule-out an acute cerebral event
3.
The participant will order the correct blood work to rule-out co-existing metabolic,
hormonal, or endocrinological disturbances.
4.
The participant will demonstrate compassion and empathy during the evaluation
and management of the patient
Critical actions checklist:
1. Places patient on a cardiac monitor with pulse oximetry
2. Obtains a bedside ECG
3. Places the patient on supplemental oxygen
4. Checks a bedside point-of-care glucose
5. Performs a full neurological exam
6. Performs a hearing test
7. Orders a CT scan to rule out acute intracranial pathology
8. Places a peripheral IV
9. Draws labs to evaluate for metabolic disturbances, infections, and endocrine or
hormonal abnormalities contributing to the symptomatology.
10. Elicits a history of vertigo, tinnitus, and hearing loss from the patient and makes the
diagnosis of Meniere’s Syndrome.
11. Obtains a neurological consult to aid in the patient’s disposition
Environment
1.
Room Set Up – Emergency Department Resuscitation Bay
a. Mannequin: SimMan 3G with a female wig
b. Equipment:
1. Cardiac Monitor
2. Blood pressure cuff (manual and automatic)
3. Peripheral IVs (18 gauge, 16 gauge)
4. Gauze
5. Tape
1
Margaret Davenport; 60 yo 8/8/1950
6. Tourniquet
7. Tegaderm
8. IV caps or heplocks
9. Oxygen Source/Tree
10. Non-rebreather
11. IV fluids (NS and LR)
12. Blood collection tubes (rainbow)
13. Urine specimen
14. Lab reports (CBC, CMP, coagulation panel, UA, cardiac enzymes)
15. Meclizine
16. Ativan
17. Antiemetics (zofran, phenergan, compazine, etc.)
18. Aspirin
19. Normal EKG
20. Normal head CT
21. Phone call to consults
Actors (optional)
1.
Nurse
2.
Paramedics to give report about the patient
3.
Patient’s husband
4.
Neurologist
5.
Radiology technician
2
Margaret Davenport; 60 yo 8/8/1950
For Examiner Only
Author:
Teresa S. Wu, MD
Case Title: “I think I’m having a stroke!”
CASE SUMMARY
CORE CONTENT AREA
Otolaryngology
SYNOPSIS OF HISTORY/ Scenario Background
A 60 y.o. female is brought in by EMS with a chief complaint of dizziness. She was outside
working on the garden when she started to feel dizzy. She went inside to “cool off” and started
developing a “headache”. Her husband called 911 because he thought she was having a
stroke.
When asked, the patient will note that her headache feels like “fullness” that came on gradually.
Now she feels like the room is spinning. She’s had no visual changes, but she feels like there is
a “buzzing in her ear”. She denies any chest pain, shortness of breath, paresthesias,
weakness, nausea, or vomiting. This is the first time she has experienced these symptoms.
She cannot recall any inciting event.
Past Medical History: HTN
Medications: Lisinopril
Allergies: PCN
Family History: HTN, CAD
Social History: Married. Retired. Denies EtOH, tobacco, or illicit drugs.
SYNOPSIS OF PHYSICAL
Patient is sitting upright in the gurney, diaphoretic, complaining of dizziness.
Her neurological exam is significant for decreased hearing on the left, nystagmus, and a positive
Romberg.
HR 90
BP 167/52
3
RR 18
O2 Sat 99%
Temp 37.6
Margaret Davenport; 60 yo 8/8/1950
For Examiner Only
CRITICAL ACTIONS
SCENARIO BRANCH POINTS/ PLAY OF CASE GUIDELINES
1. Critical Action
The participant should order a head CT or MRI to rule out an acute cerebral event.
Cueing Guideline: The patient and her husband should continue to ask the participant if she
is having a stroke.
2. Critical Action
The participant should perform a thorough neurological exam and note that the patient’s
exam is only notable for fatigable nystagmus and a positive Romberg test.
Cueing Guideline: The patient continues to complain that she feels “really, really dizzy”.
3. Critical Action
The participant should inquire more about the “roaring sound” and ask about associated
tinnitus.
Cueing Guideline: The patient starts to complain that there is a “roaring sound” in her ears
and that the sound is making her headache worse.
4. Critical Action
The participant should assess the patient’s hearing either through a gross assessment with
finger rubs or via a tuning fork (Rinne and Weber’s tests).
The patient continues to ask the participant to repeat each question asked because she is
“having a hard time hearing” him/her.
5. Critical Action
The participant should send the following blood tests to rule-out other certain metabolic
disturbances, infections, and endocrine or hormonal abnormalities contributing to the
symptomatology:
 TSH, Free T4 and T3
 CBC
 BMP
 ESR
 CRP
 UA
 FTA-ABS
Cueing Guideline: The nurse asks the participant what lab tests he/she would like to send.
4
Margaret Davenport; 60 yo 8/8/1950
Maximum Points for Critical Actions: 10 points
SCORING GUIDELINES
(Critical Action No.)
1. 2 points awarded if the CT or MRI is obtained.
2. 2 points awarded if a full neurological exam is performed. 1 point awarded if a partial
neurological exam is performed.
3. 2 points awarded if the participant elicits more history and details concerning the “roaring
sound” the patient is endorsing. 1 point awarded if the participant simply acknowledges the
complaint.
4. 2 points awarded if the participant assesses the patient’s hearing by performing both Rinne
and Weber’s tests. 1 point awarded if the participant performs only one of the above
mentioned tests or simply evaluates for gross hearing loss through finger rub.
5. 2 points awarded if the participant orders all of the blood tests listed above. 1 point awarded
if partial blood work is ordered.
5
Margaret Davenport; 60 yo 8/8/1950
For Examiner Only
HISTORY
Onset of Symptoms:
The symptoms began gradually about an hour prior to arrival to the
ED.
Background Info:
A 60 y.o. female is brought in by EMS with a chief complaint of
dizziness.
Chief Complaint:
The patient was outside working on the garden when she started to
feel dizzy. She went inside to “cool off” and started developing a
“headache”. Her husband called 911 because he thought she was
having a stroke. She has never had symptoms like this before and
she feels like her dizziness is getting worse. She feels diaphoretic
and nauseated.
Past Medical Hx:
HTN
Past Surgical Hx:
None.
Habits:
Denies smoking, ETOH, or illicit drugs.
Family Medical Hx:
HTN, CAD
Social Hx:
Marital Status: married
Children: one, healthy
Education: BS
Employment: retired
ROS:
Positive for dizziness/vertigo, “roaring in her ears”, an occipital
headache, decreased hearing, nausea, diaphoresis, and “feeling
faint”
Negative for any chest pain, palpitations, shortness of breath, visual
changes, weakness, paresthesias, abdominal pain, extremity
swelling, or pain
6
Margaret Davenport; 60 yo 8/8/1950
For Examiner Only
PHYSICAL EXAM
Patient Name: Margaret Davenport
Age & Sex: 60 y.o. female
General Appearance: Well-developed, well-nourished female in moderate distress. She is
sitting upright in the gurney, diaphoretic, and moaning.
Vital Signs: HR 90
BP 167/52
RR 18
O2 Sat 99%
Temp 37.6
Head: Normocephalic. Atraumatic.
Eyes: PERRLA bilaterally. Horizontal, fatigable nystagmus to the left. EOMI. No scleral icterus.
Ears: Normal TM’s bilaterally. Decreased hearing on the left. Weber test lateralizes to the
right. Rinne test indicates that air conduction is better than bone conduction on the right.
Mouth: Clear. Moist. No asymmetry.
Neck: Supple. No masses. No JVD. No thyroid enlargement. No midline TTP.
Skin: Warm and dry. No rashes, cyanosis, or edema. 2+ capillary refill bilaterally.
Chest: No crepitus. No signs of trauma.
Lungs: CTA bilaterally. No rales, rhonchi or wheezes. Good air movement bilaterally.
Heart: RRR. No murmurs, rubs, or gallops. Normal S1 and S2.
Back: No spinal TTP. No CVAT.
Abdomen: Soft, NT/ND. +BS. No HSM.
Extremities: No cyanosis, clubbing, or edema. Normal range of motion bilaterally.
Rectal: Normal tone. Guaiac negative.
Pelvic: No discharge or bleeding. No CMT. No adnexal fullness or TTP. Normal uterine size.
Neurological: A&O x 4. CN II is diminished grossly bilaterally. CNIII-XII grossly intact. 4+
strength bilaterally throughout. No pronator drift. +Romberg. 2+ DTR’s bilaterally throughout.
Normal heel to shin. Normal finger-to-nose. No dysdiadochokinesia.
Mental Status: Alert, coherent, with good insight.
7
Margaret Davenport; 60 yo 8/8/1950
For Examiner Only
STIMULUS INVENTORY
#1
Emergency Admitting Form
#2
BMP
#3
LFTs
#4
Magnesium
#5
Urine Drug Screen
#6
CBC
#7
Coagulation panel
#8
TSH
#9
EKG
#10
Head CT
8
Margaret Davenport; 60 yo 8/8/1950
For Examiner Only
LAB DATA & IMAGING RESULTS
Stimulus #2
Basic Metabolic Profile (BMP)
GLUCOSE
121
SODIUM
140
POTASSIUM
4.9
CHLORIDE
106
CO2
23
BUN
7
CREATININE
0.8
CALCIUM
9.3
Latest Range: 60-99 MG/DL
Latest Range: 133-145 MEQ/L
Latest Range: 3.5-5.3 MEQ/L
Latest Range: 98-108 MEQ/L
Latest Range: 23-32 MEQ/L
Latest Range: 7-23 MG/DL
Latest Range: 0.6-1.3 MG/DL
Latest Range: 8.5-10.3 MG/DL
Stimulus #3
Liver Function Tests (LFTs)
TOTAL PROTEIN
7.3
ALBUMIN
4.0
BILIRUBIN TOTAL
0.8
BILIRUBIN DIRECT
0.2
PHOSPHORUS
2.7
ALK PHOSPHATASE
78
SGOT
41
SGPT
40
Latest Range: 6.1-7.9 GM/DL
Latest Range: 3.5-5.5 GM/DL
Latest Range: 0.1-1.4 MG/DL
Latest Range: 0.0-0.4 MG/DL
Latest Range: 2.4-4.7 MG/DL
Latest Range: 0-135 IU/L
Latest Range: 0-41 IU/L
Latest Range: 0-63 IU/L
Stimulus #4
MAGNESIUM
Latest Range: 1.7-2.8 MG/DL
2.0
Stimulus #5
Urine Drug Screen
MARIJUANA SCREEN
COCAINE MET SCREEN
AMPHETAMINE SCREEN
METHAMPHETAMINE SCRN, UR
BARBITURATE SCREEN
OPIATES SCREEN
PHENCYCLIDINE SCREEN
METHADONE SCREEN
BENZODIAZEP SCRN
TRICYCL ANTIDEPRESS SCRN, UR
9
NEGATIVE
NEGATIVE
NEGATIVE
NEGATIVE
NEGATIVE
NEGATIVE
NEGATIVE
NEGATIVE
NEGATIVE
NEGATIVE
No range found
No range found
No range found
No range found
No range found
No range found
No range found
No range found
No range found
No range found
Margaret Davenport; 60 yo 8/8/1950
Stimulus #6
Complete Blood Count (CBC)
WBC
10.0
RBC
4.9
HEMOGLOBIN
13.0
HCT
39.0
MCV
92.7
MCH
31.0
MCHC
33.5
RDW
11.7
PLATELET COUNT
380
Latest Range: 4.0-10.0 THOU/CU MM
Latest Range: 4.30-5.90 M/UL
Latest Range: 13.0-17.0 GM/DL
Latest Range: 39.0-51.0 %
Latest Range: 81.0-99.0 CU MICRONS
Latest Range: 27.0-33.0 UUG
Latest Range: 32.5-36.5 %
Latest Range: 11.6-14.8 %
Latest Range: 150-400 THOU/CU MM
Differential
NEUT%
LYMPH%
MONO%
EOSIN%
BASO%
74
26
9.7
0.0
0.3
Latest Range: 40.0-74.0 %
Latest Range: 12.0-40.0 %
Latest Range: 4.0-12.0 %
Latest Range: 0.0-8.0 %
Latest Range: 0.0-2.0 %
Stimulus #7
Coags
PT
INR
15
1.0
Latest Range: 12–15 seconds
Latest Range: 0.8-1.2
Stimulus #8
TSH
Free T4
2.0
1.0
Latest Range: 0.4-5 IU/mL
Latest Range: 0.7-1.5 ng/dL
Stimulus #9
EKG:
normal
Stimulus #10
CT head:
normal
10
Margaret Davenport; 60 yo 8/8/1950
Learner Stimulus #1
ABEM General Hospital
Emergency Admitting Form
Name:
Margaret Davenport
Age:
60 year old
Sex:
Female
Method of Transportation:
EMS
Person giving information:
Patient and her husband
Presenting complaint:
Dizziness
Background: A 60 y.o. female is brought in by EMS with a chief complaint of dizziness. Her
husband is present in the room.
Triage or Initial Vital Signs
HR 90
BP 167/52
11
RR 18
O2 Sat 99%
Temp 37.6C
Margaret Davenport; 60 yo 8/8/1950
Learner Stimulus #2
Basic Metabolic Profile (BMP)
GLUCOSE
121
SODIUM
140
POTASSIUM
4.9
CHLORIDE
106
CO2
23
BUN
7
CREATININE
0.8
CALCIUM
9.3
12
Latest Range: 60-99 MG/DL
Latest Range: 133-145 MEQ/L
Latest Range: 3.5-5.3 MEQ/L
Latest Range: 98-108 MEQ/L
Latest Range: 23-32 MEQ/L
Latest Range: 7-23 MG/DL
Latest Range: 0.6-1.3 MG/DL
Latest Range: 8.5-10.3 MG/DL
Margaret Davenport; 60 yo 8/8/1950
Learner Stimulus #3
Liver Function Tests (LFTs)
TOTAL PROTEIN
7.3
ALBUMIN
4.0
BILIRUBIN TOTAL
0.8
BILIRUBIN DIRECT
0.2
PHOSPHORUS
2.7
ALK PHOSPHATASE
78
SGOT
41
SGPT
40
13
Latest Range: 6.1-7.9 GM/DL
Latest Range: 3.5-5.5 GM/DL
Latest Range: 0.1-1.4 MG/DL
Latest Range: 0.0-0.4 MG/DL
Latest Range: 2.4-4.7 MG/DL
Latest Range: 0-135 IU/L
Latest Range: 0-41 IU/L
Latest Range: 0-63 IU/L
Margaret Davenport; 60 yo 8/8/1950
Learner Stimulus #4
MAGNESIUM
14
2.0
Latest Range: 1.7-2.8 MG/DL
Margaret Davenport; 60 yo 8/8/1950
Learner Stimulus #5
Urine Drug Screen
MARIJUANA SCREEN
COCAINE MET SCREEN
AMPHETAMINE SCREEN
METHAMPHETAMINE SCRN, UR
BARBITURATE SCREEN
OPIATES SCREEN
PHENCYCLIDINE SCREEN
METHADONE SCREEN
BENZODIAZEP SCRN
TRICYCL ANTIDEPRESS SCRN, UR
15
NEGATIVE
NEGATIVE
NEGATIVE
NEGATIVE
NEGATIVE
NEGATIVE
NEGATIVE
NEGATIVE
NEGATIVE
NEGATIVE
No range found
No range found
No range found
No range found
No range found
No range found
No range found
No range found
No range found
No range found
Margaret Davenport; 60 yo 8/8/1950
Learner Stimulus #6
Complete Blood Count (CBC)
WBC
10.0
RBC
4.9
HEMOGLOBIN
13.0
HCT
39.0
MCV
92.7
MCH
31.0
MCHC
33.5
RDW
11.7
PLATELET COUNT
380
Latest Range: 4.0-10.0 THOU/CU MM
Latest Range: 4.30-5.90 M/UL
Latest Range: 13.0-17.0 GM/DL
Latest Range: 39.0-51.0 %
Latest Range: 81.0-99.0 CU MICRONS
Latest Range: 27.0-33.0 UUG
Latest Range: 32.5-36.5 %
Latest Range: 11.6-14.8 %
Latest Range: 150-400 THOU/CU MM
Differential
NEUT%
LYMPH%
MONO%
EOSIN%
BASO%
Latest Range: 40.0-74.0 %
Latest Range: 12.0-40.0 %
Latest Range: 4.0-12.0 %
Latest Range: 0.0-8.0 %
Latest Range: 0.0-2.0 %
16
74
26
9.7
0.0
0.3
Margaret Davenport; 60 yo 8/8/1950
Learner Stimulus #7
Coags
PT
INR
15
1.0
17
Latest Range: 12–15 seconds
Latest Range: 0.8-1.2
Margaret Davenport; 60 yo 8/8/1950
Learner Stimulus #8
TSH
Free T4
2.0
1.0
18
Latest Range: 0.4-5 IU/mL
Latest Range: 0.7-1.5 ng/dL
Margaret Davenport; 60 yo 8/8/1950
Learner Stimulus #9
EKG: Normal EKG demonstrating sinus tachycardia at 90-100 bpm
19
Margaret Davenport; 60 yo 8/8/1950
Learner Stimulus #10
CT Head:
20
normal
Margaret Davenport; 60 yo 8/8/1950
For Examiner
Date:
Examiner:
Examinee(s):
Scoring: In accordance with the Standardized Direct Observational Tool (SDOT)
The learner should be scored (based on level of training) for each item above with one of the
following:
NI = Needs Improvement
ME = Meets Expectations
AE = Above Expectations
NA= Not Assessed
Critical Actions
Places patient on a cardiac monitor
with pulse oximetry
Obtains a bedside ECG
Places the patient on supplemental
oxygen
Performs a full neurological exam
Performs a hearing test
Orders a CT scan to rule out acute
intracranial pathology
Places a peripheral IV
Draws labs to evaluate for metabolic
disturbances, infections, and endocrine
or hormonal abnormalities contributing
to the symptomatology.
Elicits a history of vertigo, tinnitus, and
hearing loss from the patient and
makes the diagnosis of Meniere’s
Syndrome.
Obtains a neurological consult to aid in
patient disposition.
21
NI
ME
AE
NA
Category
PC, MK, PBL
PC, MK, PBL
PC, MK, PBL
PC, MK, PBL
PC, MK, PBL
PC, MK, PBL,
SBP
PC, MK, PBL
PC, MK, PBL,
SBP
PC, MK, ICS,
SBP
PC, MK, ICS,
SBP
Margaret Davenport; 60 yo 8/8/1950
Category: One or more of the ACGME Core Competencies as defined in the SDOT
PC=
Patient Care
Compassionate, appropriate, and effective for the treatment of health problems
and the promotion of health
MK= Medical Knowledge
Residents are expected to formulate an appropriate differential diagnosis with
special attention to life-threatening conditions, demonstrate the ability to utilize
available medical resources effectively, and apply this knowledge to clinical
decision making
PBL= Practice Based Learning & Improvement
Involves investigation and evaluation of their own patient care, appraisal and
assimilation of scientific evidence, and improvements in patient care
ICS= Interpersonal Communication Skills
Results in effective information exchange and teaming with patients, their
families, and other health professionals
P=
Professionalism
Manifested through a commitment to carrying out professional responsibilities,
adherence to ethical principles, and sensitivity to a diverse patient population
SBP= Systems Based Practice
Manifested by actions that demonstrate an awareness of and responsiveness to
the larger context and system of health care and the ability to effectively call on
system resources to provide care that is of optimal value
22
Margaret Davenport; 60 yo 8/8/1950
References:
1. Minor LB, Schessel DA, Carey JP. Ménière's disease. Curr Opin
Neurol. Feb 2004;17(1):9-16.
2. Sajjadi H, Paparella MM. Meniere's disease. Lancet. Aug 2 2008;372(9636):406-14.
3. Paparella MM. Pathogenesis and pathophysiology of Meniére's disease. Acta
Otolaryngol Suppl. 1991;485:26-35.
4. Paparella MM, Djalilian HR. Etiology, pathophysiology of symptoms, and pathogenesis
of Meniere's disease. Otolaryngol Clin North Am. Jun 2002;35(3):529-45, vi.
5. Merchant SN, Adams JC, Nadol JB Jr. Pathophysiology of Meniere's syndrome: are
symptoms caused by endolymphatic hydrops?. Otol Neurotol. Jan 2005;26(1):74-81.
6. Kitahara M. Bilateral aspects of Meniére's disease. Meniére's disease with bilateral
fluctuant hearing loss. Acta Otolaryngol Suppl. 1991;485:74-7.
7. Morrison AW, Johnson KJ. Genetics (molecular biology) and Meniere's
disease. Otolaryngol Clin North Am. Jun 2002;35(3):497-516.
8. Mancini F, Catalani M, Carru M, Monti B. History of Meniere's disease and its clinical
presentation. Otolaryngol Clin North Am. Jun 2002;35(3):565-80.
9. Monsell EM. New and revised reporting guidelines from the Committee on Hearing and
Equilibrium. American Academy of Otolaryngology-Head and Neck Surgery Foundation,
Inc. Otolaryngol Head Neck Surg. Sep 1995;113(3):176-8.
10. Kentala E, Havia M, Pyykko I. Short-lasting drop attacks in Meniere's
disease. Otolaryngol Head Neck Surg. May 2001;124(5):526-30.
11. Bhattacharyya N, Baugh RF, Orvidas L, Barrs D, Bronston LJ, Cass S. Clinical practice
guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck
Surg. Nov 2008;139(5 Suppl 4):S47-81.
12. White J. Benign paroxysmal positional vertigo: how to diagnose and quickly treat
it. Cleve Clin J Med. Sep 2004;71(9):722-8.
13. Fattori B, Nacci A, Dardano A, Dallan I, Grosso M, Traino C. Possible association
between thyroid autoimmunity and Menière's disease. Clin Exp
Immunol. Apr 2008;152(1):28-32.
14. Lorenzi MC, Bento RF, Daniel MM, Leite CC. Magnetic resonance imaging of the
temporal bone in patients with Ménière's disease. Acta
Otolaryngol. Aug 2000;120(5):615-9.
15. de Sousa LC, Piza MR, da Costa SS. Diagnosis of Meniere's disease: routine and
extended tests. Otolaryngol Clin North Am. Jun 2002;35(3):547-64.
16. Wetmore SJ. Endolymphatic sac surgery for Ménière's disease: long-term results after
primary and revision surgery. Arch Otolaryngol Head Neck
Surg. Nov 2008;134(11):1144-8.
17. Pullens B, Giard JL, Verschuur HP, van Benthem PP. Surgery for Ménière's
disease. Cochrane Database Syst Rev. Jan 20 2010;CD005395.
18. Sajjadi H. Medical management of Meniere's disease. Otolaryngol Clin North
Am. Jun 2002;35(3):581-9, vii.
19. Coelho DH, Lalwani AK. Medical management of Ménière's
disease. Laryngoscope. Jun 2008;118(6):1099-108.
20. Cope D, Bova R. Steroids in otolaryngology. Laryngoscope. Sep 2008;118(9):1556-60.
21. Odkvist LM, Arlinger S, Billermark E, Densert B, Lindholm S, Wallqvist J. Effects of
middle ear pressure changes on clinical symptoms in patients with Ménière's disease--a
clinical multicentre placebo-controlled study. Acta Otolaryngol Suppl. 2000;543:99-101.
23
Margaret Davenport; 60 yo 8/8/1950
22. Havia M, Kentala E. Progression of symptoms of dizziness in Ménière's disease. Arch
Otolaryngol Head Neck Surg. Apr 2004;130(4):431-5.
Keywords for future searching functions:
vertigo, tinnitus, hearing loss, Meniere’s Disease
Has this work been published? No
24
Margaret Davenport; 60 yo 8/8/1950
Debriefing Information:
 Meniere’s Disease is also known as idiopathic endolymphatic hydrops.
 It is a disorder of the inner ear resulting in the clinical triad of: vertigo, tinnitus,
and hearing loss:
o Vertigo
 Vertigo is a subjective sensation of motion while motionless.
 At least 2 definitive episodes of vertigo of at least 20 minutes duration
must have occurred to make the diagnosis.
 Duration is usually several hours long.
 Horizontal or rotatory nystagmus is always present during attacks of
vertigo.
 Symptoms are often accompanied with nausea, vomiting, and anxiety.
 Acute attacks may be accompanied with sudden falls without loss of
consciousness. These are termed crises of Tumarkin or drop attacks.
Most studies find the incidence of drop attacks to be less than 10%. In
one case series, self-reporting of drop attacks was 72% among patients
with diagnosis of Ménière's disease.
 It is important to distinguish if the patient’s vertigo is suggestive of central
vs. peripheral causes (Table 1)
Table 1: Characteristics of Peripheral Vs. Central Causes of Vertigo
Sign of Symptom
Peripheral Vertigo
Central Vertigo
Nystagmus
-Horizontal or torsional
-Vertical, horizontal, or
-Inhibited by fixating eyes onto torsional
an object
-Not inhibited by fixating eyes
onto an object
-Diminishes with time;
fatigueable
-May last weeks to months;
not immediately fatigueable
-Does not change direction
with alteration of gaze from
-Fast phase of nystagmus
side to side
may change with gaze
alteration from side to side
Imbalance
Mild to moderate; patient is
Severe; patient is typically
usually able to walk
unable to walk or stand
Nausea and vomiting
May be severe in nature
Varies
Hearing loss or tinnitus
Commonly associated
Rarely associated
Non-auditory neurologic
Rarely associated
Commonly associated
symptoms
Latency following provocative Long (up to 20 seconds)
Short (up to 5 seconds)
diagnostic maneuver
o
o
25
Hearing loss
 Sensorineural hearing loss must be documented audiometrically in the
affected ear at least once during the course of the disease.
 There may be fluctuation in the degree of hearing loss superimposed on a
gradual decrement in function.
 Hearing loss affects low frequencies primarily.
Tinnitus and aural fullness
Margaret Davenport; 60 yo 8/8/1950
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Tinnitus is often nonpulsatile and may be described as whistling or
roaring.
 It may be continuous or intermittent.
The etiology of Meniere’s Disease is still rather controversial.
The underlying mechanism is believed to be distortion of the membranous
labyrinth due to over-accumulation of endolymph secondary to obstruction or
decreased drainage.
Obstruction or decreased drainage is felt to be from infection, trauma, allergens,
or idiopathic.
The main morbidity associated with Meniere’s Disease is the debilitating nature
of the symptoms, potential for drop attacks and subsequent trauma, and
permanent hearing loss.
If Meniere’s Disease is suspected, the examiner should perform the following
tests:
o
A full neurological exam including the Romberg test
o
Dix-Hallpike Maneuver
o
Gross hearing evaluation via finger rub
o
Rinne test with a 256 MHz tuning fork
o
Weber test with a 256 MHz tuning fork
The differential diagnoses for Meniere’s Disease is quite broad and includes, but
is not limited to:
o
Benign positional vertigo
o
Ischemic or hemorrhagic stroke
o
Migraine headache
o
Hypothyroidism or Myxedema coma
o
Temporal lobe epilepsy
o
Labyrinthitis
o
Toxicities (e.g. Salicylate)
o
Multiple sclerosis
o
TIA
o
Otitis media
o
Vestibular neuronitis
o
Meningitis
o
Brainstem tumor
o
Foreign body or cerumen in the ear canal
o
Acoustic neuromas
o
Perilymphatic fistulas
o
Labyrinth trauma
o
Herpetic encephalitis
o
CNS syphyllis
o
Wernicke’s encephalopathy
Evaluation of the patient’s symptomatology should be directed towards ruling-out
life threatening or emergent etiologies listed on this differential. Obtaining a
neurology consult can aid in the patient’s final disposition.
Treatment is symptomatic and can include:
o
Antihistamines such as Meclizine or Dimenhydranate
o
Anticholinergics such as Scopolamine
o
Antiemetics such as Compazine, Zofran, or Phenergan
o
Benzodiazepines such as ativan or valium
o
Corticosteroids such as prednisone
Refer patients to ENT for full audiometric testing.
Margaret Davenport; 60 yo 8/8/1950
 All patients should be educated about the chance for spontaneous remission
(approximately 50%) vs. the need for further evaluation and surgical intervention.
 Patients should be warned about the risks of potential drop attacks and side
effects of long term symptomatic management with medications.
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