Assignment

A patient presents to the clinic with complaints of inner ear disturbance. How would you differentiate between labyrinthitis, benign paroxysmal positional vertigo, and Meniere’s disease? Include pathophysiology, clinical presentation, physical examination, diagnostics, and treatment.

1. Labyrinthitis: cause severe vertigo, nausea, vomiting, and disequilibrium that lasts a few days and is followed by vertigo and disequilibrium that occurs with rapid head movement that could last weeks to months (Lorenzi, 2017, p. 367).

• Pathophysiology: is commonly caused by viral inflam­mation of the vestibular nerve. Other possible causes are otitis media or irritation caused by chemical products associated with acute or chronic otitis media (Lorenzi, 2017, p. 367).
• Clinical presentation: Common signs/symptoms are severe vertigo, nausea, vomiting, tinnitus, dizziness, or disequilibrium (Lorenzi, 2017, p. 367).
• Physical examination:
• A thorough evaluation of the ear, nose, and throat. A neurologic evaluation, including balance testing (Romberg test) (Lorenzi, 2017, p. 367).
• The hearing screen would be normal.
• Spontaneous nystagmus, horizontal or rotary, is seen with fast phases directed away from the affected ear.
• Frenzel lenses could be used to evaluate nystagmus for greater magnification.
• Abnormal neurologic findings suggest a central cause and should be referred for immediate neurologic evaluation (Lorenzi, 2017, p. 367).
• Diagnostics: Complete blood count (CBC) with differential if a bacterial cause is suspected. Magnetic resonance imaging (MRI) or a computed tomography (CT) scan if a tumor is suspected (Lorenzi, 2017, p. 367).
• Treatment:
• Treatment should focus on alleviating vertigo, nausea, and vomiting, treating the cause of infection, and improving ventral compensation.
• Anticholinergics, antihistamines, long-acting benzodiazepines, or antiemetics could provide symptomatic relief.
• Anticholinergics/antihistamines are the first-line agents and benzodiazepines are given to patients who have adverse effects with anticholinergic drugs.
• Meclizine 25 to 50 mg is commonly prescribed and safe to use in pregnancy.
• Antiemetics could be used for three days to relieve vomiting.
• Methylprednisolone could be prescribed daily for 22 days at diagnosis, starting with a 100-mg dose and tapering down every three days.
• When the severe symptoms pass ventral compensation could be improved with vestibular exercises obtained through physical therapy (Lorenzi, 2017, p. 368).

2. Benign Paroxysmal Positional Vertigo (BPPV): cause short periods of mild to intense dizziness that is commonly triggered changes in the position of the head (Mayo clinic, 2018).

• Pathophysiology: is caused by the accumulation of debris in the inner ear made of small crystals of calcium carbonate. The crystals shift and disperse in the semicircular canal with position change and send false signals to the brain (Le & McCabe, 2017, p. 1027).
• Clinical presentation: The most common symptoms are vertigo, with the sensation of spinning or whirling of self or the environment.
• Physical examination:
• A review of medications, herbals, and over-the-counter drugs.
• A neurologic examination with a cognitive screen. Assess cranial nerves for visual acuity, eye movements, and nystagmus.
• A motor examination to evaluate the power, muscle tone, coordination, and deep tendon reflexes.
• A sensory examination to evaluate basic vision and hearing and testing of primary sensory modalities.
• A gait and balance evaluation to evaluate stride, arm swing, tandem gait with eyes opened and then closed, and Romberg sign.
• An otologic evaluation with an otoscopic to evaluate hearing including the Weber and Rinne tests.
• A cardiovascular evaluation with cardiac rate and rhythm, auscultation of heart sounds and carotid bruits, and blood pressure measurement.
• An evaluation of orthostatic vital signs, blood pressure, and heart rate should be included.
• A neuro-otologic examination is considered when vertigo or disequilibrium problems are suspected. This assesses the vestibulo-ocular and vestibulospinal systems and distinguish between peripheral disorders and central disorders; and assess for nystagmus, position testing (Hallpike-Dix maneuver, head-fixed/body-turn maneuvers, postural sway on a foam surface, and stepping test (marching in place with the eyes closed) (Le & McCabe, 2017, p. 1025).
• Diagnostics: Diagnosis could be confirmed by the history and a positive Hallpike-Dix test result. Further tests would be needed if there are positive neurologic findings (Le & McCabe, 2017, p. 1027).
• Treatment:
• Refer to an ENT or neurology specialist if the patient does not respond to canalith repositioning procedures (Epley maneuvers, or vestibular rehabilitation).
• BPPV could resolve in a few days or weeks without treatment.
• The first-line treatment is canalith repositioning, a positioning exercise that moves ear crystal particles from the semicircular canal.
• Vestibular rehabilitation could work quicker with prolonged remission. It consists of exercises that train the brain to react less to the confusing signals sent from the inner ear.
• Meclizine could be used as a vestibular suppressant for severe vertigo.
• Canal-plugging surgery could be used in rare refractory cases (Le & McCabe, 2017, p. 1028).

3. Meniere’s Disease: cause recurrent vertigo and hearing loss.

• Pathophysiology: the exact cause is unknown but the cause it mostly viral infections or immune system-mediated mechanisms. Excess fluid and pressure build up in the labyrinth of the inner ear, distends its structures, and damages the vestibular and cochlear hair cells (Lorenzi, 2017, p. 368).
• Clinical presentation: Early-stage signs/symptoms include intermittent attacks of vertigo that last from minutes to hours, often accompanied by nausea/vomiting, pressure in the ear, low-pitched tinnitus, and unilateral hearing loss. There could be periods of remission. Late-stage signs/symptoms include frequent vertigo and constant hearing loss (Lorenzi, 2017, p. 368).
• Physical examination: A thorough evaluation of the head and neck to rule out acute otitis media or other infections. A comprehensive neurologic examination. Conduct the Weber (sound would lateralize to the unaffected ear) and the Rinne test (air conduction would be greater than bone conduction) (Lorenzi, 2017, p. 368).
• Diagnostics: Two episodes of spontaneous vertigo lasting 20 minutes with audiometrically documented hearing loss, tinnitus or aural fullness, and the exclusion of other causes is criteria for diagnosis. Initial testing includes an audiogram, and MRI to rule out central nervous system (CNS) lesions. Lab testing includes thyroid-stimulating hormone (TSH), rapid plasma reagin (RPR) to test for syphilis, serum glucose, and Lyme serologies (Lorenzi, 2017, p. 369).
• Treatment:
• If the disease is suspected, refer patients to an otolaryngologist for testing and management.
• There is no cure for the disease, and the goals of treatment are managing the symptoms.
• If immune-mediated a diagnosis is confirmed after a positive response to steroid treatment.
• Steroid treatment could reverse inner ear damage.
• Meclizine and antiemetics such as promethazine (Phenergan) could be used for symptomatic relief.
• A Meniett device could be used to generates low-pressure pulses to displace inner ear fluids and relieve symptoms (Lorenzi, 2017, p. 369).

References

Le, N., & McCabe, K. (2017). Dizziness and Vertigo. In T. M. Buttaro, J. Trybulski, P. Polgar-Bailey, & J. Sandberg-Cook, Primary care: A collaborative practice (5th ed., pp. 1027-1028). St. Louis: Elsevier. Retrieved from https://reader.yuzu.com/#/books/9780323355018/

Lorenzi, M. M. (2017). Inner ear disturbances. In T. M. Buttaro, J. Trybulski, P. Polgar-Bailey, & J. Sandberg-Cook, Primary care: A collaborative practice (5th ed., pp. 367-371). St. Louis: Elsevier. Retrieved from https://reader.yuzu.com/#/books/9780323355018/

Mayo clinic. (2018). Benign paroxysmal positional vertigo (BPPV). Retrieved from Mayo clinic: https://www.mayoclinic.org/diseases-conditions/vertigo/symptoms-causes/syc-20370055?page=0&citems=10

Pietrangelo, A. (2017). Labyrinthitis. Retrieved from Healthline: https://www.healthline.com/health/labyrinthitis#symptoms