AssessmentsVertigo: Pathology review
USMLE® Step 1 style questions USMLE
A 30-year-old woman comes to the clinic due to spinning sensation and feeling unstable. This sensation started 1 month ago and since then has gotten gradually worse. She also describes constant fatigue and tingling sensation in both of her upper extremities. She states that several months ago, she went to the emergency department for an episode of intense right eye pain with movement and the loss of color vision; this gradually improved over 2 weeks. Vital signs are within normal limits. Physical examination shows ataxia and nystagmus. A head MRI shows multiple hyperintense periventricular and cerebellar ovoid lesions. Which of the following is the most likely additional finding in this patient?
Content Reviewers:Yifan Xiao, MD
At the family medicine center, there’s a 55 year old female, named Juliette, who came to visit the doctor because she has had some episodes where she felt like “everything around her was moving”.
These episodes start abruptly and usually last a few hours.
She also complains of ringing in her left ear and feels that she can’t hear very well from that ear.
Her medical history is otherwise insignificant.
Clinical examination reveals horizontal nystagmus.
Next to Juliette, there’s a 70 year old male, named Alasdair, who is brought in by his son because an hour ago he felt that “the room around him was moving” and had difficulty in speaking.
He also complains of “seeing double”.
Clinical examination reveals vertical nystagmus.
Alright, so both Juliette and Alasdair have vertigo.
The difference is vertigo can be thought of as having an illusion of self-motion, or movement of the surrounding environment; syncope is the feeling of blacking out or fainting; and disequilibrium causes a sensation of being off balance without the sensation of the environment moving.
The vestibular system is made of the vestibular apparatus; including the three semicircular canals, the utricle and saccule, the vestibular nerve, and the vestibular structures in the brainstem and cerebellum.
Vertigo can be broken down into peripheral vertigo, which is due to damage to the vestibular apparatus, or damage to the vestibular nerve, and central vertigo, which is due to damage to the vestibular structures in the brainstem or cerebellum.
Okay, let’s take a closer look at the causes of peripheral vertigo.
The crystals obstruct the normal flow of endolymph in the canals when the head moves in a specific direction.
Like stones causing turbulence in a smooth river.
Alright, now moving onto Ménière’s disease, which is a high yield disorder!
That’s why it’s also called endolymphatic hydrops.
It’s usually slow-growing and benign meaning that the cells don’t invade surrounding tissue structures.
In neurofibromatosis type 2 there’s a deletion on chromosome 22.
This mutation inactivates merlin, allowing Schwann cells to divide uncontrollably.
As a consequence, several schwannomas develop in multiple locations.
These arteries supply the cerebellum which helps with muscle coordination and balance.
Alright, so whatever the cause, we end up with vertigo, so let’s go over some high yield signs and symptoms.
The nystagmus can be present at rest, or they can be provoked by the Dix-Hallpike maneuver.
Another thing associated with central causes is skew deviation where the eyes move upwards and rotate counterclockwise.
Other associated symptoms also provide a clue.
For example, in the exams if you see the 4 Ds: diplopia, dysphagia, dysarthria, or dysmetria, think of central vertigo, whereas auditory symptoms like hearing loss or tinnitus suggest peripheral vertigo.
There are also characteristics of the symptoms that can help you identify each specific disorder.
Episodes last less than one minute, and can be accompanied by nausea or vomiting, which can be present in all cases of vertigo.
A high yield fact is that hearing loss and tinnitus are usually absent in BPPV.
Head movement can worsen the symptoms, but the symptoms can occur at rest and don’t rely on a specific position.
Also, unlike BPPV, there may be hearing loss.
Now, Ménière’s disease typically starts between the ages of 20 and 40. Individuals with Ménière’s disease typically develop a triad of symptoms: recurrent episodic vertigo, sensorineural hearing loss, and tinnitus, and that’s something you absolutely have to remember for the exams!
The onset of symptoms is usually abrupt, and episodes usually last from 20 minutes up to 24 hours.
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