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A 67-year-old woman comes to the office because of "ringing in her ears," a feeling of
"spinning", and a progressive loss of hearing in her right ear over the past 5 months. She
says that this all began "a while ago with a slight feeling of unsteadiness." She never went to
the doctor because she thought she was "going crazy," but now her husband is getting
worried because the television needs to be much louder and she constantly says "what?"
when he speaks to her on her right side. She has no chronic medical conditions, does not
take any medications, and does not drink alcohoI. Examination shows nystagmus, but no
other abnormalities. The most likely diagnosis is
A. benign positional vertigo
B. benign recurrent vertigo
C. Menière's disease
D. toxic labyrinthitis
E. vestibular neuronitis
A 58-year-old man is evaluated in the emergency department after awakening with vertigo, ataxia, and headache. He has hypertension and stable angina, and his medications are aspirin, a β-blocker, and a statin.
On examination, his blood pressure is 170/92 mm Hg. Physical examination reveals bidirectional nystagmus and gait ataxia. CT scan of the brain is normal. Examination the following day reveals lethargy alternating with agitation, intractable hiccups, bidirectional horizontal nystagmus, normal strength, and dysmetria of the right upper and lower extremities.
Which of the following is the most likely diagnosis?
A Vestibular neuronitis
B Benign positional vertigo
C Vestibular migraine
D Menière's disease
E Cerebellar infarction
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A 75-year-old right-handed man presents with dizziness that started 1 hour ago. His dizziness consists of a spinning sensation and he feels off-balance as he walks. He reported coughing when trying to drink water earlier, but otherwise notes no symptoms. On exam, he is found to have left-sided ptosis, left facial numbness to pinprick. Gag is absent. Motor examination
is otherwise unremarkable. Sensory examination revealed decreased pinprick sensation of the right arm and leg. He is unsteady while walking, tending to lean leftward. He has an unremarkable past medical history and is taking no medications. What is the most likely diagnosis in this patient?
A) Acute vestibulitis/labyrinthitis.
B) BPV (benign positional vertigo).
C) Cerebellar stroke.
D) Brain stem stroke.
E) Meniere's attack.
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''A 67-year-old woman comes to the office because of "ringing in her ears," a feeling of
"spinning", and a progressive loss of hearing in her right ear over the past 5 months. ''
The correct answer is C. This patient has Meniere's disease, which is characterized by tinnitus, vertigo, and progressive hearing loss. It is thought to be related to a degeneration of the vestibular and cochlear hair cells. The treatment includes bed rest, a low-salt diet, dimenhydrinate, cyclizine or meclizine.
Benign positional vertigo (choice A) is characterized by paroxysmal vertigo and nystagmus. It is brought on by certain changes in position. Hearing loss is not present. The cause is idiopathic.
Benign recurrent vertigo (choice B) and vestibular neuronitis (choice E) are two names for the same syndrome, which is characterized by the sudden onset of vertigo, nausea, and vomiting. There is no change in hearing.
Toxic labyrinthitis (choice D) presents with vertigo. It is due to medications and alcohol. Aminoglycosides are among the most common culprits. This patient does not take any medications and denies any alcohol.
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A 58-year-old man is evaluated in the emergency department after awakening with vertigo, ataxia, and headache. He has hypertension and stable angina, and his medications are aspirin, a β-blocker, and a statin.
Correct Answer = E)
The classic symptoms of cerebellar stroke are headache, vertigo, and ataxia.
This patient presents with headache, vertigo, and ataxia, which are the classic presenting symptoms of ischemic or hemorrhagic cerebellar stroke. Although CT scan can exclude hemorrhage, infarcts may not be well visualized early, especially in the brainstem and cerebellum. His deterioration the following day with signs of brainstem compression (altered level of consciousness and intractable hiccups) indicates a dire situation, and urgent neurosurgical decompression is required. Peripheral vertigo may be a result of many disorders of the ear, including vestibular neuronitis, benign positional vertigo, vestibular migraine, acoustic neuroma, and Meniere's disease, but none of these causes unilateral limb ataxia, dysarthria, or hiccups. Headache may accompany vestibular migraine but is not a feature of the other peripheral disorders.
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A 75-year-old right-handed man presents with dizziness that started 1 hour ago. His dizziness consists of a spinning sensation and he feels off-balance as he walks.
correct answer is D. Although dizziness can be associated with all of the above disorders, a brain stem stroke is the most likely answer. The associated symptoms of ptosis CN3, absent gag with patient report of possible dysphagia, and crossed sensory findings (left side of face, right side of body) are most consistent with brain stem localization. In peripheral etiologies of vertigo
(answers A, B, E), one would not expect sensory phenomena, ptosis, or swallowing difficulties. In BPPV, one would expect brief attacks, lasting seconds to minutes, and not a prolonged attack. In Meniere, one would generally have a history of tinnitus and/or hearing loss (low-frequency, initially).
A pure cerebellar stroke would not be expected to have sensory findings
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