Labyrinthitis Vestibular neuritis + unilateral hearing loss = Labyrinthitis 1) Vertigo (severe)

Differentiating Benign Paroxysmal Positional Vertigo (BPPV) From Vestibular Neuritis-Labyrinthitis BENIGN PAROXYSMAL POSITIONAL VERTIGO • Age: More common in older adults • Hearing loss: None • Frequency of symptoms: Episodic (occurs with certain movements of the head) • Hallpike test: Positive usually on one side only with upbeat and torsional nystagmus and reproduction of vertigo symptoms • Head impulse test: Negative (Note: It is advised not to administer head impulse test in a patient with a clinical history consistent with BPPV.) • Epley maneuver: Highly effective • Recurrence: Frequent VESTIBULAR NEURITIS/LABYRINTHITIS • Age: More common in younger patients • Hearing loss: None in vestibular neuritis; hearing loss in labyrinthitis • Frequency of symptoms: Constant • Hallpike test: Symptoms may be worsened in head-hanging position (Note: It is advised not to administer Hallpike test in a patient with a clinical history consistent with vestibular neuritis or labyrinthitis.) • Head impulse test: Positive (corrective saccade seen) • Epley maneuver: Ineffective • Recurrence: Rare (2 to 11%) #Vertigo #BPPV #Vestibular #Neuritis #Labyrinthitis #diagnosis #neurology #comparison

Characteristics of Peripheral and Central Vertigo PERIPHERAL VERTIGO • Onset: Sudden • Intensity: Severe initially, often decreasing over time • Duration: Intermittent episodes lasting seconds to less than a minute for BPPV; continuous and lasting hours to days for vestibular neuritis • Nystagmus: Usually torsional and upbeat (fast phase beating toward forehead) in classic posterior canal BPPV; horizontal in horizontal canal BPPV; horizontal-torsional in vestibular neuritis/labyrinthitis • Head Position: Induces vertigo (BPPV); worsens vertigo (vestibular neuritis) • Neuro Findings: None • Auditory Findings: May be present, including tinnitus (Méniére's disease) and hearing loss (labyrinthitis) CENTRAL VERTIGO • Onset: Gradual or sudden • Intensity: Mild in most but can be severe in stroke and multiple sclerosis • Duration: Usually weeks, months (continuous) but can be seconds or minutes with vascular causes, such as with posterior circulation TIA • Nystagmus: Purely vertical, spontaneous and purely torsional, direction-changing on lateral gaze, downbeating (fast phase beats toward nose) • Head Position: Usually little change but can worsen with head position change • Neuro Findings: Usually present • Auditory Findings: Rarely #Peripheral #Central #Vertigo #diagnosis #findings #signs #symptoms #comparison #neurology

Diagnostic Algorithm for Dizziness and Vertigo Peripheral Vertigo: • Attacks: Sudden, severe, can last anywhere from seconds to minutes to days • Nystagmus: Varies • No neurologic findings • Auditory findings may be present Central Vertigo: • Attacks: Gradual, mild, usually continuous for weeks or months but can be sudden, severe and seconds or minutes with vascular causes • Nystagmus: Varies • Can worsen with head position change • Neurologic findings usually present • No auditory findings BPPV • Short-lived, positional episodes caused by stray otoliths in semicircular canal. Positive Hallpike test (posterior canal) or supine roll test (horizontal canal) Vestibular neuritis/labyrinthitis • Severe vertigo for days. Mild persistent vertigo up to weeks and months. No auditory symptoms (vestibular neuritis); positive hearing loss (labyrinthitis). Positive head impulse test Méniére's disease • Tinnitus. Hearing loss. Attacks in clusters. Long symptom-free intervals #Dizziness #Vertigo #Algorithm #differential #diagnosis #neurology

Peripheral and Central Causes of Vertigo Peripheral Causes (Common): - Labyrinth: Benign paroxysmal positional vertigo, Méniére disease, Perilymphatic fistula, Cogan's syndrome - Vestibular Nerve / Vestibulocochlear Nerve (CN VIII): Vestibular neuritis (a.k.a. labyrinthitis), Acoustic neuroma (a.k.a. vestibular Schwannoma; often classified as a "central vertigo"), Ramsay Hunt syndrome (a.k.a. herpes zoster oticus), Vestibular paroxysmia Central Causes (Uncommon): - Vascular - Stroke / transient ischemic attack (TIA): • Lateral medullary syndrome (a.k.a. Wallenberg syndrome) • Cerebellar infarct or hemorrhage - Non-vascular: Vestibular migraines, Multiple sclerosis - Dr. Eric Strong @DrEricStrong - Strong Medicine https://www.youtube.com/c/EricsMedicalLectures/ #Vertigo #Peripheral #Central #Causes #differential #diagnosis #neurology

Lateral Medullary Syndrome - Wallenberg's Syndrome Acute continuous vertigo due to Posterior Circulation Stroke (usually Posterior Inferior Cerebellar Artery occlusion) Clinical Findings: • Nausea/vomiting/vertigo/nystagmus - Vestibular nucleus (CN 8) • Ageusia - Solitary nucleus/tract • Ipsilateral ataxia - Inferior cerebellar peduncle • Ipsilateral facial numbness - Trigeminal nucleus (CN 5) / tract • Ipsilateral Horner's Syndrome - Sympathetic pathway • Contralateral loss of pain/temperature - Spinothalamic tract • Palatal myoclonus - Central tegmental tract • Hoarseness/dysphagia - Nucleus ambiguus (CN 9, 10) By Dr. Gabriela Figueiredo Pucci @gabifpucci @neudrawlogy #Lateral #Medullary #Syndrome #Wallenbergs #neurology #diagnosis

Mastoiditis: Pathogenesis and clinical findings Acute or Chronic Otitis Media -> Stage 1: Hyperemeia of the mastoid air cells (inflammation of middle ear mucosa leads to inflammation of the mastoid cavity as middle ear and mastoid air cells are connected) Stage 2: Transudation or exudation of fluid &/or pus within mastoid air cells (inflammation blocks antrum causing accumulation of pus in mastoid air cells) Stage 3: Necrosis of bone (air pressure increases causing decreased vascularity and destroying thin bony septae between air cells) Stage 4: Cell wall loss with coalescence into larger & irregular cavities Stage 5: Extension of inflammatory process into contiguous areas • Through aditus ad antrum -> Patent ET = resolution of infection; Obstructed ET= rupture of the tympanic membrane • Through lateral cortex of mastoid -> Subperiosteal abscess: Erythema, fluctuant, tender mass over mastoid bone, loss of postauricular crease • Inferior through medial aspect of mastoid tip -> Bezold abscess (Neck abscess between SCM & digastric muscles): Swelling & tenderness below mastoid process & under SCM • Medially to petrous air cells -> Petrositis (infection or inflammation in the petrous portion of the temporal bone): facial nerve palsy • Posteriorly to occipital bone -> Osteomyelitis • Through oval or round window -> Labyrinthitis (inflammation or infection of bony labyrinth): Tinnitus, hearing loss, nausea, vomiting, dizziness, vertigo, nystagmus • Toward inner cortical bone -> Meningitis, Venous sinus thrombosis, Temporal lobe, cerebellar, epidural, or subdural abscesses #Mastoiditis #pathophysiology #signs #symptoms #diagnosis #otology

Hearing Loss - Differential Diagnosis Framework Hearing Loss Types: • Conductive • Sensorineural • Mixed Presbycusis is the most common type in adults (bilateral age related hearing loss) History: • Duration of hearing loss? • Bilateral? • Fluctuating? • Progressive? The evaluation should also include a: • Neurologic review • History of: • Diabetes mellitus • Stroke • Vasculitis • Head or ear trauma • Use of ototoxic medications • Family history of ear conditions and hearing loss Exam: • Hearing tests such as the whispered voice test or audiometry • Patients should then undergo examination for: • Cerumen impaction • Exostoses • Other abnormalities of the external canal and tympanic membrane • Neurologic examination: ○ Cranial nerves - tumors of the auditory nerve (acoustic neuroma) and stroke may affect cranial nerves V and VII. • Head and neck masses and lymphadenitis? Infection or cancer Tuning Fork Tests (512 Hz) Weber Test: • Lateralization to good ear indicates sensorineural hearing loss • Lateralization to bad ear indicates conductive hearing loss Rinne Test: • Normal: Air > bone • Conductive hearing loss: Bone > Air conduction Conductive Hearing Loss Conductive problems involve the tympanic membrane and middle ear, and interfere with transmitting sound and converting it to mechanical vibrations. • Outer Ear: ○ Obstruction of external canal by cerumen ○ Obstruction of external canal by exostoses (surfer’s ear) ○ Obstruction of external canal by foreign body ○ Otitis externa • Middle Ear: ○ Cholesteatoma ○ Ossicular chain disruption ○ Otitis media ○ Otosclerosis Tympanic Membrane: • Perforation, tympanosclerosis Sensorineural Hearing Loss Sensorineural problems affect the conversion of mechanical sound to neuroelectric signals in the inner ear or auditory nerve (CN 8). • Unilateral: ○ Internal auditory artery infarct (Labyrinthine artery) – Sudden Onset ○ Meniere disease ○ Vestibular Schwannoma/Acoustic neuroma ○ Viral ○ Idiopathic SNH (80% to 90% of cases cause unknown) • Bilateral: ○ Presbycusis - is the most common type in adults ○ Ototoxic medications (Aminoglycosides, ASA, etc.) ○ Meningitis complications ○ Neurofibromatosis type II ○ Susac’s syndrome ○ Superficial Siderosis ○ Mitochondrial disorders ○ Noise trauma ○ MS, CVA • Infectious Conditions: ○ Labyrinthitis ○ Epstein-Barr virus ○ Group A Streptococcus ○ Herpes simplex virus ○ Herpes zoster virus ○ HIV ○ Lyme disease ○ Meningitis ○ Syphilis Cerebellopontine angle tumor/neoplasm • Trauma: ○ Barotrauma, ear trauma, or head trauma ○ Noise exposure #Hearing #Loss #Differential #Diagnosis #otology #otolaryngology

Causes of Peripheral and Central Vertigo PERIPHERAL VERTIGO 1. Benign paroxysmal positional vertigo (BPPV) - Short-lived (typically less than 30 seconds), positional, fatigable episodes; more often in older adults. 2. Vestibular neuritis/ labyrinthitis - Vertigo may develop suddenly or evolve over several hours, usually increasing in intensity for hours, then gradually subsiding over several days but can last weeks. Can be worsened with positional change. Sometimes history of viral infection precedes initial attack. Highest incidence is found in third and fifth decades. 3. Méniére's disease - Recurrent episodes of severe rotational vertigo usually lasting hours. Onset usually abrupt. Attacks may occur in clusters. Long symptom-free remissions. CENTRAL VERTIGO 1. Vascular disorders A. Vertebrobasilar insufficiency (VBI) - Should be considered in any patient of advanced age with isolated new-onset vertigo without an obvious cause. More likely with history of atherosclerosis. Can occur with neck trauma. May be preceded by an episode usually lasting minutes. B. Cerebellar hemorrhage - Sudden onset of severe symptoms. C. Occlusion of posterior inferior cerebellar artery (Wallenberg's syndrome) - Vertigo associated with significant neurologic complaints. 2. Head trauma - Symptoms begin with or shortly after head trauma. Positional symptoms most common type after trauma. Self-limited symptoms that can persist weeks to months. 3. Migrainous vertigo - Vertigo attacks can occur during the headache (in one study of 33 patients 24% always had headache with vertigo and 67% had headache sometimes with vertigo) but often occur during the headache-free interval. Most patients have a family history of migraine. Syndrome usually begins in adolescence. 4. Multiple sclerosis - Vertigo presenting symptom in 7% to 10% and appears in the course of the disease in a third. Onset may be severe. Disease onset usually between ages of 20 and 40. Often history of other attacks with varying neurologic signs or symptoms. #Peripheral #Central #Vertigo #Causes #differential #diagnosis #neurology

Relapsing Polychondritis What is it? Recurrent inflammation of the cartilage in the body (Autoimmune disorder) Who? • Most frequently: 40 and 60 years • Even as young as 20 years • Females slightly > Males • Affects all ethnicities Symptoms: • Sudden onset of pain, tenderness, and swelling of the cartilage of one or both ears (Auricular chondritis is the most common clinical manifestation) • + Nonspecific symptoms: Fever, weight loss, malaise, night sweats, and fatigue Criteria: • Recurrent bilateral auricular chondritis • Inflammatory polyarthritis (Non-erosive) • Nasal chondritis • Ocular inflammation (conjunctivitis, keratitis, uveitis, scleritis) • Tracheal chondritis • Laryngeal chondritis (Change in voice) • Cochlear damage - hearing loss • Vestibular damage - dizziness, hearing loss, nausea Inflammatory process may damage connective tissue components of: • Heart • Large vessels (aorta) • Eyes • Inner ear • Skin • Joints - Inflammation of joint cartilage (seronegative) • Kidneys • Other organs Also manifest with: • Costochondritis • Hoarseness of voice • Inflammation - glottis - dysphagia Relapsing polychondritis usually spares the earlobe (Not always though!) • Earlobe is typically not involved because it has no cartilage • Can appear like "cauliflower ear" • Violaceous discoloration • Warm and swollen • Episodic/Self-limiting Associated with other immunologically mediated diseases 30% of cases such as: • SLE • RA - Most common • Sjogren’s syndrome • MAGIC syndrome • Vexus syndrome - Associated with Polyarteritis Nodosa, GCA, Sweet syndrome, MDS & Multiple myeloma Complications: • Airway collapse or obstruction • Deafness • Loss of vision • Aortic and other large vessel aneurysms • Cardiac arrhythmia • Heart failure • Renal insufficiency • Cognitive dysfunction DDX: • Sarcoidosis • Behcet disease • Infections ○ Tuberculosis ○ Leprosy ○ Syphilis ○ Fungal ○ Bacterial ○ Viral infection • Lymphoma • GPA/EGPA • RA Diagnosis: • Clinical tests for (not sensitive or specific): ○ Anti-Matrilin-1 Ab ○ Antibodies to type II collagen • Nonspecific ↑ ESR, CRP, ANA + • Biopsy of affected tissue Treatment: • Corticosteroids: Prednisone #Relapsing #Polychondritis #rheumatology #diagnosis #management