Otorhinolaryngology (ENT)
Neuro-otology: Vertigo, Tinnitus and Facial Palsy
Neuro-otology for MBBS ENT: vertigo, BPPV and the Epley manoeuvre, Meniere disease, vestibular neuronitis, acoustic neuroma, tinnitus and facial palsy, mapped to NMC codes EN4.
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Neuro-otology: Vertigo, Tinnitus and Facial Palsy
Neuro-otology for MBBS ENT: vertigo, BPPV and the Epley manoeuvre, Meniere disease, vestibular neuronitis, acoustic neuroma, tinnitus and facial palsy, mapped to NMC codes EN4.
This chapter deals with disorders where the ear meets neurology. It covers vertigo and its peripheral and central causes, benign positional vertigo, Meniere disease, vestibular neuronitis and acoustic neuroma, along with tinnitus and facial nerve palsy, including how to separate benign from serious causes.
High-yield: Neuro-otology: Vertigo, Tinnitus and Facial Palsy
- Vertigo is an illusion of movement and points to a disorder of the vestibular system, either peripheral or central.
- Benign paroxysmal positional vertigo causes brief spinning triggered by head movement and is due to otoconia in the semicircular canals.
- The Dix-Hallpike test provokes and diagnoses posterior canal BPPV, and the Epley manoeuvre repositions the otoconia to treat it.
- Meniere disease is the triad of episodic vertigo, fluctuating sensorineural hearing loss and tinnitus, with a sense of aural fullness.
- Meniere disease is caused by endolymphatic hydrops and is managed with salt restriction, diuretics and vestibular sedatives in the acute phase.
- Vestibular neuronitis causes sudden severe vertigo lasting days without hearing loss, often after a viral illness.
- Labyrinthitis resembles vestibular neuronitis but is accompanied by hearing loss because the cochlea is also involved.
- An acoustic neuroma (vestibular schwannoma) causes progressive unilateral sensorineural hearing loss, tinnitus and imbalance and is imaged with gadolinium MRI.
- Central vertigo is suggested by other neurological signs, direction-changing nystagmus and a normal head impulse test.
- Tinnitus is the perception of sound without an external source and is often associated with sensorineural hearing loss.
- Bell palsy is an idiopathic lower motor neuron facial palsy treated early with corticosteroids, with good recovery in most cases.
- In lower motor neuron facial palsy the forehead is involved, whereas in upper motor neuron palsy the forehead is spared.
- Ramsay Hunt syndrome is facial palsy with a vesicular rash in the ear from herpes zoster of the geniculate ganglion.
- The head impulse test, nystagmus and test of skew (HINTS) help separate peripheral from central causes of acute vertigo.
Common causes of vertigo
- **BPPV:** Brief spinning on head movement. Dix-Hallpike positive. Treated with the Epley manoeuvre.
- **Meniere disease:** Episodic vertigo, fluctuating hearing loss, tinnitus and aural fullness. Endolymphatic hydrops.
- **Vestibular neuronitis:** Sudden prolonged vertigo, no hearing loss, often post-viral.
- **Acoustic neuroma:** Progressive unilateral sensorineural loss with imbalance. MRI with gadolinium.
NMC competencies in this chapter
- **EN4.18:** Vertigo: causes, evaluation and principles of management
- **EN4.19:** Meniere disease and benign paroxysmal positional vertigo
- **EN4.20:** Tinnitus: causes and management
- **EN4.21:** Facial nerve palsy: causes, evaluation and management
Frequently Asked Questions
What is the triad of Meniere disease?
Episodic vertigo, fluctuating sensorineural hearing loss and tinnitus, usually with a sense of aural fullness. It is caused by endolymphatic hydrops.
How is BPPV diagnosed and treated?
The Dix-Hallpike test provokes brief positional vertigo and nystagmus, confirming posterior canal BPPV, and the Epley repositioning manoeuvre relieves it by moving the otoconia out of the canal.
How do I tell an upper from a lower motor neuron facial palsy?
In lower motor neuron palsy, such as Bell palsy, the forehead is weak on the affected side. In upper motor neuron palsy the forehead is spared because it has bilateral cortical supply.
What is Ramsay Hunt syndrome?
It is facial palsy caused by herpes zoster of the geniculate ganglion, with a painful vesicular rash in and around the ear, and it carries a poorer prognosis than Bell palsy.
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