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					                                                               Margaret Davenport; 60 yo 8/8/1950


Author: Teresa S. Wu, MD                           Reviewer:     Thomas Payton, MD

Case Title:       “I think I’m having a stroke!”

Target Audience: medical students, physicians’ assistants, nurse practitioners, residents

Primary Learning Objectives: key learning objectives of the scenario
       1.     The participant will obtain a detailed history and perform a comprehensive
              neurological exam.
       2.     The participant will formulate a broad & comprehensive differential diagnosis for
              patients presenting with vertigo.
       3.     The participant will avoid anchoring into a diagnosis and will carefully consider
              the data presented in the case.
       4.     The participant will explain the pathophysiology of Meniere’s Disease and offer
              options for symptomatic control and surgical treatment.

Secondary Learning Objectives:
      1.     The participant will actively manage and reassess the patient’s symptoms (IV
             antiemetics, benzodiazepines, IVF’s, etc.)
      2.     The participant will order the correct tests to rule-out an acute cerebral event
      3.     The participant will order the correct blood work to rule-out co-existing metabolic,
             hormonal, or endocrinological disturbances.
      4.     The participant will demonstrate compassion and empathy during the evaluation
             and management of the patient


Critical actions checklist:
         1. Places patient on a cardiac monitor with pulse oximetry
         2. Obtains a bedside ECG
         3. Places the patient on supplemental oxygen
         4. Checks a bedside point-of-care glucose
         5. Performs a full neurological exam
         6. Performs a hearing test
         7. Orders a CT scan to rule out acute intracranial pathology
         8. Places a peripheral IV
         9. Draws labs to evaluate for metabolic disturbances, infections, and endocrine or
             hormonal abnormalities contributing to the symptomatology.
         10. Elicits a history of vertigo, tinnitus, and hearing loss from the patient and makes the
             diagnosis of Meniere’s Syndrome.
         11. Obtains a neurological consult to aid in the patient’s disposition

Environment
       1.   Room Set Up – Emergency Department Resuscitation Bay
            a. Mannequin: SimMan 3G with a female wig
            b. Equipment:
               1. Cardiac Monitor
               2. Blood pressure cuff (manual and automatic)
               3. Peripheral IVs (18 gauge, 16 gauge)
               4. Gauze
               5. Tape
              1
                                                        Margaret Davenport; 60 yo 8/8/1950

                  6. Tourniquet
                  7. Tegaderm
                  8. IV caps or heplocks
                  9. Oxygen Source/Tree
                  10. Non-rebreather
                  11. IV fluids (NS and LR)
                  12. Blood collection tubes (rainbow)
                  13. Urine specimen
                  14. Lab reports (CBC, CMP, coagulation panel, UA, cardiac enzymes)
                  15. Meclizine
                  16. Ativan
                  17. Antiemetics (zofran, phenergan, compazine, etc.)
                  18. Aspirin
                  19. Normal EKG
                  20. Normal head CT
                  21. Phone call to consults


Actors (optional)
       1.      Nurse
       2.      Paramedics to give report about the patient
       3.      Patient’s husband
       4.      Neurologist
       5.      Radiology technician




           2
                                                         Margaret Davenport; 60 yo 8/8/1950

For Examiner Only

Author:          Teresa S. Wu, MD

Case Title: “I think I’m having a stroke!”


                                        CASE SUMMARY


CORE CONTENT AREA

Otolaryngology


SYNOPSIS OF HISTORY/ Scenario Background

A 60 y.o. female is brought in by EMS with a chief complaint of dizziness. She was outside
working on the garden when she started to feel dizzy. She went inside to “cool off” and started
developing a “headache”. Her husband called 911 because he thought she was having a
stroke.

When asked, the patient will note that her headache feels like “fullness” that came on gradually.
Now she feels like the room is spinning. She’s had no visual changes, but she feels like there is
a “buzzing in her ear”. She denies any chest pain, shortness of breath, paresthesias,
weakness, nausea, or vomiting. This is the first time she has experienced these symptoms.
She cannot recall any inciting event.

Past Medical History: HTN

Medications: Lisinopril

Allergies: PCN

Family History: HTN, CAD

Social History: Married. Retired. Denies EtOH, tobacco, or illicit drugs.


SYNOPSIS OF PHYSICAL

Patient is sitting upright in the gurney, diaphoretic, complaining of dizziness.
Her neurological exam is significant for decreased hearing on the left, nystagmus, and a positive
Romberg.

HR 90     BP 167/52       RR 18   O2 Sat 99%    Temp 37.6




           3
                                                        Margaret Davenport; 60 yo 8/8/1950

For Examiner Only

                           CRITICAL ACTIONS
SCENARIO BRANCH POINTS/ PLAY OF CASE GUIDELINES


1. Critical Action

   The participant should order a head CT or MRI to rule out an acute cerebral event.

   Cueing Guideline: The patient and her husband should continue to ask the participant if she
   is having a stroke.

2. Critical Action

   The participant should perform a thorough neurological exam and note that the patient’s
   exam is only notable for fatigable nystagmus and a positive Romberg test.

   Cueing Guideline: The patient continues to complain that she feels “really, really dizzy”.

3. Critical Action

   The participant should inquire more about the “roaring sound” and ask about associated
   tinnitus.

   Cueing Guideline: The patient starts to complain that there is a “roaring sound” in her ears
   and that the sound is making her headache worse.

4. Critical Action

   The participant should assess the patient’s hearing either through a gross assessment with
   finger rubs or via a tuning fork (Rinne and Weber’s tests).

   The patient continues to ask the participant to repeat each question asked because she is
   “having a hard time hearing” him/her.

5. Critical Action

   The participant should send the following blood tests to rule-out other certain metabolic
   disturbances, infections, and endocrine or hormonal abnormalities contributing to the
   symptomatology:
    TSH, Free T4 and T3
    CBC
    BMP
    ESR
    CRP
    UA
    FTA-ABS

Cueing Guideline: The nurse asks the participant what lab tests he/she would like to send.

          4
                                                         Margaret Davenport; 60 yo 8/8/1950

Maximum Points for Critical Actions: 10 points

SCORING GUIDELINES
(Critical Action No.)
1. 2 points awarded if the CT or MRI is obtained.
2. 2 points awarded if a full neurological exam is performed. 1 point awarded if a partial
   neurological exam is performed.
3. 2 points awarded if the participant elicits more history and details concerning the “roaring
   sound” the patient is endorsing. 1 point awarded if the participant simply acknowledges the
   complaint.
4. 2 points awarded if the participant assesses the patient’s hearing by performing both Rinne
   and Weber’s tests. 1 point awarded if the participant performs only one of the above
   mentioned tests or simply evaluates for gross hearing loss through finger rub.
5. 2 points awarded if the participant orders all of the blood tests listed above. 1 point awarded
   if partial blood work is ordered.




                5
                                                   Margaret Davenport; 60 yo 8/8/1950


For Examiner Only

                                     HISTORY


Onset of Symptoms:   The symptoms began gradually about an hour prior to arrival to the
                     ED.

Background Info:     A 60 y.o. female is brought in by EMS with a chief complaint of
                     dizziness.

Chief Complaint:     The patient was outside working on the garden when she started to
                     feel dizzy. She went inside to “cool off” and started developing a
                     “headache”. Her husband called 911 because he thought she was
                     having a stroke. She has never had symptoms like this before and
                     she feels like her dizziness is getting worse. She feels diaphoretic
                     and nauseated.

Past Medical Hx:     HTN

Past Surgical Hx:    None.

Habits:              Denies smoking, ETOH, or illicit drugs.

Family Medical Hx:   HTN, CAD

Social Hx:           Marital Status: married
                     Children: one, healthy
                     Education: BS
                     Employment: retired

ROS:
                     Positive for dizziness/vertigo, “roaring in her ears”, an occipital
                     headache, decreased hearing, nausea, diaphoresis, and “feeling
                     faint”

                     Negative for any chest pain, palpitations, shortness of breath, visual
                     changes, weakness, paresthesias, abdominal pain, extremity
                     swelling, or pain




             6
                                                        Margaret Davenport; 60 yo 8/8/1950


For Examiner Only

                                       PHYSICAL EXAM


Patient Name: Margaret Davenport                     Age & Sex: 60 y.o. female

General Appearance: Well-developed, well-nourished female in moderate distress. She is
sitting upright in the gurney, diaphoretic, and moaning.

Vital Signs: HR 90     BP 167/52     RR 18     O2 Sat 99%    Temp 37.6

Head: Normocephalic. Atraumatic.

Eyes: PERRLA bilaterally. Horizontal, fatigable nystagmus to the left. EOMI. No scleral icterus.

Ears: Normal TM’s bilaterally. Decreased hearing on the left. Weber test lateralizes to the
right. Rinne test indicates that air conduction is better than bone conduction on the right.

Mouth: Clear. Moist. No asymmetry.

Neck: Supple. No masses. No JVD. No thyroid enlargement. No midline TTP.

Skin: Warm and dry. No rashes, cyanosis, or edema. 2+ capillary refill bilaterally.

Chest: No crepitus. No signs of trauma.

Lungs: CTA bilaterally. No rales, rhonchi or wheezes. Good air movement bilaterally.

Heart: RRR. No murmurs, rubs, or gallops. Normal S1 and S2.

Back: No spinal TTP. No CVAT.

Abdomen: Soft, NT/ND. +BS. No HSM.

Extremities: No cyanosis, clubbing, or edema. Normal range of motion bilaterally.

Rectal: Normal tone. Guaiac negative.

Pelvic: No discharge or bleeding. No CMT. No adnexal fullness or TTP. Normal uterine size.

Neurological: A&O x 4. CN II is diminished grossly bilaterally. CNIII-XII grossly intact. 4+
strength bilaterally throughout. No pronator drift. +Romberg. 2+ DTR’s bilaterally throughout.
Normal heel to shin. Normal finger-to-nose. No dysdiadochokinesia.

Mental Status: Alert, coherent, with good insight.




           7
                                               Margaret Davenport; 60 yo 8/8/1950

For Examiner Only

                                 STIMULUS INVENTORY


#1    Emergency Admitting Form

#2    BMP

#3    LFTs

#4    Magnesium

#5    Urine Drug Screen

#6    CBC

#7    Coagulation panel

#8    TSH

#9    EKG

#10   Head CT




         8
                                                Margaret Davenport; 60 yo 8/8/1950


For Examiner Only

                           LAB DATA & IMAGING RESULTS

Stimulus #2
Basic Metabolic Profile (BMP)
GLUCOSE                    121       Latest Range: 60-99 MG/DL
SODIUM                     140       Latest Range: 133-145 MEQ/L
POTASSIUM                  4.9       Latest Range: 3.5-5.3 MEQ/L
CHLORIDE                   106       Latest Range: 98-108 MEQ/L
CO2                        23        Latest Range: 23-32 MEQ/L
BUN                        7         Latest Range: 7-23 MG/DL
CREATININE                 0.8       Latest Range: 0.6-1.3 MG/DL
CALCIUM                    9.3       Latest Range: 8.5-10.3 MG/DL

Stimulus #3
Liver Function Tests (LFTs)
TOTAL PROTEIN              7.3       Latest Range: 6.1-7.9 GM/DL
ALBUMIN                    4.0       Latest Range: 3.5-5.5 GM/DL
BILIRUBIN TOTAL            0.8       Latest Range: 0.1-1.4 MG/DL
BILIRUBIN DIRECT           0.2       Latest Range: 0.0-0.4 MG/DL
PHOSPHORUS                 2.7       Latest Range: 2.4-4.7 MG/DL
ALK PHOSPHATASE            78        Latest Range: 0-135 IU/L
SGOT                       41        Latest Range: 0-41 IU/L
SGPT                       40        Latest Range: 0-63 IU/L

Stimulus #4
MAGNESIUM                  2.0       Latest Range: 1.7-2.8 MG/DL

Stimulus #5
Urine Drug Screen
MARIJUANA SCREEN                     NEGATIVE            No range found
COCAINE MET SCREEN                   NEGATIVE            No range found
AMPHETAMINE SCREEN                   NEGATIVE            No range found
METHAMPHETAMINE SCRN, UR             NEGATIVE            No range found
BARBITURATE SCREEN                   NEGATIVE            No range found
OPIATES SCREEN                       NEGATIVE            No range found
PHENCYCLIDINE SCREEN                 NEGATIVE            No range found
METHADONE SCREEN                     NEGATIVE            No range found
BENZODIAZEP SCRN                     NEGATIVE            No range found
TRICYCL ANTIDEPRESS SCRN, UR         NEGATIVE            No range found




          9
                                   Margaret Davenport; 60 yo 8/8/1950


Stimulus #6
Complete Blood Count (CBC)
WBC                     10.0   Latest Range: 4.0-10.0 THOU/CU MM
RBC                     4.9    Latest Range: 4.30-5.90 M/UL
HEMOGLOBIN              13.0   Latest Range: 13.0-17.0 GM/DL
HCT                     39.0   Latest Range: 39.0-51.0 %
MCV                     92.7   Latest Range: 81.0-99.0 CU MICRONS
MCH                     31.0   Latest Range: 27.0-33.0 UUG
MCHC                    33.5   Latest Range: 32.5-36.5 %
RDW                     11.7   Latest Range: 11.6-14.8 %
PLATELET COUNT          380    Latest Range: 150-400 THOU/CU MM

Differential
NEUT%                   74     Latest Range: 40.0-74.0 %
LYMPH%                  26     Latest Range: 12.0-40.0 %
MONO%                   9.7    Latest Range: 4.0-12.0 %
EOSIN%                  0.0    Latest Range: 0.0-8.0 %
BASO%                   0.3    Latest Range: 0.0-2.0 %


Stimulus #7
Coags
PT                      15     Latest Range: 12–15 seconds
INR                     1.0    Latest Range: 0.8-1.2

Stimulus #8
TSH                     2.0    Latest Range: 0.4-5 IU/mL
Free T4                 1.0    Latest Range: 0.7-1.5 ng/dL

Stimulus #9
EKG:        normal

Stimulus #10
CT head:     normal




         10
                                                      Margaret Davenport; 60 yo 8/8/1950



Learner Stimulus #1


                                   ABEM General Hospital
                                 Emergency Admitting Form


Name:                           Margaret Davenport
Age:                            60 year old
Sex:                            Female
Method of Transportation:       EMS
Person giving information:      Patient and her husband
Presenting complaint:           Dizziness


Background: A 60 y.o. female is brought in by EMS with a chief complaint of dizziness. Her
husband is present in the room.



Triage or Initial Vital Signs


HR 90    BP 167/52      RR 18   O2 Sat 99%    Temp 37.6C




         11
                                           Margaret Davenport; 60 yo 8/8/1950


Learner Stimulus #2


Basic Metabolic Profile (BMP)
GLUCOSE                    121   Latest Range: 60-99 MG/DL
SODIUM                     140   Latest Range: 133-145 MEQ/L
POTASSIUM                  4.9   Latest Range: 3.5-5.3 MEQ/L
CHLORIDE                   106   Latest Range: 98-108 MEQ/L
CO2                        23    Latest Range: 23-32 MEQ/L
BUN                        7     Latest Range: 7-23 MG/DL
CREATININE                 0.8   Latest Range: 0.6-1.3 MG/DL
CALCIUM                    9.3   Latest Range: 8.5-10.3 MG/DL




        12
                                           Margaret Davenport; 60 yo 8/8/1950

Learner Stimulus #3


Liver Function Tests (LFTs)
TOTAL PROTEIN              7.3   Latest Range: 6.1-7.9 GM/DL
ALBUMIN                    4.0   Latest Range: 3.5-5.5 GM/DL
BILIRUBIN TOTAL            0.8   Latest Range: 0.1-1.4 MG/DL
BILIRUBIN DIRECT           0.2   Latest Range: 0.0-0.4 MG/DL
PHOSPHORUS                 2.7   Latest Range: 2.4-4.7 MG/DL
ALK PHOSPHATASE            78    Latest Range: 0-135 IU/L
SGOT                       41    Latest Range: 0-41 IU/L
SGPT                       40    Latest Range: 0-63 IU/L




        13
                                             Margaret Davenport; 60 yo 8/8/1950


Learner Stimulus #4


MAGNESIUM             2.0   Latest Range: 1.7-2.8 MG/DL




        14
                                          Margaret Davenport; 60 yo 8/8/1950


Learner Stimulus #5


Urine Drug Screen
MARIJUANA SCREEN               NEGATIVE            No range found
COCAINE MET SCREEN             NEGATIVE            No range found
AMPHETAMINE SCREEN             NEGATIVE            No range found
METHAMPHETAMINE SCRN, UR       NEGATIVE            No range found
BARBITURATE SCREEN             NEGATIVE            No range found
OPIATES SCREEN                 NEGATIVE            No range found
PHENCYCLIDINE SCREEN           NEGATIVE            No range found
METHADONE SCREEN               NEGATIVE            No range found
BENZODIAZEP SCRN               NEGATIVE            No range found
TRICYCL ANTIDEPRESS SCRN, UR   NEGATIVE            No range found




        15
                                  Margaret Davenport; 60 yo 8/8/1950


Learner Stimulus #6


Complete Blood Count (CBC)
WBC                     10.0   Latest Range: 4.0-10.0 THOU/CU MM
RBC                     4.9    Latest Range: 4.30-5.90 M/UL
HEMOGLOBIN              13.0   Latest Range: 13.0-17.0 GM/DL
HCT                     39.0   Latest Range: 39.0-51.0 %
MCV                     92.7   Latest Range: 81.0-99.0 CU MICRONS
MCH                     31.0   Latest Range: 27.0-33.0 UUG
MCHC                    33.5   Latest Range: 32.5-36.5 %
RDW                     11.7   Latest Range: 11.6-14.8 %
PLATELET COUNT          380    Latest Range: 150-400 THOU/CU MM

Differential
NEUT%                   74     Latest Range: 40.0-74.0 %
LYMPH%                  26     Latest Range: 12.0-40.0 %
MONO%                   9.7    Latest Range: 4.0-12.0 %
EOSIN%                  0.0    Latest Range: 0.0-8.0 %
BASO%                   0.3    Latest Range: 0.0-2.0 %




         16
                               Margaret Davenport; 60 yo 8/8/1950


Learner Stimulus #7


Coags
PT                    15    Latest Range: 12–15 seconds
INR                   1.0   Latest Range: 0.8-1.2




        17
                                Margaret Davenport; 60 yo 8/8/1950



Learner Stimulus #8


TSH                   2.0   Latest Range: 0.4-5 IU/mL
Free T4               1.0   Latest Range: 0.7-1.5 ng/dL




          18
                                                  Margaret Davenport; 60 yo 8/8/1950


Learner Stimulus #9


EKG: Normal EKG demonstrating sinus tachycardia at 90-100 bpm




        19
                            Margaret Davenport; 60 yo 8/8/1950




Learner Stimulus #10


CT Head:           normal




        20
                                                        Margaret Davenport; 60 yo 8/8/1950


For Examiner


Date:                   Examiner:                            Examinee(s):
Scoring: In accordance with the Standardized Direct Observational Tool (SDOT)

The learner should be scored (based on level of training) for each item above with one of the
following:
        NI = Needs Improvement
        ME = Meets Expectations
        AE = Above Expectations
        NA= Not Assessed

Critical Actions                              NI   ME   AE     NA       Category
Places patient on a cardiac monitor                                    PC, MK, PBL
with pulse oximetry
Obtains a bedside ECG                                                  PC, MK, PBL
Places the patient on supplemental                                     PC, MK, PBL
oxygen
Performs a full neurological exam                                      PC, MK, PBL
Performs a hearing test                                                PC, MK, PBL
Orders a CT scan to rule out acute                                     PC, MK, PBL,
intracranial pathology                                                     SBP
Places a peripheral IV                                                 PC, MK, PBL
Draws labs to evaluate for metabolic                                   PC, MK, PBL,
disturbances, infections, and endocrine                                    SBP
or hormonal abnormalities contributing
to the symptomatology.
Elicits a history of vertigo, tinnitus, and                            PC, MK, ICS,
hearing loss from the patient and                                          SBP
makes the diagnosis of Meniere’s
Syndrome.
Obtains a neurological consult to aid in                               PC, MK, ICS,
patient disposition.                                                       SBP




          21
                                                        Margaret Davenport; 60 yo 8/8/1950



Category: One or more of the ACGME Core Competencies as defined in the SDOT


      PC=   Patient Care
            Compassionate, appropriate, and effective for the treatment of health problems
            and the promotion of health
      MK= Medical Knowledge
            Residents are expected to formulate an appropriate differential diagnosis with
            special attention to life-threatening conditions, demonstrate the ability to utilize
            available medical resources effectively, and apply this knowledge to clinical
            decision making
      PBL= Practice Based Learning & Improvement
            Involves investigation and evaluation of their own patient care, appraisal and
            assimilation of scientific evidence, and improvements in patient care
      ICS= Interpersonal Communication Skills
            Results in effective information exchange and teaming with patients, their
            families, and other health professionals
      P=    Professionalism
            Manifested through a commitment to carrying out professional responsibilities,
            adherence to ethical principles, and sensitivity to a diverse patient population
      SBP= Systems Based Practice
            Manifested by actions that demonstrate an awareness of and responsiveness to
            the larger context and system of health care and the ability to effectively call on
            system resources to provide care that is of optimal value




        22
                                                       Margaret Davenport; 60 yo 8/8/1950



References:

   1. Minor LB, Schessel DA, Carey JP. Ménière's disease. Curr Opin
       Neurol. Feb 2004;17(1):9-16.
   2. Sajjadi H, Paparella MM. Meniere's disease. Lancet. Aug 2 2008;372(9636):406-14.
   3. Paparella MM. Pathogenesis and pathophysiology of Meniére's disease. Acta
       Otolaryngol Suppl. 1991;485:26-35.
   4. Paparella MM, Djalilian HR. Etiology, pathophysiology of symptoms, and pathogenesis
       of Meniere's disease. Otolaryngol Clin North Am. Jun 2002;35(3):529-45, vi.
   5. Merchant SN, Adams JC, Nadol JB Jr. Pathophysiology of Meniere's syndrome: are
       symptoms caused by endolymphatic hydrops?. Otol Neurotol. Jan 2005;26(1):74-81.
   6. Kitahara M. Bilateral aspects of Meniére's disease. Meniére's disease with bilateral
       fluctuant hearing loss. Acta Otolaryngol Suppl. 1991;485:74-7.
   7. Morrison AW, Johnson KJ. Genetics (molecular biology) and Meniere's
       disease. Otolaryngol Clin North Am. Jun 2002;35(3):497-516.
   8. Mancini F, Catalani M, Carru M, Monti B. History of Meniere's disease and its clinical
       presentation. Otolaryngol Clin North Am. Jun 2002;35(3):565-80.
   9. Monsell EM. New and revised reporting guidelines from the Committee on Hearing and
       Equilibrium. American Academy of Otolaryngology-Head and Neck Surgery Foundation,
       Inc. Otolaryngol Head Neck Surg. Sep 1995;113(3):176-8.
   10. Kentala E, Havia M, Pyykko I. Short-lasting drop attacks in Meniere's
       disease. Otolaryngol Head Neck Surg. May 2001;124(5):526-30.
   11. Bhattacharyya N, Baugh RF, Orvidas L, Barrs D, Bronston LJ, Cass S. Clinical practice
       guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck
       Surg. Nov 2008;139(5 Suppl 4):S47-81.
   12. White J. Benign paroxysmal positional vertigo: how to diagnose and quickly treat
       it. Cleve Clin J Med. Sep 2004;71(9):722-8.
   13. Fattori B, Nacci A, Dardano A, Dallan I, Grosso M, Traino C. Possible association
       between thyroid autoimmunity and Menière's disease. Clin Exp
       Immunol. Apr 2008;152(1):28-32.
   14. Lorenzi MC, Bento RF, Daniel MM, Leite CC. Magnetic resonance imaging of the
       temporal bone in patients with Ménière's disease. Acta
       Otolaryngol. Aug 2000;120(5):615-9.
   15. de Sousa LC, Piza MR, da Costa SS. Diagnosis of Meniere's disease: routine and
       extended tests. Otolaryngol Clin North Am. Jun 2002;35(3):547-64.
   16. Wetmore SJ. Endolymphatic sac surgery for Ménière's disease: long-term results after
       primary and revision surgery. Arch Otolaryngol Head Neck
       Surg. Nov 2008;134(11):1144-8.
   17. Pullens B, Giard JL, Verschuur HP, van Benthem PP. Surgery for Ménière's
       disease. Cochrane Database Syst Rev. Jan 20 2010;CD005395.
   18. Sajjadi H. Medical management of Meniere's disease. Otolaryngol Clin North
       Am. Jun 2002;35(3):581-9, vii.
   19. Coelho DH, Lalwani AK. Medical management of Ménière's
       disease. Laryngoscope. Jun 2008;118(6):1099-108.
   20. Cope D, Bova R. Steroids in otolaryngology. Laryngoscope. Sep 2008;118(9):1556-60.
   21. Odkvist LM, Arlinger S, Billermark E, Densert B, Lindholm S, Wallqvist J. Effects of
       middle ear pressure changes on clinical symptoms in patients with Ménière's disease--a
       clinical multicentre placebo-controlled study. Acta Otolaryngol Suppl. 2000;543:99-101.

        23
                                                     Margaret Davenport; 60 yo 8/8/1950

   22. Havia M, Kentala E. Progression of symptoms of dizziness in Ménière's disease. Arch
       Otolaryngol Head Neck Surg. Apr 2004;130(4):431-5.


Keywords for future searching functions:
vertigo, tinnitus, hearing loss, Meniere’s Disease

Has this work been published? No




         24
                                                          Margaret Davenport; 60 yo 8/8/1950



Debriefing Information:
           Meniere’s Disease is also known as idiopathic endolymphatic hydrops.
           It is a disorder of the inner ear resulting in the clinical triad of: vertigo, tinnitus,
              and hearing loss:
              o Vertigo
                  Vertigo is a subjective sensation of motion while motionless.
                  At least 2 definitive episodes of vertigo of at least 20 minutes duration
                     must have occurred to make the diagnosis.
                  Duration is usually several hours long.
                  Horizontal or rotatory nystagmus is always present during attacks of
                     vertigo.
                  Symptoms are often accompanied with nausea, vomiting, and anxiety.
                  Acute attacks may be accompanied with sudden falls without loss of
                     consciousness. These are termed crises of Tumarkin or drop attacks.
                     Most studies find the incidence of drop attacks to be less than 10%. In
                     one case series, self-reporting of drop attacks was 72% among patients
                     with diagnosis of Ménière's disease.
                  It is important to distinguish if the patient’s vertigo is suggestive of central
                     vs. peripheral causes (Table 1)

Table 1: Characteristics of Peripheral Vs. Central Causes of Vertigo
      Sign of Symptom                   Peripheral Vertigo                 Central Vertigo
Nystagmus                         -Horizontal or torsional         -Vertical, horizontal, or
                                  -Inhibited by fixating eyes onto torsional
                                  an object                        -Not inhibited by fixating eyes
                                  -Diminishes with time;           onto an object
                                  fatigueable                      -May last weeks to months;
                                  -Does not change direction       not immediately fatigueable
                                  with alteration of gaze from     -Fast phase of nystagmus
                                  side to side                     may change with gaze
                                                                   alteration from side to side
Imbalance                         Mild to moderate; patient is     Severe; patient is typically
                                  usually able to walk             unable to walk or stand
Nausea and vomiting               May be severe in nature          Varies
Hearing loss or tinnitus          Commonly associated              Rarely associated
Non-auditory neurologic           Rarely associated                Commonly associated
symptoms
Latency following provocative Long (up to 20 seconds)              Short (up to 5 seconds)
diagnostic maneuver

               o   Hearing loss
                    Sensorineural hearing loss must be documented audiometrically in the
                      affected ear at least once during the course of the disease.
                    There may be fluctuation in the degree of hearing loss superimposed on a
                      gradual decrement in function.
                    Hearing loss affects low frequencies primarily.
               o   Tinnitus and aural fullness


          25
                                              Margaret Davenport; 60 yo 8/8/1950

             Tinnitus is often nonpulsatile and may be described as whistling or
              roaring.
           It may be continuous or intermittent.
    The etiology of Meniere’s Disease is still rather controversial.
    The underlying mechanism is believed to be distortion of the membranous
     labyrinth due to over-accumulation of endolymph secondary to obstruction or
     decreased drainage.
    Obstruction or decreased drainage is felt to be from infection, trauma, allergens,
     or idiopathic.
    The main morbidity associated with Meniere’s Disease is the debilitating nature
     of the symptoms, potential for drop attacks and subsequent trauma, and
     permanent hearing loss.
    If Meniere’s Disease is suspected, the examiner should perform the following
     tests:
     o       A full neurological exam including the Romberg test
     o       Dix-Hallpike Maneuver
     o       Gross hearing evaluation via finger rub
     o       Rinne test with a 256 MHz tuning fork
     o       Weber test with a 256 MHz tuning fork
    The differential diagnoses for Meniere’s Disease is quite broad and includes, but
     is not limited to:
     o       Benign positional vertigo
     o       Ischemic or hemorrhagic stroke
     o       Migraine headache
     o       Hypothyroidism or Myxedema coma
     o       Temporal lobe epilepsy
     o       Labyrinthitis
     o       Toxicities (e.g. Salicylate)
     o       Multiple sclerosis
     o       TIA
     o       Otitis media
     o       Vestibular neuronitis
     o       Meningitis
     o       Brainstem tumor
     o       Foreign body or cerumen in the ear canal
     o       Acoustic neuromas
     o       Perilymphatic fistulas
     o       Labyrinth trauma
     o       Herpetic encephalitis
     o       CNS syphyllis
     o       Wernicke’s encephalopathy
    Evaluation of the patient’s symptomatology should be directed towards ruling-out
     life threatening or emergent etiologies listed on this differential. Obtaining a
     neurology consult can aid in the patient’s final disposition.
    Treatment is symptomatic and can include:
     o       Antihistamines such as Meclizine or Dimenhydranate
     o       Anticholinergics such as Scopolamine
     o       Antiemetics such as Compazine, Zofran, or Phenergan
     o       Benzodiazepines such as ativan or valium
     o       Corticosteroids such as prednisone
    Refer patients to ENT for full audiometric testing.
26
                                             Margaret Davenport; 60 yo 8/8/1950

  All patients should be educated about the chance for spontaneous remission
   (approximately 50%) vs. the need for further evaluation and surgical intervention.
  Patients should be warned about the risks of potential drop attacks and side
   effects of long term symptomatic management with medications.




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