Dizziness and Nausea – OSCE Case

What do you mean by dizziness: do you feel faint, or like the room is spinning?

“I feel like everything is spinning around me, and it is making me feel sick”

Was the onset sudden, or gradual?

“The symptoms came on all of a sudden”

What was the duration of vertigo: seconds, minutes, or longer?

“The symptoms lasted for several minutes”

Was there any obvious trigger for the episode?

“No, not that I am aware of”

Any previous episodes?

“I have had a few episodes in the past, but have not sought help for them, none have been as severe as this one”

Neurological features: weakness, sensory loss, visual loss, ataxia

“No, I haven’t had any of these”

Headache

“I have not had a headache”

Hearing loss

“I haven’t noticed any changes in my hearing, but I haven’t really paid attention to it”

Tinnitus

“I have had some ringing in my ears – a constant high-pitched noise”

Otalgia

“I haven’t had any pain in my ears”

Vomiting

“I feel really sick, but haven’t vomited”

Previous illness

“I was well up until the symptoms came on”

• Upper limb neurological examination
• Lower limb neurological examination
• Cranial nerve examination
• Cerebellar examination
• Otoscopy

Examination findings

Upper and lower limb neurological examination:

• Normal tone in all four limbs, no clonus or pronator drift
• No neck stiffness
• MRC power scale: 5 for both upper and lower limbs
• No sensory loss
• Reflexes normal (with reinforcement)

Cranial nerve examination:

• Normal visual acuity; no ophthalmoplegia or evidence of nystagmus
• No facial sensory loss; normal bulk of muscles of mastication
• No facial asymmetry or impairment of movements of facial expression
• Evidence of gross hearing loss in the left ear, with Rinne’s positive bilaterally and Weber’s test lateralising to the right
• Normal swallowing and gag reflex
• Normal trapezius function and tongue movements

Cerebellar examination:

• No dysdiadochokinesia, ataxia or evidence of speech impairment
• No past pointing or intention tremor

Otoscopy:

• Mild wax build-up in both ears, no evidence of impaction
• Tympanic membrane intact, cone of light present.
• No evidence of erythema or fluid

Rinne’s test, somewhat confusingly, is stated to be positive if the test is normal. The tuning fork will be heard louder when placed next to the ear than when placed on the mastoid process, as air conduction is greater than bone conduction. A bilaterally positive Rinne’s test indicates no evidence of conductive hearing loss in either ear.

Weber’s test will lateralise to the affected ear in the setting of conductive hearing loss, and to the unaffected ear if sensorineural hearing loss is present. Therefore, given the finding of a bilaterally positive Rinne’s test, Weber’s lateralising to the right suggests the presence of left-sided sensorineural hearing loss.

Pure tone audiometry is the most appropriate investigation for any patient with hearing impairment detected clinically. This will allow for confirmation of the examination findings and can classify the type and severity of the hearing loss.

• Inner ear pathologies: benign paroxysmal positional vertigo (BPPV), Meniere’s disease, labyrinthitis, vestibular neuritis, acoustic neuroma
• Neurological disease: cerebellar stroke, vestibular migraine, multiple sclerosis

Those included in bold are the most likely in this case

This patient has presented with the classic triad of features seen in Meniere’s disease: vertigo, tinnitus and sensorineural hearing loss, classically worse at lower frequencies (although the patient had not noticed this hearing change). Patients also often complain of a sensation of ‘aural fullness’ although this was not present in this case.

Nausea and vomiting due to vestibular dysfunction are best treated by medications that antagonise histamine receptors. Promethazine is a first-generation (sedating) anti-histamine that is commonly used as a vestibular suppressant.

The pathophysiology of Meniere’s disease is still poorly understood, but an increase in levels of endolymph within the semi-circular canals (referred to as endolymphatic hydrops) is thought to play a role.

Interventions to reduce the levels of fluid within the inner ear have shown some benefits in clinical trials, and therefore, patients may be recommended to adopt a low salt diet or initiate diuretic therapy to reduce the chance of recurrent episodes developing.

Prochlorperazine is a first-generation antipsychotic that acts on D2 receptors, as well as cross-reacting with histamine receptors. As per all drugs in this class, there is a risk of extrapyramidal side effects due to the dopamine blockade.

An acute dystonic reaction is an example of such a complication; this involves involuntary contraction of extremity muscles and may require procyclidine as treatment. QT prolongation, rather than shortening, can also be associated with the medication.