EMQs in Clinical Medicine.pdf - Peshawar Medical College

88 Neurology
ANSWERS
28 Dizziness and vertigo
Answers: J F D B I
J
F
D
A 45-year-old woman presents with a left-sided facial palsy and vertigo.
She has impaired hearing on her left side and a vesicular rash is
noted around her external auditory meatus.
Ramsay Hunt syndrome is the name attributed to herpes zoster infection
of the geniculate ganglion. The external auditory meatus receives some
sensory innervation from the facial (VII) nerve, hence the vesicular rash
over this area.
Aciclovir is the treatment of choice.
A 55-year-old man presents with a history of recurrent spontaneous
attacks of vertigo, hearing loss and tinnitus. These attacks last up to
2 h and are sometimes associated with vomiting.
Menière’s disease is associated with the triad of vertigo, tinnitus and
deafness. The aetiology is unclear and some authorities suggest that it
may arise from a dilatation of the endolymphatic system. The vertigo
may be disabling and associated with vomiting. The deafness is of a sensorineural
nature. Rest is advised for acute attacks. Long-term prophylaxis
involves the use of vestibular sedatives, e.g. cinnarizine or
betahistine, but results are disappointing.
A 65-year-old woman presents with vertigo, vomiting and dysphagia.
On examination there is a left-sided Horner’s syndrome, and loss of
pain and temperature on the right side of the face.
The posterior inferior cerebellar artery (PICA) supplies the dorsal lateral
medullary plate and parts of the posterior medial cerebellum. PICA
thrombosis results in lesions affecting cranial nerves, descending tracts
and the cerebellum that are known collectively as ‘lateral medullary
syndrome’.
Ipsilateral signs include:
– decreased pain and temperature sensation of the face (descending tract
and nucleus of nerve V)
– palatal, vocal fold paralysis (nerve IX, X involvement)
– Horner’s syndrome (sympathetic tract)
– cerebellar signs, e.g. ataxia, nystagmus.
Contralateral signs include:
– decreased pain and temperature sensation of the body (spinothalamic
tract)
– lateral medullary syndrome, eponymously known as Wallenberg’s
syndrome.