A 36-year-old woman comes to the emergency department due to a persistent spinning sensation associated with nausea and vomiting. Since the onset of symptoms 2 days ago, the patient has stayed in bed most of the time due to feeling unsteady when walking. She has had no headache, hearing loss, speech disturbance, or muscle weakness. Two weeks ago, she had an upper respiratory infection with sore throat, right ear fullness, and a feeling of "muffled" hearing. Medical history is notable for childhood asthma, and her only medication is a combined oral contraceptive pill. This patient's history is most consistent with which of the following diagnoses?

Question

A 36-year-old woman comes to the emergency department due to a persistent spinning sensation associated with nausea and vomiting.  Since the onset of symptoms 2 days ago, the patient has stayed in bed most of the time due to feeling unsteady when walking.  She has had no headache, hearing loss, speech disturbance, or muscle weakness.  Two weeks ago, she had an upper respiratory infection with sore throat, right ear fullness, and a feeling of "muffled" hearing.  Medical history is notable for childhood asthma, and her only medication is a combined oral contraceptive pill.  This patient's history is most consistent with which of the following diagnoses?

Quizplus · Accepted Answer

11ec25c8_d39a_62d3_bc81_53a3273c6587_MD0003_00 This patient has acute, persistent vertigo consistent with vestibular neuritis (VN). VN is a self-limited disorder of the vestibulocochlear nerve (CN VIII) that sometimes follows a viral upper respiratory infection. VN can be associated with significant nausea and vomiting as well as impaired gait, with the patient falling toward the affected side. VN associated with unilateral hearing loss is termed labyrinthitis. The diagnosis of VN is based on clinical findings. Patients exhibit nystagmus that is suppressed when they direct their vision toward a stationary target (consistent with peripheral rather than central vertigo). Head thrust test is usually abnormal. In this test, the patient is asked to look at a fixed target while the head is rapidly rotated. Patients with normal vestibular function maintain visual fixation; however, in patients with VN, the eyes move away and then return to the target with a horizontal saccade. Because VN is usually self-limited, patients can be managed expectantly. Management may also include vestibular suppressants (eg, meclizine), corticosteroids, and vestibular rehabilitation. (Choice A) Acute mastoiditis is a potential complication of acute otitis media. Typical symptoms include posterior ear pain, headache, erythema over the mastoid bone, and fever. (Choice B) Although benign paroxysmal positional vertigo also causes severe vertigo often accompanied by nausea, the episodes are recurrent, brief (<1 min), and triggered by changes in head position. (Choice C) Ménière disease causes recurrent episodic (rather than persistent) vertigo with concurrent hearing loss and a feeling of fullness in the ear. This patient's previous ear fullness and sense of muffled hearing were likely related to her upper respiratory infection, and the time course makes VN much more likely. (Choice D) A perilymphatic (labyrinthine) fistula is a complication of head injury or barotrauma that causes leakage of fluid from the semicircular canal. A perilymphatic fistula causes vertigo, nystagmus, hearing loss, and tinnitus that is triggered by sneezing, straining, or sudden loud noises (Tullio phenomenon). (Choice E) Vestibular migraine causes vertigo that is variable in severity, typically lasts several minutes to a few hours, and is usually associated with headache or other migrainous phenomena (eg, photophobia). Educational objective: Vestibular neuritis is a self-limited disorder of the vestibulocochlear nerve (CN VIII) that sometimes follows a viral upper respiratory infection. Vestibular neuritis with unilateral hearing loss is termed labyrinthitis. References: Vestibular neuritis. (http://www.ncbi.nlm.nih.gov/pubmed/24057821)

A 36-Year-Old Woman Comes to the Emergency Department Due to a Persistent