The patient I hate to see most in the world is geriatric vertigo. For a long time, I worked in a hospital that considered vertigo a nuisance complaint. Give them enough Antivert, diazepam or fluids and they’ll get better and go home. I thought vertigo was a benign, self-limiting problem.
That was until I worked at a regional stroke center. Someone with vertigo came in and I asked the doc, “I have a guy with vertigo, you don’t MRI them, right?” He says, “John, we MRI everything.” So, I start doing MRIs on these geriatric patients and I’m seeing cerebellar stroke after cerebellar stroke.
Vertigo should scare you. I think it’s one of the most dangerous presentations. Geriatric vertigo is very dangerous, in my experience.
You know there are some peripheral causes of vertigo and some central ones. This tells us benign versus potentially lethal. We have to categorize each patient as peripheral or central in order to know how to work them up and whether they need to go to a stroke center.
Weber and Rinne Test
You’re thinking right now about how much you hated the Weber and Rinne test. Let me tell you, it’s helpful and I’m going to show you how. It divides conductive hearing loss from neurosensory hearing loss. That’s important because if it’s conductive hearing loss, we can manage that. It’s not a big deal. If it’s neurosensory, you better pick up the phone and call ENT. If you don’t manage a neurosensory hearing loss correctly, they can go deaf. ENT will take a 3 AM phone call and give you respect if you have acute neurosensory hearing loss.
Close your eyes and vigorously hum. Then, put your finger in your ear, deep enough that it’s a little uncomfortable and hum again. Which ear was it loudest in?
You just did a poor man’s Weber test by creating vibrations, just like the tuning fork. Weber goes towards wax, indicating a conductive hearing problem. So, if someone says they can’t hear out of one ear, have them hum with the tuning fork on their forehead. Can they hear it louder in the affected ear? If so, it’s conductive and I’m not as scared of it. If the sound is louder in the unaffected ear, that suggests neurosensory hearing loss. That’s concerning.
Rinne is a little bit trickier, but not a lot trickier. Sound vibrations go much longer through the air than through a solid. It’s about a 2:1 ratio. If I take a tuning fork and touch it to the skin behind my ear, I can hear it for a certain amount of time, say 20 seconds. That’s bone conduction. The amount of time I can hear the fork when it’s in the air outside my ear should be about 40 seconds. With a conductive hearing problem, bone conduction will be longer than air conduction.
When we have vertigo and hearing loss together, we have to sift through that.
Intermittent versus Constant Vertigo
Is your patient’s vertigo intermittent or constant? If it’s constant, it’s a virus, either vestibular neuritis or labyrinthitis. Intermittent vertigo is either BPPV or Meniere’s.
You have to look at vertigo, intermittent or constant, relative to their hearing. Remember it this way: you ask, “Ma’am, how’s your hearing?” If she says it’s good, you make a check on the chart. The checkmark looks like the letter V. If the letter V is in the type of vertigo, they have good hearing. In both BPPV and vestibular neuritis, hearing is good. In Meniere’s and labyrinthitis, hearing is off.