10 Vertigo

Question 1

What is vertigo

Answer 1

Perception of movement when none exists that results from a mismatch between the visual, vestibular, and proprioceptive sensory systems

Question 2

Some features of peripheral vertigo

Answer 2

1. Intense spinning
2. Abnormal head impulse test
3. Peripheral signs on all three bedside tests of HINTS

Question 3

Some features of central vertigo

Answer 3

1. Headache more likely
2. Vertical nystagmus
3. Head impulse test usually normal
4. Central signs on at least one of 3 bedside tests of HINTS

Question 4

What is Ramsay Hunt syndrome?

Answer 4

“Herpes zoster oticus”
Varicella-zoster virus reactivation in the geniculate ganglion of CN VII
Sometimes with involvement of the vestibular (Scarpa’s) ganglion of CN VIII
Presents with deafness, veritigo, facial nerve palsy, and vesicles in side the external auditory canal

Question 5

What is Ménière’s syndrome?

Answer 5

Characterized by vertigo, unilateral tinnitus, sense of fullness, and diminished hearing
Due to endolymph buildup in the labyrinth

Question 6

What is BPPV?

Answer 6

Benign paroxysmal positional vertigo
Caused by loose otoconia that most commonly enter the posterior semicircular canal
Veritigo results from head movement

Question 7

Maneuvers done in BPPV

Answer 7

Dx: Dix-Hallpike maneuver
Tx: Epley maneuver

Question 8

How to perform Dix-Hallpike maneuver?

Answer 8

1. Begin with the patient seated with the head turned 45 deg to the right
2. Rapidly lower the patient to a supine position, with the head hanging over the edge of the bed and the neck in 20 degrees of extension
3. A positive test is when the patient experience a short-lived rotatory nystagmus, with rapid eye beating toward the affected (dependent) ear that ‘s associated with an acute episode of vertigo
4. If positive, proceed with the Epley maneuver
5. If negative, repeat the maneuver with the the head turned 45 degrees to the left.

Question 9

How to perform the Epley maneuver?

Answer 9

1. After a positive Dix-Hallpike and after nystamus and symptoms resolve (30-60 seconds, patient is currently in supine position with the head hanging 20º below the examining table), gently rotate the head 90º to the unaffected side
2. After nystagmus and symptoms resolve, roll the patient on the the shoulder of the unaffected side as the head turns another 90º so it is nearly facedown.
3. After nystagmus and symptoms resolve, return the patient to a sitting position with legs dangling off the side of the table and the head to the midline

Question 10

Remaks on the Epley maneuver

Answer 10

1. The patient may experience vertigo during any step of this procedure.
2. The Epley maneuver may be repeated if necessary.
3. If the Epley maneuver is not successful in relieving symptoms, consider instructing the patient in vestibular rehabilitation therapy (VRT, e.g., Brandt-Daroff exercises)

Question 11

Most common cause of peripheral vertigo

Answer 11

BPPV

Question 12

2nd most common cause of peripheral vertigo

Answer 12

Vestibular neuritis

Question 13

Most common cause of central vertigo

Answer 13

Vestibular migraine
but much underdiagnosed

Question 14

Vertigo with no hearing loss

Answer 14

Consider vestibular neuronitis
- sudden onset of severe vertigo
- thought to be viral in nature
- tx: antihistamine/antiemetics

Question 15

Vertigo + Hearing loss
No tinnitus

Answer 15

Consider acoustic neuroma

Question 16

Vertigo + hearing loss + tinnitus

Answer 16

Consider Meniere’s disease
1. Tx: antihistamine/antiemetics, diurestcs
2. Diet <1 g added salt per day
3. ENT referral

Question 17

Vertigo + hearing loss + tinnitus + recurrent URI or otitis media

Answer 17

Consider bacterial labyrinthitis

Question 18

Causes of central vertigo

Answer 18

Cerebellar hemorrhage or infarction
Lateral medullary infarction of the brainstem (Wallenberg syndrome)
Vertebrobasilar insufficiency
Vertebral artery dissection
Multiple sclerosis
Neoplasms of the 4th ventricle
Vestibular migraine (most common, but much underdiagnosed)

Question 19

For most causes of peripheral vertigo, pharmacologic therapies in the ED may include

Answer 19

Antihistamines and anticholinergics
Diphenhydramine 25-50 mg IM/IV/PO Q4
Meclizine 25 mg PO Q6-Q12
And patients may be discharged home with follow-up

Question 20

Indicated drugs for Meniere’s syndrome

Answer 20

Flunarizine (calcium) antagnists)
Betahistine (vasodilator)
48 mg PO 3x/day for up to 6-12 months

Question 21

Patients with suspected central vertigo

Answer 21

Should have imaging studies performed and emergent specialty referral
Neurosurgery - posterior fossa hemorrhage or brain tumors
Neurology - ischemic stroke or vertebral artery dissection

Question 22

Chiropractic adjusments/manipulations may cause

Answer 22

Vertebral artery dissection (may also result from MVC, violent sneezing)