What are the causes of vertigo?
Peripheral:
- benign paroxysmal positional vertigo
- Meniere’s disease
- vestibular neuronitis or neuroma
- labyrinthitis
Central:
- posterior circulation stroke
- tumour (cerebellum or brain stem)
- multiple sclerosis
- vestibular migraine
What are the distinguishing features of peripheral and central vertigo?
Peripheral:
- sudden onset
- short duration
- often associated with hearing loss/tinnitus
- intact coordination
- more severe nausea
Central:
- gradual onset
- persistent, longer duration
- usually no hearing loss/tinnitus
- impaired coordination
- mild nausea
Describe benign paroxysmal positional vertigo
- Recurrent episodes of sudden onset vertigo triggered by head movements
- More common in older people, and women
- Caused by calcium carbonate crystals (otoliths) becoming displaced in the semi-circular canals (e.g. due to ageing, head injury, viral infections, or idiopathic)
- The otoliths disrupt the normal flow of endolymph, often stimulating hair cells even after the head has stopped moving, giving conflicting sensory inputs which produces the symptoms
What are the clinical features of benign paroxysmal positional vertigo?
Vertigo:
- provoked by head movements (commonly turning over in bed)
- sudden onset
- lasting 20-60 seconds
Other symptoms:
- often associated with nausea
- no hearing loss/tinnitus
Positive Dix-Hallpike Manoeuvre:
- patient sits upright, head turned 45° towards
- rapidly lower patient until head is hanging off edge of bed
- hold head still turned and extended for 30-60s and watch for rotational nystagmus (and vertigo symptoms)
What is the management for benign paroxysmal positional vertigo?
General advice:
- limit symptoms by getting out of bed slowly and reducing head movements
- consider safety of driving and occupational hazards
- usually self-resolving
Epley manoeuvre:
- start sat upright with head turned 45° to the right
- quickly lie down, still with head turned 45° and head slightly extended over edge of bed
- turn head slowly 90°, now facing left
- roll body and head another 90°, now lying on left side facing down
- sit up slowly to the side of the bed, keeping head turned to the left, then return to looking forwards
- hold each step for 30-60sor until dizziness tops, repeat as many times as needed, reverse directions for left-sided symptoms
Brandt-Daroff exercises:
- start sat upright, turn head 45° to the right
- quickly lie down on the left side, hold for 30s or until dizziness stops
- sit up straight, looking forwards
- repeat on the other side (look left, lie on right side), repeat as needed
Describe vestibular neuronitis
- Inflammation of the vestibular nerve, causing sudden onset vertigo
- Caused by viral infection (e.g. HSV, VZV) which cause inflammation and disrupt the normal functioning of the vestibular nerve, so that inappropriate signals about head movements are sent to the brain
What are the clinical features of vestibular neuronitis?
Vertigo:
- sudden onset
- persistent (days-weeks)
Other symptoms:
- nausea and vomiting (can be severe)
- balance problems
- may have spontaneous horizontal nystagmus
- no hearing loss/tinnitus
Positive head impulse test:
- patient sat upright, fixing eyes on examiner’s nose
- examiner rapidly rotates head in one direction, then repeat on other side
- abnormal vestibular function will cause corrective saccades (normal vestibular function will keep eyes fixed on nose)
What is the management of vestibular neuronitis?
- Prochlorperazine or antihistamines (e.g. cyclizine, promethazine): short course to relieve symptoms
- May need admission if dehydrated due to vomiting
- Vestibular rehabilitation exercises for persistent problems
Describe labyrinthitis
- Inflammation of the inner ear, specifically the labyrinth (vestibular system and cochlea)
- Caused by a viral infection spreading from the respiratory tract or middle ear (e.g. herpesviruses, influenza, mumps)
What are the clinical features of labyrinthitis?
Vertigo:
- sudden onset
- lasts for days-weeks
Other symptoms:
- nausea and vomiting
- balance problems
- may have spontaneous horizontal nystagmus
- sensorineural hearing less (bilateral or unilateral, mild to severe)
- tinnitus
Positive head impulse test:
- patient sat upright, fixing eyes on examiner’s nose
- examiner rapidly rotates head in one direction, then repeat on other side
- abnormal vestibular function will cause corrective saccades (normal vestibular function will keep eyes fixed on nose)
What is the management of labyrinthitis?
- Prochlorperazine or antihistamines (e.g. cyclizine or promethazine): short course to relieve symptoms
- Antibiotics for bacterial labyrinthitis: often due to otitis media or meningitis
Describe Meniere’s disease
- Long-term disorder of the inner ear with recurrent flares of symptoms
- Thought to be caused by excessive build up of endolymph within the labyrinth of he inner ear, causing high pressures and disrupted sensory signals
- Most common in middle ages
What are the clinical features of Meniere’s disease?
- Vertigo (episodes lasting minutes-hours, no triggered by movement)
- Tinnitus (episodic with vertigo or constant, often unilateral)
- Sensorineural hearing loss (fluctuates with vertigo, or permanent, usually unilateral, low frequencies)
- Sensation of fullness in the ears
- Balance problems (persisting after vertigo)
- Spontaneous unilateral nystagmus during acute attacks
What is the management of Meniere’s disease?
- Acute attacks: prochlorperazine or antihistamines (e.g. cyclizine or promethazine)
- Prophylaxis to reduce frequency of the attacks: betahistine or vestibular rehabilitation exercises
Describe acoustic neuroma
- Also known as vestibular schwannoma
- Benign, slow-growing tumour arising from Schwann cells of the vestibulocochlear nerve (CN 8)
- Typically presents in 40-60 year olds with gradually progressing symptoms
- Bilateral acoustic neuromas are associated with neurofibromatosis type 2
What are the clinical features of acoustic neuroma?
- Sensorineural hearing loss: often first symptom, unilateral, progressive
- Tinnitus
- Vertigo and/or balance issues: vestibular dysfunction
- Facial weakness: compression of adjacent facial cranial nerve 7
- Headache, nausea, vomiting: increased cranial pressure and brainstem compression due to large tumours
What investigations are needed for acoustic neuroma?
- Audiometry: shows unilateral sensorineural hearing loss
- Brain MRI: detailed image of tumour
What is the management of acoustic neuroma?
- Conservative: if small, asymptomatic, regular audiometry and MRI monitoring
- Surgical resection: invasive partial or total removal of tumour, risk of injury to cranial nerves 7 or 8
- Stereotactic radiotherapy: less invasive, controls tumour growth
Describe sudden sensorineural hearing loss and it’s causes
Sensorineural hearing loss developing over less than 72 hours, often unilateral, may resolve over days/weeks or be permanent, requiring urgent ENT referral, caused by…
- idiopathic
- infection (e.g. meningitis, HIV, mumps)
- ototoxic medications (e.g. loop diuretics, gentamicin, chemotherapy drugs)
- Meniere’s disease
- stroke
- migraine
- multiple sclerosis
- acoustic neuroma
