What is vertigo?
- It’s a symptom, not a diagnosis
- False sensation of movement of the person or their surroundings in the absence of any movement
What’s the difference between peripheral and central vertigo?
Peripheral - A problem with the inner ear affecting the labyrinth or vestibular nerve. Most common.
Central - Pathology in the brain eg brainstem or cerebellum.
What are causes of peripheral vertigo?
- Benign paroxysmal positional vertigo
- Vestibular neuronitis and labyrinthitis
- Meniere’s disease
- Perilymphatic fistula, vestibular ototoxicity (rare)
What are causes of central vertigo?
- Vestibular migraines
- Stroke and TIA
- Cerebellar tumour
- Acoustic neuroma
How would you explode vertigo as a symptom?
- Onset, duration, frequency
- Aggravating factors
- Severity and effect on daily activities
What system reviews should you ask?
- Nausea and vomiting
Otological - Hearing loss, ear discharge, fullness in ears, tinnitus
Neurological - Headache, diplopia, visual disturbances, dysphagia, paraesthesia, muscle weakness, ataxia, migraine aura
What should you ask in past medical history?
- Recent upper resp tract infection/ear infection
- Migraines
- Head trauma
- CVD risk factors
- Medications theyre on
What examinations should you do?
- ENT examination
- Neurological examination
- CVS examination
What is the Romberg’s test and what does it show?
- Stand up straight with feet together, can they maintain balance with their eyes closed?
- A positive test shows problems with vestibular function
What is a Dix-Hallpike manoeuvre and what does it show?
- Check first if they have a neck or back problem, cvd problems such as carotid syncope
- Keep their eyes open and look straight ahead
- Sit upright on the couch and look 45 degrees turned
- Lie the person down so neck is extended 20-30 degrees over the couch with test ear down
- Observe eyes for 30 seconds for torsional nystagmus
- Shows BPPV if positive
What is the head impulse test and what does it show?
- Ask if they have any neck pathology first
- Sit upright and fix gaze on examiner, turn head 10-20 degrees to one side
- Eyes should stay fixed on the examiner in a normal response
- A corrective saccade shows a positive response and shows loss of horizontal semicircular canal pathology to the side to which the test is positive
What is alternate cover test and what does it show?
- Patient looks at examiners nose, and cover right eye and left eye a number of time
- Focus on one eye at a time and watch for vertical correction with the covered eye is uncovered
- If vertical correction, raises suspicion of a stroke with acute vestibular syndrome
What are symptoms of benign paroxysmal positional vertigo?
- Symptoms are brought on by specific movements/positions
- Vertigo typically lasts less than 1 minute, asymptomatic between episodes
- N+V
- Lightheadedness and imbalance can occur longer than the vertigo episode
- Hearing and tinnitus is not a feature
What are symptoms of vestibular neuronitis and labrynthitis?
- Rotational vertigo occurs spontaneously, may be sudden
- Worsened by changing head position but initially constant even when head is still
- Acute symptoms settle in a few days but recovery is 2-6 weeks
- Nausea, vomiting, malaise, pallor, sweating
- Poor balance
- Hearing loss and tinnitus ONLY in labrynthitis
- No focal neurology
What are symptoms of Meniere’s disease?
- Episodes of spontaneous vertigo for at least 20 minutes but no longer than a few hours
- Roaring tinnitus during attacks, can become permanent
- Fluctuating sensorineural hearing loss
- Aural fullness in advance of attack
What is the treatment for BPPV?
Advice -
- Most people recover over several weeks but can recur
- Simple repositioning can alleviate symptoms, get out of bed slowly and don’t look upwards
- Driving and workplace issues
Cure -
- Epley manoeuvre. Full recovery can take days to a couple of weeks.
- Semont manoeuvre
What are signs of vestibular neuronitis?
- Nystagmus is present but is usually fine horizontal with fast phase away from affected ear
- Positive head impulse test
What is the management for vestibular neuronitis?
- Symptoms will settle on their own over several weeks, even if no treatment is given
- Alcohol, tiredness and illness will have a greater effect on balance
- Bed rest may be necessary
What is the management for vestibular neuronitis?
- Symptoms will settle on their own over several weeks, even if no treatment is given
- Alcohol, tiredness and illness will have a greater effect on balance
- Bed rest may be necessary
- Safety issues eg driving, work, falls
- Short course prochlorperazine/cinnirazine/cyclizine up to 3 days
- Return if not resolved in a week
What is the management for Meniere’s disease?
- Admit to hospital if severe symptoms
- Refer to ENT consultant to confirm diagnosis
- Audiology assessment if suspected hearing loss
Advise: - No cure for Meniere’s but the vertigo will improve with treatment
- Acute attack settles within 24hrs for most people
- Inform DVLA, risk of machinery
Symptomatic treatment - - Prochlorperazine, cyclizine short course during attack
- Betahistine as a preventative of attacks
