Vertigo

Question 1

Vertigo is defined as

Answer 1

an episodic sudden sensation of circular motion of the body or of its surroundings or an illusion of motion (a rotatory sensation).

Question 2

Other terms used by the patient to describe this symptom

Answer 2

everything spins
my head spins
the room spins
whirling
reeling
swaying
pitching
rocking

Question 3

It is frequently accompanied by

Answer 3

1. Autonomic symptoms such as

• nausea
• retching
• vomiting
• pallor
• sweating

2. Nystagmus
3. Tinnitus and Hearing disorders,

• since 80–85% of causes are due to an ear problem

Question 4

Vertigo is characteristically precipitated by

Answer 4

1) standing
2) turning the head
3) movement

Question 5

Walking with vertigo

Answer 5

Patients have to walk carefully

• nervous about descending stairs or crossing the road
• usually seek support.

Pt is usually very frightened and tends to remain immobile during an attack.

Pts may feel as though they are being impelled by some outside force that tends to pull them to one side, especially while walking.

Question 6

Pathophysiology

Answer 6

True vertigo is a symptom of disturbed function involving the vestibular system or its central connections.

It invariably has an organic cause.

Question 7

Peripheral disorders; Causes

Answer 7

involving vestibular labyrinth, semicircular canals, or vestibular nerve

1. Labyrinth:

• labyrinthitis: viral or suppurative
• Ménière syndrome
• benign paroxysmal positional vertigo (BPPV)
• drugs/ ototoxicity
• trauma
• chronic suppurative otitis media
• motion sickness

2. Eight nerve:

• vestibular neuronitis
• acoustic neuroma
• drugs / ototoxicity

Cervical spine dysfunction

It is not uncommon to observe vertigo in patients with cervical spondylosis or post-cervical spinal injury.

It has been postulated that this may be caused by the generation of abnormal impulses from proprioceptors in the upper cervical spine.

Some instances of benign positional vertigo are associated with disorders of the cervical spine.

Question 8

Central disorders; Causes

Answer 8

Involving cerebral cortex, cerebellum, brainstem

1) . Brain stem (TIA or stroke):
a. vertebrobasilar insufficiency
b. infarction

• Severe vertigo, often in association with hiccoughs and dysphagia, is a feature of the variety of brain stem infarctions known as the lateral medullary syndrome due to posterior inferior cerebellar artery (PICA) thrombosis.
• There is a dramatic onset of vertigo with cerebellar signs, including ataxia and vomiting.
• There are ipsilateral cranial nerve (brain stem) signs with contralateral spinothalamic sensory loss of the face and body.
• Diagnosis is by CT or MRI scanning.

2). Cerebellum:

• degeneration
• tumours

3) . Migraine
4) . Multiple sclerosis

• The lesions may occur in the brain stem or cerebellum.
• Young patients who present with a sudden onset of vertigo with ‘jiggly’ vision but without auditory symptoms should be considered as having MS
• 5% of cases of MS present with vertigo.

Question 9

The most common causes of recurrent spontaneous vertigo are ?

Answer 9

Ménière syndrome and vestibular migraine

Question 10

Assessment

Answer 10

1. Gain an accurate description to determine if episode is vertigo.
   * Check for associated nausea, vomiting, earache, hearing loss, and tinnitus.
2. Determine if pt is experiencing central or peripheral vertigo by completing a neuro- otological examination including:

• cerebellar tests
• gait
• cranial nerve exam
• otoscopy
• head impulse test
• tuning fork test.

3. If central vertigo, the cause is likely to be neurological.
4. If peripheral vertigo with unilateral hearing loss, and no red flags, see Asymmetrical Sensorineural Hearing Loss pathway.
5. If peripheral vertigo without new unilateral hearing loss, see common causes of vertigo.
6. History and examination will help determine the most likely cause.
7. If vertigo lasts for:

• < 1 minute, benign positional vertigo (BPV) is likely.
• 24 hours, vestibular neuronitis is likely.

8. Consider medications or alcohol as a possible cause.

Question 11

Symptomatic relief of acute vertigo :
pharmaceutical options

Answer 11

1) Anti-emetics:

• prochlorperazine
• metoclopramide

2) Antihistamines:

• promethazine
• betahistine

3) Benzodiazepines (short period use for vertigo):

• diazepam
• lorazepam

Question 12

General management

Answer 12

1. Provide explanation and reassurance as anxiety exacerbates vertigo.
2. Discuss the driving implications especially if Meniere’s disease with sudden or severe attacks.
3. IV fluids only indicated if vomiting with dehydration that does not respond to antiemetics and oral rehydration.
4. Manage any underlying condition: BPPV, MD etc

Question 13

General management, request

Answer 13

If any red flags, request acute ENT/otolaryngology assessment.

If central vertigo, request acute general medicine assessment or acute neurology assessment.

If ongoing chronic problems, consider review by NZ Dizziness and Balance Centre.

Question 14

When to refer?

Answer 14

1) Vertigo of uncertain diagnosis, especially in children
2) Possibility of tumour, or bacterial infection
3) Vertigo in presence of suppurative otitis media despite antibiotic therapy
4) Presumed viral labyrinthitis not abating after 3/12
5) Vertigo following trauma
6) Presumed Ménière’s, not responding to conservative medical management
7) Evidence of vertebrobasilar insufficiency
8) BPPV persisting for >12 mths despite Rx with particle repositioning exercises

Question 15

Practice tips

Answer 15

1. A careful drug history often pinpoints the diagnosis.
2. Always consider cardiac arrhythmias as a cause of acute dizziness.
3. Consider phenytoin therapy as a cause of dizziness in an epileptic patient.
4. If an intracerebral metastatic lesion is suspected, consider the possibility of carcinoma of the lung as the primary source.
5. Three important office investigations to perform:

• lying, sitting and standing BP
• hyperventilation
• head positional testing

6. Cervical vertigo is very common
   * appropriate cervical mobilisation methods with care should be considered.
7. BPPV is also common:

• prescribing a set of exercises to desensitise the labyrinth is recommended.
• Use either the Brandt–Daroff procedure
• or the Cawthorne–Cooksey program.

8. Think of migraine particularly in a younger pt presently with unexplained recurrent vertigo.

Question 16

Recurrent vestibulopathy

Answer 16

Episodic vertigo ± vomiting of similar duration to Meniere

No hearing loss, tinnitus or focal neurological signs

Peak age 30–50 yrs, M = F

Aetiology unknown—possibly migraine variant

Treatment is symptomatic.