Vertigo

Question 1

Vertigo

Answer 1

Sensation of the room spinning

Question 2

Presentation of vertigo

Answer 2

Dizziness

Associated with:

• Nausea and vomiting
• Sweating
• Feeling generally unwell

Question 3

Sensory inputs for balance

Answer 3

Vision
Proprioception
Signals from the vestibular system

Question 4

Pathophysiology of vertigo

Answer 4

Mismatch between the sensory inputs of balance

Question 5

Rombergs test

Answer 5

Closing your eyes whilst standing to see if you can balance

Question 6

Vestibular nerve

Answer 6

Vestibular nerve carries signals from the vestibular apparatus to the vestibular nucleus in the brainstem and the cerebellum

Question 7

Classification of vertigo

Answer 7

• Peripheral problem - affecting the vestibular system

- Central problem - involving the brainstem or the cerebellum

Question 8

Common causes of peripheral vertigo

Answer 8

Benign paroxysmal positional vertigo

Ménière’s disease

Vestibular neuronitis

Labyrinthitis

Question 9

Other causes of peripheral vertigo

Answer 9

Trauma to the vestibular nerve

Vestibular nerve tumours (acoustic neuromas)

Otosclerosis

Hyperviscosity syndromes

Ramsay Hunt syndrome

Question 10

Causes of central vertigo

Answer 10

Posterior circulation infarction (stroke)

Tumour

Multiple sclerosis

Vestibular migraine

Question 11

Features of central vertigo

Answer 11

Sustained, non positional vertigo

Question 12

Posterior circulation infarction presentation

Answer 12

Sudden onset

Associated with other symptoms, such as ataxia, diplopia, cranial nerve defects or limb symptoms

Question 13

Tumour presentation

Answer 13

Gradual onset with associated symptoms of cerebellar or brainstem dysfunction

Question 14

Multiple sclerosis

Answer 14

Relapsing and remitting symptoms, with other associated features of multiple sclerosis, such as optic neuritis or transverse myelitis

Question 15

History of vertigo

Answer 15

Onset 
Duration 
Hearing loss or tinnitus 
Coordination 
Nausea

Question 16

Examination for vertigo

Answer 16

Ear examination -signs of infection or other pathology

Neurological examination -central causes of vertigo (e.g., stroke or multiple sclerosis)

CVS exam - CVS causes of dizziness (e.g., arrhythmias or valve disease)

Special tests

Question 17

Special tests for vertigo

Answer 17

Romberg’s test - problems with proprioception or vestibular function

Dix-Hallpike manoeuvre - to diagnose BPPV

HINTS examination - to distinguish between central and peripheral vertigo

Question 18

HINTS examination

Answer 18

HI – Head Impulse
N – Nystagmus
TS – Test of Skew

Question 19

Head Impulse Test

Answer 19

1. Patient sitting upright and fixing their gaze on the examiner’s nose
2. The examiner holds the patient’s head and rapidly jerks it 10-20 degrees in one direction while the patient continues looking at the examiner’s nose.
3. The head is moved slowly back to the centre before repeating in the opposite direction.
4. Ensure they have no neck pain or pathology before performing the test.

Question 20

Abnormal head impulse test

Answer 20

Abnormally functioning vestibular system - the eyes will saccade (rapidly move back and forth) as they eventually fix back on the examiner

Peripheral cause of vertigo - may be positive

Central cause - normal

Question 21

Test of Skew

Answer 21

1. Patient sitting upright and fixing their gaze on the examiner’s nose.
2. The examiner covers one eye at a time, alternating between covering either eye.
3. The eyes should remain fixed on the examiner’s nose with no deviation.

Question 22

Abnormal test of skew

Answer 22

Vertical correction when an eye is uncovered (the eye has drifted up or down and needs to move vertically to fix on the nose when uncovered) - indicates a central cause of vertigo

Question 23

Management of peripheral vertigo

Answer 23

Peripheral vertigo:

• Prochlorperazine
• Antihistamines promethazine
• Betahistine - Meniere’s disease

Avoid triggers and triptans - vestibular migraine

Question 24

DVLA advice for vertigo

Answer 24

Patients must not drive and must inform the DVLA if they are liable to “sudden and unprovoked or unprecipitated episodes of disabling dizziness”

Question 25

Management of central vertigo

Answer 25

Referral for CT/ MRI head to establish cause