What is balance?
The result of Visual, Proprioceptive, and Vestibular input
Draw the vestibular system
Draw and explain the hair cells inn the capula
Angular acceleration/deceleration
Explain the saccule and utricle
Linear Acceleration / Deceleration
Explain vestibular ocular reflex (VOR)
What is vertigo?
The hallucination of movement or motion
Causes of vertigo
- Central (brain and CNS)
- Stroke (posterior)
- SOL/tumour
- MS/demyelination
- Peripheral (vestibular system)
- BPPV
- Labyrinthitis
- Vestibular neuritis
- Meniere’s disease
3 most common causes of vertigo
- Posterior circulation stroke/TIA
- Acute vestibulopathy (vestibular neuritis, labyrinthitis)
- BPPV (Benign paroxysmal positional vertigo)
Clinical presentation of vertigo (central pathology, labyrinthine pathology, BPPV)
Explain BPPV
- Head position related to vertigo
- Adaptation and fatigability
- Mechanical problem (medications not very useful)
- Caused by floating otoconia which get stuck in one of the semi-circular canals
- Associated with ageing, head injury, T2DM, vit D def
- Duration of vertigo: seconds to a minute
- Can occur on both sides simultaneously
Explain the Epley maneuver
- Careful consideration for frail elderly, limited neck movements, Rheumatoid arthritis, Ank spond etc
- Don’t need to rapidly perform the Dix Hallpike
- Could use a Tilt table if very difficult circumstances
- Keep momentum going with the Epley
- The semicircular canals age too and anatomy can vary which can limit success
- If bilateral symptoms fix one side at a time
- Consider review in a week
How to check is vertigo is peripheral or central?
HINTS
Head Impulse Test
Nystagmus
Test of Skew
Head Impulse Test (HI)
- Assessing the VOR (Vestibular Ocular Reflex)
- Normal in stroke
- If positive = reassuring (peripheral cause) – imaging may not be needed
- If negative = could be central or peripheral
- Side being tested = side towards the head thrust
Nystagmus (N)
- If direction changing = central cause
Test of Skew - ‘Cover Test’ (T)
- Refixation on cover test if vertical correction = central cause
Peripheral vs central vertigo
Peripheral
- Positive HIT
- Unidirectional Nystagmus
- Normal TOS
- Normal smooth pursuit and saccades
- Can walk
Central
- Normal HIT
- Alternating Nystagmus
- Abnormal TOS
- Abnormal smooth pursuit and saccades
- If cannot walk
Room is spinning constantly
Nauseated, vomited a few times
Off balance, struggling to walk in straight line
HINTS…
Head Impulse – positive
Nystagmus to the right
No refixation
Peripheral or central?
Peripheral
DIAGNOSIS?
Acute vestibulopathy
Short course of vestibular sedative and vestibular exercises
See GP if not improving
Room is spinning constantly
Nauseated, vomited a few times
Off balance, struggling to walk in straight line
HINTS…
Head Impulse – normal
Nystagmus to the right and left
Vertical refixation
Peripheral or central?
Central
DIAGNOSIS?
Stroke (until proven otherwise)
Urgent brain imaging and refer to stroke team
Room only spins for a few seconds when head in certain positions
Getting into or out of bed
Reaching into cupboard
Bending to tie shoe laces
No symptoms sat talking to you
Dix Hallpike positive on the right
You do an Epley
Immediately feels a lot better
Discharged with follow up with GP/Falls Clinic
DIAGNOSIS:
BPPV
(Right Posterior Canal)
