Vertigo, part 2

Question 1

Most common cause of vertigo presentation in all clinical settings, including the ED

Answer 1

BPPV
(a peripheral cause of vertigo)

Question 2

2nd most common cause of vertigo presentation in the ED

Answer 2

Vestibular migraine
(a central cause of vertigo)

the 2nd most common peripheral cause of vertigo is vestibular neuritis

Question 3

Key points in BPPV

Answer 3

Less than 2-minute episodes of vertigo, initiated by head movement (e.g., lying down, rolling over in bed, or getting out of bed)

Dix-hallpike test shows vertical upward and rotatory nystagmus

Question 4

Describe vestibular neuritis

Answer 4

2nd most common peripheral cause of vertigo.

The likely cause is a virus.

The patient develops a prolonged contiuous bout of vertigo that is intense for several days. and then resolves over days, weeks, or months.

There is no associated war pain, hearing loss, or tinnitus in vestibular neuritis.

Question 5

Describe labyrinthitis

Answer 5

a complication of acute otits media

Unlike vestibular neuritis, patients with labyrinthitis complain of ear pain, hearing loss, or tinnitus

Question 6

Most feared cause of vertigo

Answer 6

Cerebellar/brainstem stroke

Patients with cerebellar stroke may develop edema causing acute hydrocephalus or brainstem compression that leads to increased disability or death.

Question 7

Remarks on vertigo in the ED

Answer 7

The fear of missing a stroke can lead the clinician to pursue advanced diagnostic imaging in patients with benign peripheral conditions.

Fortunately, the most common peripheral causes of vertigo presenting to the ED , BPPV and vestibular neuritis, can often be differentiated from cerebellar stroke by history, physical examination, and focused bedside testing.

Question 8

The presence of dizziness increases with age and is due to:

Answer 8

Decreases in visual acuity, proprioception , and vestibular input,

plus an increase in free-floating otoconia within the semicircular canals

Older patients are also more likely to take medications that cause dizziness (e.g., loop diuretics, salicylates, neuroleptics)

Question 9

Diagnostic of BPV

Answer 9

Short episodes of vertical upward nystagmus with a rotatory component during the Dix-Hallpike test

Question 10

Patients who are _________ should have a central cause of vertigo ruled out

Answer 10

unable to stand unaided.

This is in contrast to the patient with peripheral vertigo; they may be very reluctant to stand or walk but are able in general to do so.

Question 11

This presentation suggests cerebellar hemorrhage

Answer 11

A significant and persistent headache that accompanies vertigo

Question 12

This presentation suggests vertebral artery dissection

Answer 12

vertigo and neck pain

Question 13

Positional changes in vertigo

Answer 13

Vertigo made worse by positional change can be seen in BPPV, vestibular neuritis, and cerebellar stroke.

Note that head movements can worsen both central and peripheral vertigo.

Question 14

Remarks on testing for nystagmus

Answer 14

Since nystagmus may be suppressed by visual fixation, avoid having the patient stare at your finger or light source when observing for nystagmus.

Observe for spontaneous nystagmus, which can be seen when the patient is looking straight ahead (primary gaze).

Also observe for gaze-evoked nystagmus by having the patient look approximately 30 degrees from primary gaze to the left and right.

Question 15

What to do to avoid visual fixation?

Answer 15

place a blank piece of paper close to the side of the patient’s head and ask the patient to look through the paper as if it is not there

Question 16

Most common form of BPPV

Answer 16

Posterior canal BPPV

Question 17

When is it appropriate to perform a DHT?

Answer 17

DIX-HALLPIKE TEST (DHT):
When patient has dizziness less than 2 minutes, initiated by head movements only AND has no spontaneous or gaze-evoked nystagmus.

Question 18

Remarks on performing DHT

Answer 18

To observe for nystagmus, instruct the patient to keep the eyes open throughout the test, even if vertigo occurs.

A positive DHT consists of a few seconds (up to 15) of latency, in which the patient is asymptomatic, followed by the onset of vertigo with a crescendo-decrescendo pattern of nystagmus that typically lasts roughly 15 to 30 seconds.

Question 19

Nystagmus in DHT

Answer 19

The nystagmus is a combination of vertical upward and rotatory, with the upper poles of the eyes beating toward the downward ear.

When the patient looks more toward the upward ear, the nystagmus becomes more vertical and more rotatry when looking toward the downward ear.

The downward ear is the affected ear.

Question 20

What is the HINTS PLUS test?

Answer 20

Head Impulse test
Nystagmus
Test of Skew
PLUS testing for acute hearing loss

Question 21

Imaging is indicated in which patients even without HINTS plus testing?

Answer 21

Those with:
- neurologic symptoms and/or deficits are or were present
- significant headache or neck pain
- unable to stand unaided

Question 22

Neurologic symptoms or deficits indicative of a central cause

Answer 22

Focal weakness or paresthesia of face or limbs
Diplopia, dysarthria, dysphonia, dysphagia, dysmetria
Spontaneous vertical nystagmus (not during Dix-Hallpike test)

Question 23

Should be considered first-line treatment for posterior canal BPPV

Answer 23

Epley maneuver

Question 24

In Epley maneuver, hold each position for

Answer 24

the length of time the patient is having vertigo, plus another 30 seconds

Question 25

Disposition in BPPV

Answer 25

10 minutes after Epley maneuver, repeat the DHT. If the post-Epley DHT produces no vertigo or nystagmus, the patient can be discharged withoiut any restriction on activity. It is not unusual for patients whose vertigo and nystagmus have resolved to feel slightly "off" for a day or two after being treated successfully.

Question 26

Treatment of horizontal canal BPPV

Answer 26

**Gufoni maneuver** *Patients would present as pure horizontal nystagmus when testing both left and right sides with the* ***supine roll test***

Question 27

Remarks on horizontal canal BPPV

Answer 27

Horizontal canal BPPV is **rarer**, **resolves spontaneously more quickly**, and is _more difficult to assess and treat_ than posterior canal BPPV. Thus, it is reasonable to refer the patient with suspected horizontal canal BPPV to a clinician familiar with the diagnosis for further management.

Question 28

Least common form of BPPV

Answer 28

Anterior canal BPPV - patient would experience **downward vertical** nystagmus during the DHT. It can be treated with the deep head hanging maneuver.