Vertigo Simplified

Gary KroukampKingsbury HospitalTygerberg Hospital

At the end of this talk…• Define vertigo• Diagnose - just by the history• Refer • Investigate • Manage

Definitions

Dizziness/lightheadedness: A distorted sense of one’s spatial relationship

Vertigo: Hallucination of rotatory motion

Unsteadiness: Difficulty with gait/Tendency to fall to one side

Blackouts: Loss of consciousness

Giddiness – Who the hell knows?

Anatomy and Physiology

Input Output

Vision

Proprioception

Vestibular labyrinth

Central integration

Cortical awareness

Visual adaptation

Musculosceletal

Autonomic nervous system

Anatomy and Physiology

Anatomy and Physiology

History

1. Describing character of symptoms 2. Onset – Sudden or Gradual3. Frequency4. Duration5. Severity6. Aggravating factors (activity, darkness)

7. Associated symptoms (N+V, Tinnitus, Hearing loss)

9. Trauma8. Medical history (CVS, Psych, CNS)

10. Medications/Alcohol

Peripheral Central Syncopal Psychogenic

Vertigo Dizziness Blackout ‘Out of body’

Episodic Continuous Episodic Variable

N+V Other CNS Simptoms

+- CVS history

Anxiety

Visual fixation

Visual fixation

History

Examination

1. General

2. Vital signs

3. ENT -Middle ear disease, hearing(audiogram)

4. Neurologic -Cranial nerves, Cerebellum, Nystagmus

5. Cardiovascular -postural hypotension, pulse, carotid bruits, Cardiac murmurs

6. Manoeuvers -Hallpike

Special Investigations

1. FBC (Infection, leukemia)

3. ECG (Arythmias, previous MI)

5. MRI

4. Electronystagmography, Videonystagmo- graphy

2. VDRL, Bloodglucose, Thryroid functions

Causes

Otological (Peripheral) vs Non-otological (Central)

Otological causes

1. External ear (Foreign body, impacted wax)

2. Middle ear disease

3. Trauma -Temporal bone fracture)

4. Menière’s disease

5. BPPV

6. Labyrinthitis

7. Vestibular neuronitis (Viral)

8. Other -Syphilis, Ototoxic drugs, Acoustic

neuroma

Characteristics of Inner Ear Disorders

• Dysequilibrium, not fainting• Definite attacks/episodes• “True vertigo”• Severe• Often with N & V• Other Inner Ear symptoms

Clinical Scenario 1• Mrs JW• 59 years old• 3 week h/o dizziness• Some nausea, no vomiting• Wakes her up at night• Worse on rolling over to the left• Worse on reaching up to high shelf

BPPV

Episodic Vertigo on position change

Pathology: Otoliths in semicircular canals

Diagnosis: Dix-Hallpike manoeuvre with rotational nystagmus

Treatment: Repositioning manoeuvres, Epley

Clinical Scenario 2• Mr SP• 43 yo• Dizzy “attacks” for 3 years• 4 to 5 per year• Last 2 to 3 hours• N&V• Has to lie down• Tinnitus and muffled hearing left ear

Menière’s disease Endolymphatic hydropsEndolymphatic hydrops

1. Young to middle age

2. Episodic attacks

3. Cardinal features -Vertigo, Tinnitus, Hearing loss, Fullness

4. Management

- Medical -Serc, mild diuretics

- Reduction of Caffeine, smoking, salt, 3L water

- Reassurance and Vestibular sedatives

Menière’s disease

• Surgery now largely abandoned in favour of

• Middle ear installation of Gentamycin• Middle ear installation of Steroids

Clinical scenario 3• Mrs RvW• 36 yo• Sudden onset severe dizziness 2 days ago• N&V• Unable to stand/falls over• Normal hearing• Blurring of vision• Left beating nystagmus

Vestibular Neuronitis

• Viral labyrinthitis• Nonspecific viral illness followed 6/52 by a sudden onset

of vertigo, nausea + vomiting• Initially severe- gradual resolution over 10 days• Rx: Steroids

• Vestibular suppressants

Labyrinthitis

Infection of Vestibular labyrinth, associated with URTI

Rapid onset vertigo with nystagmus and hearing loss

First 24 hrs worse, normally resolve after 36 hrs

Clinical Scenario 4• Mr AD• 74 yo man• Gradual onset hearing loss R ear – for years• Also tinnitus R ear• Vague poor balance • 1 episode vertigo 4 years ago• Hearing worse after this

Acoustic/Vestibular Schwannoma

• Benign, slow-growing tumor in vestibular division of eighth cranial nerve

• Not episodic vertigo• MRI with gadolinium is reliable +cost-effective• Rx: “Radiosurgery”Gamma knife/ Surgery

Characteristics of Central Causes

• Continuous• Dysequilibrium more vague, not “True Vertigo”• Less severe imbalance, can still function

Non-otological (Central)

1. Vascular -Vertebrobasilar insufficiency, TIA, postural hypotension, Cardiac dys- rythmias, Valvular lesions, Wallenberg syndrome, Medullary infarction, Inter- nal auditory artery obstruction, Verte- brobasilar migraine, Subclavian Steel syndrome

2. Trauma -Head injury

4. Infectious -Meningitis, Ramsay Hunt Syndrome

3. Ageing -multifactorial

5. Demyelinating diseases eg. MS

6. Epilepsy

7. Toxic -Alcohol, Anticonvulsants

8. Psychogenic –Hyperventilation,Anxiety

Non-otological (Central)

9. Tumour

10. Metabolic -thyroid, hypo- and hyperglycaemia, Addison’s disease

11. Congenital -Familial episodic ataxia, Hydro- cephalus, Arnold-Chiari malformation)

Clinical Scenario 5• Mrs TH• 28 yo• Poor balance and swaying 6 months• After a cruise Durban to Cape Town• Better with exercise• Better with alcohol

Mal de Debarquement Syndrome• After travel by ship• Improvement with exercise/alcohol• Psychogenic?/Anxiety• Overly focused on balance correction• Reassurance/exercise

Conclusion• History!• Clinical Picture• Not everyone has Meniere’s• Appropriate referral• Management according to diagnosis