Vertigo

Lucy Webber

Vertigo = ‘Hallucination of movement’

Disturbance of vestibular system

CENTRAL PERIPHERAL

CENTRAL NERVOUS SYSTEM

OTOLOGICAL CAUSES

Cerebellar haemorrhage/ischaemia Vertebrobasilar insufficiency

Head & neck trauma Multiple Sclerosis

Vertebrobasilar Migraine Hypoglycaemia

Tumours Migraine

Meningitis/encephalitis Degenerative

BPPV Ménières Disease Acute labyrithitis

Otitis Media (Acute/Chronic suppurative)

Acoustic Neuroma Cholesteatoma

Foreign body/wax

Background

• Common presentation • Typically rotational • Illusion of tilting to one side/swaying• Feeling of imbalance when standing/walking• Diagnosis relies on accurate hx and examination • Often described by pts as ‘dizziness’, ‘spinning’,

‘lightheadedness’, ‘unsteadiness’

History• Onset and duration of first attack • Associated symptoms:

• Exacerbating/relieving factors – effects of change in posture, head/neck movements, darkness

• PMHx: Diabetes, CV disease, ear problems, trauma• DHx • SHx: ETOH intake, recreational drugs

OTOLOGICAL: Otalgia, otorrhoea, change in hearing, tinnitus

NON-OTOLOGICAL: Nausea & vomiting, fever, systemic upset, preceding viral illness

Examination

• Full neurological exam incl. cerebellar exam (DANISH)• Otoscopy, Rinnes/Weber’s Tests• HINTS exam (YouTube video) – Head Impulse, Nystagmus, Test of Skew – Presence of 1 of 3 signs sensitivity of 100%, specificity of

96% for dx of stroke!

HINTS Exam• Head Impulse

– Pt fixes eyes on examiner’s nose. Head quickly rotated. Normal side eyes remain fixated. Affected side eyes make corrective saccade to fix on target

– Abnormal VOR reflex suggests peripheral pathology

• Nystagmus – Vertical/bidirectional nystagmus = central pathology

• Test of Skew – Cover/uncover test pt focuses on examiner’s nose. Refixation of eyes/vertical

misalignment suggests central pathology

Approach to Vertigo

Benign Paroxysmal Positional Vertigo (BPPV) • Commonest cause • Debris in semicircular canals

Sx: - Dizziness induced by sudden head movement- Nausea- Lasts 30-60 secs Signs: - Nystagmus towards affected side Ix: - Dix-Hallpike manoeuvreTx: - Epley’s manoeuvre - Vestibular exercises - Reassurance

Ménière’s Disease• Severe endolymphatic hydrops – abnormal fluctuation in endolymph fluid = inner ear pressure • Idiopathic

Acute Labyrinthitis• Inner ear inflammation • Vestibular neuronitis/neuritis – affects balance only, no hearing loss • Typical age of onset: 30-60yrs • Causes: Viral, bacterial, head injury, • drugs • 95% of pts - single episode

Otitis Media• Causes: Viral/bacterial infection, allergies Inflamed mucous membranes Eustachian tube

dysfunction • Common bacterial infections: Strep. pneumoniae, H. influenzae, M. catarrhalis, Staph.

Aureus

Refer to ENT if: Failure of resolution Persistent discharge Recurrent episodes (≥3 in 6mths, ≥ 4 in 1

yr) - grommets Complications: VIIth nerve palsy,

mastoiditis

CVA • Most common cause of central

vertigo • Posterior Circulation Stroke

– Cranial nerve palsy & contralateral motor/sensory deficit

– Bilateral motor/sensory deficit– Conjugate eye movement disorder– Cerebellar dysfunction – Isolated homonymous hemianopia

• Admit• MRI with DWI (CT has 16% sensitivity for

posterior fossa pathology) • Bleed Refer to Neurosurgeons • Ischaemia Aspirin 300mg for 2/52