15/02/2015

Question 0

In a patient presenting with vertigo, what would indicate the need to send them to hospital urgently?

Answer 0

Any signs of stroke/brainstem stroke, such as weakness, paralysis, dysarthria, cranial nerve palsies.
Suspicion of meningitis: fever, headache, sometimes also neck stiffness and photophobia
Sudden total unilateral hearing loss, as this could also indicate acute ischaemia of the labyrinth itself, or of the brainstem.

Question 1

Which conditions cause vertigo associated with a cold or other URTI?
What other signs and symptoms might there be?

Answer 1

Labyrinthitis and vestibular neuritis cause vertigo associated with URTI. Labyrinthitis is inflammation of the labyrinth of the inner ear, vestibular neuritis is inflammation of the vestibular nerve. The vast majority of the time, the cause is viral infection.

Other signs and symptoms: nausea and vomiting due to the vertigo
Vertigo may be worsened by sitting up and improved on lying down
Mild hearing loss in the affected side in labyrinthitis
Horizontal Nystagmus
Pain in the ear is rare, and more suggestive of bacterial cause, again rare.

Question 2

How do you manage a patient with labyrinthitis/vestibular neuritis?

Answer 2

Ensure that they do not need to go to hospital (no sudden total unilateral deafness, no signs of stroke)
Advise the patient to lie down with eyes closed during an attack
Advise the patient not to drive or operate machinery until they are sure they are better
Correct any dehydration that may be present due to vomiting (advise to keep drinking)
Medicate for nausea with prochlorperazine (buccal is good route due to vomiting) or promethazine
Safetynet for stroke signs

Question 3

Which structure is most commonly affected in Benign positional paroxysmal vertigo?
What are some causes/predisposing factors to developing BPPV? (5)

Answer 3

Posterior semicircular canal.

Most BPPV is idiopathic. Causes can be attributed in about 40% and include:

Head injury.
Spontaneous degeneration of the labyrinth.
Post-viral illness (viral neuronitis).
Complication of stapes surgery.
Chronic middle-ear disease.

Question 4

What are the first line treatments in Ménière’s disease?
What do you advise the patient with Ménière’s disease?
What other treatments might an ENT referral lead on to?

Answer 4

The acute attacks of vertigo and nausea can be treated with prochlorperazine, cinnarizine or promethazine. May need buccal administration if severe vomiting.
Intramuscular steroid injection followed by a tapering dose of oral steroids has also been recommended.

Any driver with vertigo must send a form to the DVLA. Each case will be considered on individual merit. Safety - if prone to sudden vertigo, consider safety and risks with activities involving heights, dangerous machinery, swimming, etc

After an acute attack of vertigo, patients naturally tend to sit still. Encourage them to move around to promote central compensation, where the brain uses vision and other senses to compensate for the loss of vestibular function.

Prophylaxis: Consider a trial of betahistine (initially 16 mg three times a day) to reduce the frequency and severity of attacks.

Consider a vestibular rehabilitation programme in refractory cases.

If the patient is still struggling, refer to ENT. They may consider treatment with gentamycin to damage labyrinthine cells and improve vertigo. Some risk of sensorineural hearing loss. There are also some surgical options for Ménière’s, as well as other less invasive procedures delivered by specialists.

If the patient described a distinct ‘pop’ of the ear before the vertigo started, refer to ENT much sooner, as it is more likely to be a rare perilymphatic fistula rather than Ménière’s.