Dizziness and Vertigo

Question 1

What is vertigo

Answer 1

Vertigo - illusion of movement when there isn’t

IMPORTANT TO UNDERSTAND WHAT PATIENT MEANS BY DIZZINESS OR VERTIGO

Question 2

How do we normally maintain our balance

-what happens when we cannot maintain out balance

Answer 2

INPUT
Vision, vestibular labyrinths, sensory systems

Modulated by higher centers

• extrpyramidal system
• cerebellum
• reticular formation

OUTPUT
Autonomic pathways - cardiovasccular function optimised for motion
Veestibuloocular reflex => eyes remain stable
Vestibulospinal reflex => maintain posture
Perception of orientation from vestibular cortex => we feel balanced

Autonomic pathway affected => N+V
Vestibuloocular reflex affected => nystagmus
Vestibulospinal reflex => cannot maintain posture
Perception of orientation from vestibular cortex => dizzy

Question 3

Nystagmus

• types
• what is normal

Answer 3

Periodic rhythmic eye movements

• pendular
• jerk - side named after fast phase

Normal nystagmus
-at extremes of gaze

Question 4

Key features of peripheral vestibular nystagmus

-3 main diagnoses

Answer 4

Horizontal
Maximal in direction of gaze
Suppresses with fixation
UNIDIRECTIONAL

Vestibular neuritis
BPPV
Meniere’s

Question 5

Key features of non vestibular nystagmus

-5 main diagnoses

Answer 5

Vertical or rotating nystagmus

Migraine
BS, cerebellar infarct
Tumour
MS

Question 6

Vestibular neuritis

• presentation
• pathophysiology

Answer 6

Single episode, lasts for days
Preceded by URTI
Vertigo, N+V, unable to get out of bed

Horizontal unidirectional nystagmus
Positive head impulse test

Inflammation of vestibular nerve after viral infection

The more they move, the more likely they are to recover
Supportive - hydration and rehabilitation
N+V - cinnarizine but can be sedating so stop ASAP

Question 7

When is vestibular neuritis not likely

Answer 7

Other CN signs
Head thrust is normal
Abnormal nystagmus
Hearing loss

Question 8

BPPV

• presentation
• pathophysiology
• diagnosis
• management

Answer 8

CaCO3 debris falls into semicircular canal => stimulate vestibular hairs uneccaserily

S-mins
Triggered by rolling over in bed
Episodes cluster
More common with age and other ear pathology

DixHallpike - tilt head to one side, quickly lie them down

• ensure patient keeps eyes open so you can assess for nystagmus
• UPBEAT ROTATIONAL NYSTAGMUS

Management
-Epley - reposition otoliths

Question 9

Meniere’s disease

• history
• diagnosis
• management

Answer 9

First episode similar to vestibular neuritis
Before - aural fullness
During - 30min-1hour
-incapacitating vertigo => N+V+D
-unilateral tinnitus, low freq hearing loss
After - exhaustion after attacks

Normal between attacks
-self limiting but often left with hearing loss
Can become bilateral

Pathology - endolymphatic hydrops

Diagnosis
-Hx, audiometry

Prevention of attacks
-low Na, thiazides (bendroflumethazide), betahistine

Stop attacks - prochlorperazine - N+V

If not enough

• Intratympanic CS
• Surgery

Question 10

Vestibular migraine

• presentation
• management

Answer 10

Often not associated with headache
Normal hearing
Mins-days
Migraine triggers

Manage like you would with a migraine

Question 11

Non vestibular causes of vertigo

Answer 11

Anxiety/panic disorder
Stroke
Presyncopal