Dizziness and Vertigo Flashcards
What is vertigo?
Vertigo = sensation of spinning and movement of the surrounding environment
=> important to distinguish between true vertigo and generalised dizziness and disequilibrium
Women > Men [3:1]
What are the causes of vertigo originating from the labyrinth?
- Benign paroxysmal positional vertigo (BPPV)
- Vestibular neuritis
- Meniere’s disease
What are the other causes of vertigo?
Vertebrobasilar ischaemia
Viral labyrinthitis
Acoustic neuroma
Vestibular migraine
Posterior circulation stroke
Trauma
Multiple sclerosis
Ototoxicity e.g. gentamicin
What is benign paroxysmal positional vertigo (BPPV)?
BPPV - most common cause of vertigo.
Calcium crystals sometimes detach from the utricle and end up inside the semicircular canals. When these crystals move inside the canals, they send incorrect signals to the brain about the position. This results in ‘world is spinning’ sensation => vertigo
Characterised by:
=> sudden onset of dizziness & vertigo triggered by changes in head position i.e. rolling over in bed or gazing upwards
=> age of onset = 55 years
=> associated with nausea
=> each episode lasts ~10-20seconds
How is benign paroxysmal positional vertigo (BPPV) diagnosed?
Positive Dix-Hallpike manoeuvre
=> tests for canalithiasis (calcium crystals) of posterior semi-circular canal - most common cause of BPPV
- With patient sitting upright, turn the head 45degrees
- Lie the patient with the head turned and over-hanging the edge of the bed and look for nystagmus
- Repeat on contralateral side
=> Positive Dix-Hallpike manoeuvre if it provokes paroxysmal vertigo and nystagmus
How is benign paroxysmal positional vertigo managed?
- Epley manoeuvre (successful in 80%)
If problem in right ear:
=> Start by sitting on a bed
=> Turn your head 45 degrees to the right
=> Quickly lie back, keeping your head turned
=> Turn your head 90 degrees to the left, without raising it.
=> Turn your head and body another 90 degrees to the left, into the bed.
=> Sit up on the left side.
- Vestibular rehabilitation i.e. Brandt-Daroff exercises in persistent cases
- Betahistine - for prevention?
* Repeat in opposite direction if left ear affected
What is vestibular neuritis?
Vestibular neuritis causes vertigo following a viral infection.
Characterised by:
=> recurrent vertigo attacks lasting >24hours - days
=> nausea & vomiting
=> horizontal nystagmus
*nystagmus = involuntary, rapid, uncontrollable eye movements either vertically, horizontally or rotatory
=> no hearing loss or tinnitus
*treat with a anti-emetics in acute phase
What are the differentials for vestibular neuritis?
Viral labyrinthitis
Posterior circulation stroke
=> HiNTs can be used to differentiate posterior circulation stroke (central cause of vertigo) from vestibular neuritis (peripheral cause of vertigo)
Hi = Head impulse test N = Nystagmus Ts = Test of skew
Peripheral cause of vertigo: Positive head impulse test, unidirectional and horizontal nystagmus, negative test of skew
How is vestibular neuritis managed?
- Vestibular rehabilitation exercises for chronic symptoms - first line
- Buccal / IM prochlorperazine for rapid relief for severe cases
- Short oral course of prochlorperazine or anti-histamine i.e. cinnarizine, cyclizine, promethazine for less severe cases
What is viral labyrinthitis?
Inflammatory disorder of the membranous labyrinth affecting both vestibular and cochlear end organs.
Labyrinthitis can be viral, bacterial or assoc. with systemic disease
=> viral labyrinthitis is the most common
Age of onset 40 - 70 years
How do you differentiate between labyrinthitis and vestibular neuritis?
In vestibular neuritis only vestibular nerve is involved therefore there is no hearing impairment
In labyrinthitis both vestibular nerve and the labyrinth are involved, resulting in both vertigo and hearing impairment
What is the clinical presentation of viral labyrinthitis?
Patients typically present with an acute onset of:
=> vertigo - not triggered by movement but exacerbated by it
=> nausea and vomiting
=> hearing loss - unilateral or bilateral, with varying severity
=> tinnitus
=> preceding or concurrent symptoms of upper respiratory tract infection
Signs of labyrinthitis:
=> spontaneous unidirectional horizontal nystagmus towards the unaffected side
=> sensorineural hearing loss shown by Rinne’s test and Weber test
=> abnormal head impulse test - signifies an impaired vestibulo-ocular reflex
=> gait disturbance - the patient may fall towards the affected side
How is viral labyrinthitis managed?
- Episodes are self-limiting
2. Prochlorperazine or anti-histamines helps reduce the sensation of dizziness
What is Meniere’s disease?
Meniere’s disease = disorder of the inner ear of unknown cause.
=> excessive pressure and progressive dilation of the endolymphatic system
Characterised by:
=> recurrent episodes of vertigo, tinnitus and hearing loss (sensorineural)
*vertigo is the prominent symptom
=> sensation of aural fullness / pressure
=> Nystagmus and a positive Romberg test
=> lasts minutes to hours
=> symptoms are unilateral but may become bilateral after a number of years
How does the natural history of meniere’s disease follow?
- Symptoms resolve in majority of patients after 5-10 years
- Majority of patients left with a degree of hearing loss
- Psychological distress is common
