Module 8.8 - Vertigo

Question 1

What is vertigo?

Answer 1

• A false sensation of movement (either you or your surroundings) and is usually associated with disequilibrium (sense of light-headedness).
• NOTE * It is important to determine a true vertigo, during which a patient experiences a spinning sensation, from lightheadedness, which typically has a different etiology.

Question 2

What diseases cause vertigo?

Answer 2

A. Viral syndromes (vestibular neuronitis)

B. Labyrinthitis

C. Meniere disease

D. Vascular disease (thrombosis or disruption in an artery/vein)

E. Damage to Cranial Nerve VIII (from tumors, meningitis or trauma)

F. Damage to brain stem nuclei (from meningitis, multiple sclerosis, hemorrhage or brain abscess)

Question 3

What can cause lightheadedness?

Answer 3

• Dehydration
• Hypotension
• Hypoglycemia/hyperglycemia
• Heart block
• Infection
• Cardiovascular and cerebellar perfusion

Question 4

What can cause the symptom of vertigo?

Answer 4

• Vestibular disturbances
• Middle ear disturbance
• Cerebellar disease

Question 5

What are some subjective/physical exam findings associated with vertigo?

Answer 5

A. Sense of movement or rotation

B. Light-headedness

C. Tinnitus

D. Hearing impairment

E. Nausea/vomiting

F. Nystagmus

G. Carotid bruits

H. Positional hypotension

I. Positive Romberg sign

Question 6

What laboratory/diagnostic tests are used to diagnose vertigo?

Answer 6

A. Thyroid-stimulating hormone to rule out hypothyroidism

B. Hematocrit to rule out anemia

C. Fasting blood glucose level

D. Electrolytes and therapeutic drug levels

E. Consider alcohol level, drug screen

F. Audiogram/tympanogram evaluation

G. Referral to ENT

H. Consider CT or MRI brain, carotid Doppler studies and Holter monitor.

Question 7

Describe the medical management for patients with vertigo

Answer 7

Treatment is done symptomatically with:

Vestibular suppressants:

1. Meclizine (Antivert) 25-100mg po every 6 hours prn
2. Diazepam (Valium) 2.5-5mg po q hs
3. Scopolamine (Transderm scope patch), Apply 1 patch q 3 days.

Antiemetics:

1. Ondansetron (Zofran) 4-8 mg po q 12 hours
2. Metoclopramide (Reglan) 10mg q 6 hours; or
3. Promethazine (Phenergan) 12.5-25mg po (tablet) or per rectum (suppository) q 4 hours prn nausea/vomiting. NOTE* caution side effect and risk of falls in the elderly

Question 8

What is meniere’s disease?

Answer 8

• A disorder of the inner ear that causes a set of episodic symptoms including vertigo, hearing loss, tinnitus and a sensation of fullness in the affected ear.
• Typically affects men and women in equal numbers between the ages of 20 – 50 y.o.
• Cause is unknown
• Episodes typically last from 20 minutes to 4 hours
• Hearing loss is often intermittent, occurring mainly at the time of the vertigo attack.
• Usually the hearing loss involves mainly the lower pitches, but over time this often affects tones of all pitches
• After months or years of the disease, hearing loss often becomes permanent.

Question 9

What are the treatment options for patients with Meniere’s Disease?

Answer 9

• Low salt diet and/or diuretic
• Anti-vertigo medications
• Intratympanic injection with either gentamycin or dexamethasone
• Air pressure pulse generator
• surgery

Question 10

What are some red flags in the assessment of patient’s with dizziness/vertigo?

Answer 10

• Near Fainting or fainting
• Slurred speech, numbness of face or limbs, or loss of limb movement
• Visual changes, particularly diplopia
• Acute onset, associated with nausea/vomiting