Vertigo

Question 1

What is Vertigo?

Answer 1

Sensation that there is movement between the patient and the environment.

Question 2

Physiology of Vestibular System (6).

Answer 2

1. 3 Loops - Semicircular Canals filled with Endolymph Fluid.
2. As the head turns, the fluid shifts inside the canals.
3. Fluid shift is detected by Stereocilia in the Ampulla of the canal.
4. Sensory Input transmitted to brain by Vestibular Nerve.
5. Vestibular Nerve carries signals from Vestibular Apparatus to Vestibular Nucleus in Brainstem and Cerebellum.
6. Vestibular Nucleus - CN III, IV, VI and Thalamus, Spinal Cord and Cerebellum.

Question 3

Types of Causes of Vertigo (2).

Answer 3

1. Peripheral - Vestibular System.

2. Central - Brainstem/Cerebellum.

Question 4

Peripheral Causes of Vertigo (9).

Answer 4

1. Benign Paroxysmal Positional Vertigo.
2. Ménière’s disease.
3. Vestibular Neuronitis.
4. Labyrinthitis.
5. Trauma to Nerve.
6. Otosclerosis.
7. Hyperviscosity Syndrome.
8. Acoustic Neuroma.
9. Herpes Zoster Infection (Facial Nerve Weakness and Vesicles around Ear = Ramsay-Hunt Syndrome).

Question 5

Central Causes of Vertigo (4).

Answer 5

1. Posterior Circulation Infarction (Stroke) = Sudden.
2. Tumour - Gradual.
3. MS.
4. Vestibular Migraine.

Question 6

Differences Between Central Vertigo and Peripheral Vertigo (5).

Answer 6

1. Sudden (P) and Gradual (C).
2. Short (P) and Persistent (C).
3. Hearing Loss/Tinnitus (P) and Not (C).
4. Co-ordination Intact (P) and Impaired (C).
5. Nausea Severe (P) and Mild (C).

Question 7

Examinations of Vertigo (4).

Answer 7

1. Ear.
2. Neurology (Central Causes) including Cerebellar Examination.
3. Cardiovascular.
4. Special Tests.

Question 8

Special Tests in Vertigo (3).

Answer 8

1. Romberg’s Test (Proprioception/Vestibular Function).
2. Dix-Hallpike Manœuvre (Diagnose BPPV).
3. HINTS (Distinguish Between Central and Peripheral Causes).

Question 9

What is the HINTS Examination? (3)

Answer 9

1. Head Impulse Test : Sit upright and fix gaze on examiner’s nose. Hold patient’s head and rapidly jerk it 0-20 degrees in one direction but tell patient to keep focused on the nose (saccadic movement (trains) if abnormal = peripheral).
2. Nystagmus (unilateral horizontal = peripheral; vertical or bilateral horizontal = central).
3. Test of Skew (Alternate Cover Test) - focus on examiner’s nose and alternate cover of eyes = vertical correction = central.

Question 10

Management of Vertigo (3).

Answer 10

1. Referral for CT/MRI.
2. Treat Underlying Cause.
3. DVLA : Inform if liable to sudden/unprovoked/unprecipitated episodes.

Question 11

Management of Peripheral Vertigo (2).

Answer 11

1. Prochlorperazine.

2. Antihistamines e.g. Cyclizine, Cinnarizine, Promethazine.