Vertigo

Question 1

what is vertigo?

Answer 1

impression or illusion of movement when there is none

often accompanied by nausea and/or vomiting.

Question 2

how to distinguish btw dizziness and vertigo

Answer 2

dizziness is lightheadedness

Question 3

causes of vertigo

Answer 3

peripheral (ear)

central (brain)

Question 3

sx of peripheral vertigo

Answer 3

sudden in onset
severe
lasting sec or mins or sometimes hours or days
may be - positional
may be - ass with auditory sx like tinnitus or hearing loss

Question 4

sx of central vertigo

Answer 4

milder nystagmus usually vertical not changes with position
mostly neurological sx
not ass with auditory sx

Question 5

causes: peripheral vertigo

Answer 5

Meniere’s disease
labyrinthitis
vestibular neuritis
BPPV
otitis media
wax or FB
acoustic neuroma

Question 6

causes: central vertigo

Answer 6

-Infection: meningitis, brain abscess
-Post-traumatic
-Subclavian steal syndrome
-Vertebrobasilar insufficiency
-Stroke / cerebellar hemorrhage
-MS

Question 7

examination

Answer 7

-neurological exam
-nystagmus esp. with changes in position
-ear exam - to look for TM
-Dix Hallpike maneuver
-HINTS exam

Question 8

HINTS exam

Answer 8

The Head Impulse, Nystagmus, Test of Skew (HINTS) …

Question 9

The head impulse

Answer 9

To perform the head impulse test:
Gently move the patient’s head side to side, making sure the neck muscles are relaxed.
Then ask the patient to keep looking at your nose whilst you turn their head left and right.
Turn the patient’s head 10-20° to each side rapidly and then back to the midpoint.

Question 10

unidirectional nystagmus

Answer 10

Unidirectional nystagmus is reassuring and more likely to be of peripheral origin. When nystagmus changes direction or is vertical, it is much more likely to be associated with central pathologies.

Question 11

bidirectional nystagmus

Answer 11

Bidirectional nystagmus, in particular, is highly specific for stroke. In this case, the saccadic movement beats in the direction that the patient is looking, then changes direction with their gaze (gave-evoked nystagmus).

Question 12

test of skew

Answer 12

1. Ask the patient to look at your nose and subsequently cover one of their eyes.
2. Then, quickly move your hand to cover the patient’s other eye. During this process, observe the uncovered eye for any vertical and/or diagonal corrective movement.
3. Repeat this manoeuvre on the other eye.

Question 13

interpretation of test of skew

Answer 13

Any abnormal movement observed here, often associated with vertical diplopia, is highly specific for a central cause of vertigo.

Question 14

HINTS exam result

Answer 14

head impulse:
peripheral- abnormal
central - normal

nystagmus:
peripheral - unidirectional
central - bidirectional or vertical

Test of skew:
peripheral - no vertical skew means diplopia
central - vertical diplopia

Question 15

vertigo and driving

Answer 15

no driving

document in the notes

write to the GP

Question 16

BPPV: causes

Answer 16

MCC otolith in the post semicircular canal

post head injury

Question 17

BPPV: sx

Answer 17

-Sudden-onset vertigo
-positional in nature
-lasting for seconds or minutes at a time
-recurring, sometimes into the long term
-may be associated nausea and/or vomiting.

Question 18

BPPV: dx

Answer 18

Dix Hallpike manauver

Question 19

BPPV: tx

Answer 19

no medical tx
Epley’s maneuver
vestibular exercises

Question 20

Acute labyrinthitis/vestibular neuronitis: sx

Answer 20

usually follow a URTI
severe
positional in nature
nausea and vomiting +/-
sometimes hearing loss

Question 21

Acute labyrinthitis/vestibular neuronitis: tx

Answer 21

cyclizine 50 mg PO TDS

if hearing loss -refer to ENT

recovery - within days -weeks

Question 22

Ménière’s disease: sx

Answer 22

vertigo
tinnitus
hearing loss
N/V may be
lasted for hours
recurrent

Question 23

Ménière’s disease: tx

Answer 23

-oral cinnarizine or buccal prochlorperazine
-refer to the ENT team.

Question 24

Acoustic neuroma (or vestibular schwannoma): sx

Answer 24

slow onset
deafness
vertigo
tinnitus
CN V, VI, XI, X

Question 25

Vertebrobasilar insufficiency

Answer 25

-headache and/or
-neurological symptoms/signs (eg diplopia, weakness, ataxia, dysarthria). -Refer to the medical team.

Question 26

Stroke/cerebellar hemorrhage

Answer 26

sudden onset of headache
vertigo
ataxia
cerebellar signs.

Question 27

Multiple sclerosis

Answer 27

vertigo
N/V +/-
eye signs

Question 28

unknown cause

Answer 28

refer to ENT/medics