Vertigo

Question 1

Causes of vertigo

Answer 1

Peripheral/vascular:
- BPPV
- Meniere’s disease
- Labrynthitis, neuronitis
Central:
- Vestibular schwannoma
- Multiple sclerosis
- Stroke
- Head injury
- Inner syphilis
Drugs: gentamicin, loop diuretics (furosemide), metronidazole, co-trimoxazole

Question 2

Investigations for vertigo

Answer 2

Hearing test (consider… audiometry, calorimetry, LP, MRI)
Cranial nerves examination
Dix-Hallpike & Epley manoeuvre
Romberg’s test (if positive, consider vestibular or proprioceptive disorders)

Question 3

Signs and symptoms of viral labyrinthitis

Answer 3

Sudden onset vertigo (exacerbated by head movement/opening eyes)
N&V
Hearing may be affected
Nystagmus

Hx Recent viral infection e.g. URTI

Question 4

Symptoms and signs of vestibular neuronitis

Answer 4

Sudden onset vertigo (exacerbated by head movement/opening eyes), recurrent attackes lasting hours or days
N&V
Nystagmus

Hx Recent viral infection e.g. URTI

(hearing not affected)

Question 5

Symptoms and signs of vestibular migraine

Answer 5

Sudden onset vertigo + N&V
Chronic migraine headache Hx

Question 6

Management for vestibular neuronitis and viral labyrinthitis

Answer 6

Acute phase:
- Less severe → PO cyclizine or prochlorperazine (stopped after few days – can delay recovery)
- Severe → buccal / IM prochlorperazine
·
Chronic → vestibular rehabilitation exercises [referral to balance specialist – 2ww]

Question 7

Features of BPPV

Answer 7

Gradual onset vertigo
Triggered by change in head position
Each episode lasts 20-30 seconds

Question 8

Features of menieres disease

Answer 8

Associated with hearing loss, tinnitus, sensation of fullness/pressure in one or both ears

Question 9

Features of vertebrobasilar ischaemia

Answer 9

Elderly patient
Dizziness on extension of neck

Question 10

Features of acoustic neuroma

Answer 10

Hearing loss, vertigo, tinnitus
Absent corneal reflex is important sign
Associated with neurofibromatosis type 2

Question 11

Describe the Dix-Hallpike manoeuvre

Answer 11

1. Ask the patient to sit upright on the examination couch.
2. Adjust the patient’s position so that when supine, their head will hang over the edge of the bed, allowing for head extension below the horizontal plane.
3. Position yourself standing behind the patient.
4. Turn the patient’s head 45º to one side (i.e. left or right) – if the patient has suggested turning their head to a particular side appears to trigger the symptoms, you should try this side first.
5. Whilst supporting the neck, move the patient from their sitting position to a supine position in one brisk smooth motion, ensuring their head hangs over the bed 30º below the horizontal plane. Ask the patient to keep their eyes open throughout this process.
6. Inspect the patient’s eyes carefully for evidence of nystagmus for at least 30 seconds.
7. If no nystagmus is observed on the assessment of the first side (i.e. left or right), the test is then complete for that side and you should carefully help the patient sit back up.
8. In the case of a negative Dix-Hallpike test on the first side, after a short break, the test should be repeated on the other side, turning the patient’s head in the opposite direction during step 4. If no nystagmus is observed on assessment of the other side, the patient should be sat up and an alternative diagnosis to BPPV should be considered.
9. If the test is positive, the characteristics of the patient’s nystagmus should be observed (see details below) and you should then consider performing the Epley manoeuvre.

If the test is positive, the patient will complain of vertigo and you should be able to observe nystagmus directly.

Question 12

Describe the Epley menoeuvre

Answer 12

When performing the Epley manoeuvre, each position should be maintained until full resolution of symptoms and nystagmus has been achieved for at least 30 seconds:

1. The Epley manoeuvre typically follows on from a positive Dix-Hallpike test, so we will assume the patient is still positioned lying flat, with the head hanging over the end of the bed, turned 45º away from the midline towards the affected side.
2. Turn the patient’s head 90º to the contralateral side, approximately 45º past the midline, still maintaining neck extension over the bed. Keep the patient in this position for 30 seconds.
3. Whilst maintaining the position of the patient’s head, ask the patient to roll onto their shoulder (on the side their head is currently turned towards).
4. Once the patient is on their side, rotate the patient’s head so that they are looking directly towards the floor. Maintain this position for 30 seconds to a minute.
5. Sit the patient up sideways, whilst maintaining head rotation.
6. Once the patient is sitting upright, the head can be re-aligned to the midline and the neck can be flexed so that the patient is facing downwards (chin to chest). Maintain this position for 30 seconds.

The entire procedure can be repeated 2-3 times if needed, however, this will depend on whether the patient is able to tolerate further manoeuvres (as they often precipitate vertigo).