Vertigo Flashcards
Benign paroxysmal positional vertigo
Loose dislodge otoliths free floating within endolymph of semicircular canals
- Posterior semicircular canal most commonly affected
Clinical features of BPPV
- Episodic vertigo
- Lasts for 30s to 1 minute
- Precipitated by changes in head positions
- Better with rest, closure of eyes, lying perfectly still
- Nil hearing loss or tinnitus
- Inner ear
- Can “reoccur” due to residual symptoms
“short intense 30s following sudden head movements”
When to perform dix-hallpike maneuver?
Perform on patients with short episodes (30s) or vertigo initiated by head movement and NO spontaneous nystagmus
- BPPV, orthostatic hypotension
How to diagnose BPPV?
Perform dix-hallpike maneuver
+ve result: patient experiences vertigo and nystagmus
=> suggests BPPV related to the posterior canal
Steps of dix-hallpike maneuver
- Sit patient on edge of bed with eyes open
- Turn patient’s head 45 degrees to one side
- Support patient’s head while he lies supine to where his head is below horizontal plane (30 degrees extended)
- Watch for onset of vertigo and nystagmus for 20-30s for latency of nystagmus
- Sit patient up, wait 30s and test other side
Features of nystagmus of BPPV
- Latency (10-30s) before onset of nystagmus
- Crescendo-decrescendo
- Seconds
- Rotatory
- Towards ground: Geotropic
- Upon sitting, nystagmus may reverse in direction
- Fatiguability
Management of BPPV
- Epley maneuver**
- Reassure patient that it is self-limiting and resolves spontaneously (within 6 weeks)
If refractory to conservative treatment: - Surgery: Posterior semicircular canal occlusion
Steps of epley maneuver
- Support patient’s head while he is lying supine, head turned 45 degrees to affected side, 30 degrees extended below horizontal plane
- WAIT for nystagmus and vertigo to stop - Turn head 90 degrees to other side (ie. 45 degrees facing opposite side)
- WAIT for nystagmus and vertigo to stop - Move patient from lying on his back to lying on side that head is facing (head is now pointing nose down)
- WAIT for nystagmus and vertigo to stop - Sit patient up sideways while maintaining head position
- Once patient is sitting upright, head can be realigned to the midline and neck can be flexed
- WAIT FOR 30s
Meniere’s disease
- Episodic, RECURRENT
- Spontaneous
- Vertigo
- Tinnitus
- Ear fullness
- Fluctuating low-tone SNHL on audiogram
- Lasts > 20 minutes up to 24h each episode
- N/V
- Debilitating
- Unilateral initially but can become bilateral
Signs of Definite Meniere’s Disease
- 2 or more spontaneous attacks of vertigo, each lasting 20 mins to 12h
AND - Audiometrically documented low- to midfrequency SNHL in affected ear on at least 1 occasion before, during or after 1 of the episodes of vertigo
AND - Fluctuating aural symptoms (hearing loss, tinnitus, ear fullness) in the affected ear
AND - Other causes excluded by other tests
Management for Meniere’s disease
Acute: Bed rest, stemetil (vestibular suppressant), betahistine
Long term:
- Reduce salt, caffeine, alcohol
- Stress management
- Steroids
- Diuretics
Definitive treatment: - Intratympanic Gentamicin injection to middle ear to destroy labyrinth (Ototoxic, can inject to kill cells)
-> 5 day daily injections
If failed, Surgery:
- Labyrinthectomy
- Endolymphatic sac surgery
- Vestibular nerve sectioning
Vestibular migraine
- Recurrent episodes of vertigo associated with migraine headache, photophobia, migraine auras
- Migraine and vertigo doesn’t have to occur together, but there’s an increase number of headaches during the period of getting recurrent vertigo
- Spontaneous
- Lasts mins to hours
- Common in post-menopausal women
-> Headaches when younger, dizziness when older - Motion sensitivity, symptoms during menstrual periods
- Variable presentations
- No good test for it, Dx of exclusion
- Prophylactic medications: Calcium channel blocker, propranolol
Vestibular neuritis
Inflammation of vestibular portion of 8th cranial nerve
Clinical features of vestibular neuritis
- Acute, persistent peripheral vertigo
- Nil hearing loss
- A/w severe nausea, vomiting
- Recent viral infection (URTI)
- Lasts for hours to days
- Fever, chills
- Gait instability
- Ear fullness
Labyrinthitis
Inflammation of membranous labyrinth in inner ear
