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
Clinical features of labyrinthitis
- Acute, persistent, peripheral vertigo
- WITH hearing loss
+/- Tinnitus - A/w severe nausea, vomiting
- Recent viral infection (URTI)
- Lasts for hours to days
- Fever, chills
- Gait instability
- Ear fullness
Management of vestibular neuritis/labyrinthitis
Acute phase (abort)
- Vestibular sedatives (stemetil)
- Bed rest
- Betahistine
- (for labyrinthitis +/- steroids)
Convalescent phase (maintain)
- Betahistine
- Vestibular rehabilitation
Central causes of vertigo
Posterior circulation stroke
Hemorrhagic stroke
TIA
Vertebrobasilar Insufficiency
Multiple sclerosis
Vestibular problems are all external/middle/inner ear problems?
Inner ear
How to differentiate between central and peripheral causes of vertigo?
Perform HINTs examination
How to perform HINTs examination?
Head impulse:
- Hold patient’s head and suddenly turn it right or left by 30 degrees
- NO catch up saccade: normal OR central
- Catch up saccade: peripheral
-> Vestibular-ocular reflex affected → Cannot fixate on target → Catch-up saccade
Nystagmus:
- No nystagmus: normal
- Unidirectional: peripheral
- Bidirectional: central
Test of skew:
- Alternately cover one eye, then the other
- No vertical skew: normal or peripheral
- Vertical skew: central
ANY 1/3 suggestive of central cause is worrying
Features of peripheral nystagmus
- Equal in direction, speed and amplitude in both eyes
- Does not change direction with gaze
- Never purely vertical
- Suppressed by fixation
How to perform vestibular-ocular reflex?
- Instruct patients to keep her eyes fixed on a target
- Examiner grabs the patient’s head between her hands, and quickly + unpredictably jerks it slightly to one side
In a normal response/central cause (intact VOR): the person will be able to maintain gaze fixation on the target
In an abnormal response/peripheral cause (lost VOR): the person will be unable to fix his eyes on the visual target and his eyes will get “dragged” off the target by the head turn. This is then followed by a quick corrective saccade back to fix on the target again
What is observed in normal response/central cause (intact VOR)?
The person will be able to maintain gaze fixation on the target
