Vertigo Flashcards
Does associated nausea and vomiting indicate a peripheral or central cause?
Peripheral
Features of peripheral vertigo - onset, duration, intensity
Sudden onset
Paroxysmal
Intense
Lasts minutes or hours
Features of central vertigo - onset, duration, intensity
Insidious or sudden onset
Continuous
Less intense
Lasts days or weeks
Direction of nystagmus in peripheral vs central vertigo (horizontal, vertical, torsional)
Peripheral - Horizontal or torsional nystagmus
Central - Vertical
Peripheral or central position related?
Peripheral - Aggravated with position change
Central - Not position‑related
Associated sx with peripheral vertigo
Tinnitus or deafness common or new onset
Associated with nausea and vomiting, blocked feeling in ear
Associated sx with central vertigo
Associated with ataxia, facial numbness or weakness, diplopia, dysphagia, hemiparesis, difficulty walking, skew deviation
Are tinnitus or deafness common with central vertigo?
No tinnitus or deafness
Examples of peripheral causes of vertigo
BPPV
Meniere disease
Vestibular neuronitis
Examples of central causes of vertigo
Stroke
Haemorrhage
Vertebrobasilar insufficiency (VBI)
TIA
MS
Neoplasm
Migraine
If central vertigo, look for __________ signs and consider a stroke, as the cause is likely to be neurological
Cerebellar and brainstem signs
Brainstem signs
Vertigo, nystagmus, diplopia, dysarthria, dysphagia, and ocular skew deviation.
Hemiparesis, facial weakness, or numbness.
Cerebellar signs
Ataxia
Difficulty standing or walking
When to use HINTS test
Continuous vertigo
To differentiate between a central and peripheral cause
Ménière’s disease is a triad of…
Vertigo, tinnitus, and hearing loss
Is BPPV associated with tinnitus or hearing loss
No
BPPV is triggered by…
Occurs with head turning or head movements
Do patients with BPPV have disequilibrium?
May have disequilibrium.
Associated sx with BPPV
Nausea and vomiting
Duration of vertigo with BPPV
Attacks last less than 1 minute and settle if head is kept still
BPPV usually resolves within…
Resolves in days
Do patients with Ménière’s have dysequilibrium?
Persistent dysequilibrium
Associated sx with Ménière’s
“Pressure sensation” in the affected ear
Tinnitus which worsens with time.
Hearing loss which comes and goes and eventually is permanent
Ménière’s typically lasts _____ hours
1 to 24 hours
Characteristic presentation of vertigo with vestibular neuritis
A single, severe episode of vertigo, lasting at least 48 hours
Associated symptoms with vestibular neuritis
Associated with nausea and vomiting, and may have preceding viral infection
Duration of vertigo with vestibular neuritis
Lasts hours to days
Vestibular neuritis typically resolves within ______
1 week
Is vestibular neuritis associated with tinnitus or hearing loss?
No
Vertigo with unilateral hearing loss and otitis media is suggestive of…
Acute bacterial labyrinthitis
When to refer to ENT
Concern of acute bacterial labyrinthitis (acutely)
Peripheral vertigo not settling
Sudden unilateral hearing loss with peripheral vertigo –> manage as per asymmetrical sensorineural hearing loss
How successful is the Epley mannouvre?
Successful in about 50% of cases
Management vestibular neuritis
Prochlorperazine TDS or scopolamine patches (not funded)
If recurrent attacks of vestibular neuritis consider prescribing…
Self-administered antiemetics e.g., buccal prochlorperazine (not fully funded)
When to follow up with vestibular neuritis
Most patients recover within a week.
Review the patient if vertigo persists after 2 weeks
Management of Ménière disease if acute attack
Consider antiemetics e.g., prochlorperazine (buccal or intramuscular), cyclizine, promethazine.
Discuss:
- potential triggers, such as a high‑salt diet, caffeine, and alcohol
- hearing aids
- tinnitus management
- support groups
Pharmacological treatments for prophylaxis in Ménière disease
Thiazide diuretics or betahistine can be used as prophylaxis. Betahistine may reduce the frequency or severity of attacks.
Vestibular rehab/physio can be useful if
Recurrent vertigo e.g. BPPV
Implications on driving if a patient has vertigo
No general prohibition on driving with vertigo
Except if attacks of are sudden, or unpredictable, and are sufficiently disabling that they may impair an individual’s ability to drive safely, eg unable to concentrate on driving
If the vertigo is due to a peripheral cause, there should be no abnormal neurological signs other than __________
Nystagmus and possibly hearing loss.
When to do a Dix Hallpike test
A Dix-Hallpike positional test is essential for all patients presenting with, or with a history of, vertigo who do not have spontaneous nystagmus while upright
How do you tell which side is affected in peripheral vertigo? (by looking at nystagmus)
Nystagmus from a peripheral cause is usually horizontal with a slow component to the symptomatic side (affected ear) and a fast component (VOR) to the opposite side.
The direction of the nystagmus is defined by __________
The fast component, i.e. left, right, up or down-beating
Features of nystagmus that would suggest a peripheral cause
Fatigues with time
Goes away with fixation (e.g. asking the patient to stare at your finger)
Starts after a short delay
Does not change direction with gaze
Vertical nystagmus is usually a sign of…
An underlying central lesion.
The upward torsional nystagmus of BPPV is the only exception.
Recurring episodes of vertigo, usually lasting for several hours, associated with fluctuating hearing, tinnitus and aural fullness is suggestive of…
Ménière’s disease
Meniere’s disease is caused by…
Excess of cochlear endolymph (endolymphatic hydrops) which eventually “refluxes” into the semicircular canals to cause vertigo. As the vertigo episodes continue, hearing may decline to a “flat” sensorineural loss at 60 dB
What age group does Meniere’s occur in?
Usually > 40yo, but in one-third of people it starts > 60yo
Diagnosis of Meniere’s
Classical symptoms + pure tone audiogram
A MRI scan to exclude retrocochlear pathology is usually required
Goal of treatment in Meniere’s
Currently there is no treatment which can reverse the hydrops and the hearing loss.
The goal of management is symptom control.
ENT possible management of Meniere’s
Intratympanic gentamicin - placed in the middle ear through a myringotomy then absorbed into the inner ear.
Does not treat the underlying pathology, but disables the semicircular canal receptors causing the vertigo episodes. A single treatment usually results in cessation of vertigo for several years.
A single, severe episode of vertigo, lasting at least 48 hours is suggestive of ____________
Vestibular neuritis
Recurrent, fluctuating vertigo that occurs with a throbbing headache, photophobia or transient visual symptoms is likely to be…
Vestibular migraine
Treatment of vestibular migraine
Treat as for migraine, if vertigo persists, reconsider the initial diagnosis (it is easily confused with Ménière’s disease) and consider referral to an otolaryngologist.
