Vertigo (2)

Question 1

What can peripheral vestibular dysfunction mimic?

What is Vertigo?
→ What can it be categorised into?

What is Dizziness?

What is the vestibular system?
→ What are its functions?

Answer 1

➊ Stroke

➋ Illusion of movement, which includes sensation of rotation of self (internal spinning) or environment as well as sensation of being pulled downwards/sideways or the room tilting
→ • Peripheral – Problem with vestibular system
• Central – Problem with brainstem/cerebellum

➌ Generic term that may refer to light-headedness, faintness, giddiness, floating sensation, unsteadiness, imbalances

➍ Motion sensors of head for rotation, linear acceleration, gravity
→ Stabilise gaze, maintain head and body posture, get subjective sense of movement, and get orientation in space

N.B. These pts are 12x more likely to fall, therefore is the most common cause of accidental death in 75+

Question 2

What are the central causes?

Answer 2

• Stroke (Posterior circulation infarction)
• Tumour
• MS
• Vestibular Migraine

Question 3

What are the peripheral causes?

Answer 3

• Benign Paroxysmal Positional Vertigo (BPPV)
• Vestibular Neuronitis (VN)
• Labyrinthitis
• Meniere’s Disease

Question 4

Benign Paroxysmal Positional Vertigo (BPPV):
Which SCC is most commonly affected?
→ How is it affected?

What’s the cause?

How does it present?
→ What won’t there be?

What is used to diagnose it?
→ What is seen in a +ve result?

How is it treated?

Answer 4

➊ Posterior SCC
→ Debris forms inside

➋ 50% spontaneous, but can occur secondary to Head injury, Whiplash injury, Post-VN

➌ Brief (20-30 secs) episodes of vertigo induced by moving head position
→ No HL or Tinnitus

➍ Dix-Hallpike manoeuvre
→ Reproduction of vertigo, and observation of rotational nystagmus

➎ * Epley manoeuvre (or Semont)
* Brandt Daroff exercises are commonly used by GP’s to enable patients to treat BPPV at home

Question 5

Vestibular Neuronitis (VN):
What occurs here?
→ What is usually associated with?

How does it present?
→ How does it differentiate from Labrynthitis?

What may these pts develop afterwards?

How is it managed?

Answer 5

➊ Inflammation of Vestibular nerve
→ Viral URTI

➋ Sudden onset of Vertigo, which is worse at the beginning and gradually improves with time
→ No HL or Tinnitus - This is because it doesn’t affect the cochlear nerve

N.B. These pts don’t have any focal neurological symptoms (e.g. diplopia or dysarthria).

➌ BPPV

➍ Symptomatic relief of N+V with Prochlorperazine or an Antihistamine

Question 6

Labyrinthitis:
How does it present?
→ What is usually associated with?

Why does it cause HL and Tinnitus, along with the vertigo?

What is used to diagnose it?
→ What does a +ve indicate?

How is it managed?

Answer 6

➊ Acute Vertigo, associated with HL, Tinnitus, and Ear fullness
→ Viral URTI

N.B. There are no focal neurological symptoms (for example diplopia or dysarthria).

➋ It affects the cochlear nerve

➌ Head Impulse Test
→ Peripheral cause of vertigo e.g. labyrinthitis or vestibular neuronitis

➍ * Acute - Prochlorperazine, Antihistamine for N+V symptoms
* Prophylactic – Betahistine

Question 7

Meniere’s Disease:
How does it present?

How is it managed?

Answer 7

➊ Recurrent attacks of Vertigo lasting 12-24 hrs with unilateral hearing loss, tinnitus, and ear fullness

➋ • Acute - Prochlorperazine, Antihistamine for N+V symptoms
• Prophylactic – Betahistine

Question 8

Investigations:
What should be included in the history?

What are the red flag symptoms?

Answer 8

➊ • Room spinning or Light-headedness?
• Sudden or Gradual?
• Intermittent or Persistent?
• Positional or not?
• HL or Tinnitus? – NO, think BPPV or VN. YES, think Labyrinthitis or Meniere’s

➋ • Neurological symptoms
• Headache

Question 9

Examination:
Which exams should be done?

Which special test should be done?
→ What is the Head Impulse used to do?
→ What would the result of Nystagmus indicate?
→ How is Skew tested? What does the result indicate?

Answer 9

➊ * Otoscopy
* Neurological
* Cerebellar
* Cardiovascular

➋ HINTS Plus (Head Impulse Nystagmus Test of Skew plus Hearing)
→ Help distinguish between Central and Peripheral vertigo (Normal response is for the eyes to remain focused on the examiners nose. It’s abnormal if there’s a Corrective saccade once the head is turned, which indicates a peripheral cause)
→ * Unilateral horizontal nystagmus → Peripheral cause
* Bilateral/vertical nystagmus → Central cause
→ Examiner covers one eye of the pt and then takes it away while looking for a vertical corrective movement as an indication of vertical misalignment → Central cause