VERTIGO Flashcards
What is vertigo?
The erroneous impression of movement
What are the central causes of vertigo?
Cerebrovascular disease - inner ear stroke or TIA
Migraine
Multiple sclerosis
Vertebrobasilar insufficiency/ischaemia
Cervical vertigo (provoked by a particular neck posture no matter what the orientation of the head is to gravity)
Drug induced
What are the peripheral causes of vertigo?
Common:
Benign paroxysmal positional vertigo (BPPV)
Menieres disease
Vestibular neuritis
Viral labyrinthitis
Rare:
Vestibular schwannoma
Suppurative middle ear disease affecting the inner ear (eg cholesteatoma or acute suppurative otitis media)
When taking a history, how can you dissociate true vertigo from dizziness?
Vertigo is often described as the room spinning. There must be a real sense of movement. In contrast, dizziness is often described as feeling light headed or having a funny turn.
How might the length of time that vertigo last for help you narrow down your differential diagnoses?
If it lasts for seconds - likely to be BPPV
If it lasts for minutes to hours - likely to be Menieres disease
If it lasts for days to weeks - likely to be vestibular neuritis
What special tests should you perform in someone with vertigo?
Gait assessment
Romberg’s test - vestibular lesions the patient will tend to fall to that side
Unterberger’s test - Patient walks on the spot for 30 seconds with eyes closed. Rotation greater than 30 degrees suggests vestibular pathology.
Dix-Hallpike test
What are the features of benign paroxysmal positional vertigo (BPPV)?
Momentary (10-20 seconds) vertiginous sensation associated with sudden changes in head position, typically rolling over in bed.
Nausea
What is the pathophysiology of benign paroxysmal positional vertigo (BPPV)?
Thought to be due to debris in the inner ear
What age group are more commonly affected by benign paroxysmal positional vertigo (BPPV)?
Average age of onset is 55. Very rare to affect younger patients.
What is the special test used to diagnose benign paroxysmal positional vertigo (BPPV)?
Dix-Hallpike test - aims to replicate the symptoms by a rapid change in head movement
How do you treat benign paroxysmal positional vertigo (BPPV)?
Symptomatic relief:
Epley maneuver
Semont maneuver
Teach patient to do Brandt-Darroff exercises at home
BPPV will usually resolve spontaneously after a weeks or months
What is Meniere’s disease?
It is poorly understood but it appears to be due to recurrent increases in endolymph pressure within the vestibule with progressive dilation of the endolymphatic system. This leads to bouts of otological and vestibular hyperstimulation.
What age group are most commonly affected by Meniere’s disease?
Middle aged adults but may be seen at any age
What are the symptoms of Meniere’s disease?
Triad of:
Vertigo (lasting hours and associated with vomiting and nausea)
Tinnitus
Sensorineural hearing loss
Also sensation of aural fullness is a common feature
Episodes last minutes to hours
Are symptoms of Meniere’s disease such as tinnitus and sensorineural hearing loss typically unilateral or bilateral?
Unilateral but bilateral symptoms may develop after a number of years.
What are the clinical signs of Meniere’s disease?
Nystagmus
Positive Romberg’s tests
How do we manage someone with vertigo, tinnitus and sensorineural hearing loss suggestive of Meniere’s disease?
ENT referral to confirm diagnosis
Treatment of acute attacks: prochlorperazine IM or buccal, admission is sometimes necessary
Salt restricted diet and diuretics are used to counteract the increased endolymphatic pressure
Patients should inform the DVLA. The current advice is to cease driving until satisfactory control of symptoms is achieved
What prophylactic medication can be given to someone with Meniere’s disease?
Betahistine may be of benefit
What is the natural history and prognosis of Meniere’s disease?
Symptoms resolve in the majority of patients within 5-10 years
Most patients will be left with a degree of hearing loss
What is vestibular neuritis?
Viral infection of the vestibular nerve
What is the difference between vestibular neuritis and viral labyrinthitis?
The aetiological difference is poorly understood. Labyrinthitis suggests an element of labyrinth involvement however the evidence is poor. Vestibular neuritis is nearly always viral whereas labyrinthitis can in rare occasions be bacterial from middle ear infections.
The clinical distinction is made on whether or not there is associated hearing loss. Vestibular neuritis does not involve hearing loss whereas hearing may be affected in labyrinthitis.
What are the features of vestibular neuritis?
Recurrent vertigo attacks lasting hours to days
Recent viral infection
Importantly no hearing loss
Nystagmus
What are the features of acute labyrinthitis?
Sudden onset vertigo
Recent viral infection
Nausea and vomiting
Hearing will often be affected
May be features of middle ear infection in which case suspect bacterial aetiology
What viruses most commonly cause vestibular neuritis and viral labyrinthitis?
Tends to be herpes viruses
What investigations may be done in someone who presents with vertigo on the back of a recent viral illness suggestive of vestibular neuritis?
vHIT test - eliminates stroke as a cause
What are the complications of vestibular neuritis or labyrinthitis?
Can lead to BPPV
How do we manage someone with vestibular neuritis?
Management is supportive. Anti-emetics such as prochlorperazine are used. They also have vestibular sedative effect.
However, they must only be used in the first few days as they interfere with the adaptive processes of the vestibular system. The patient is encouraged to mobilise where possible to help with the adaptive process.
What is the syndrome related to vestibular neuritis caused by varicella-zoster in the geniculate ganglion of seventh cranial nerve?
Ramsay-Hunt syndrome
What are the clinical features of Ramsay-Hunt syndrome?
Auricular pain
Facial nerve palsy
Vesicular rash around the ear
Vertigo
Tinnitus
How do we treat Ramsay-Hunt syndrome?
Oral aciclovir
Corticosteroids
What is the other name for vestibular schwannoma?
Acoustic neuroma
What is a vestibular schwannoma?
A benign, slow growing tumour which originates from the Schwann cells surrounding the vestibular division of the 8th cranial nerve. The 7th and 5th cranial nerves can also be affected adding to the symptoms it causes.
How common are vestibular schwannomas (acoustic neuromas) relative to other brain tumours?
They account for 5% of all intracranial tumours and 90% of all cerebellopontine angle tumours.
What disease is associated with bilateral vestibular schwannoma?
Neurofibromatosis type 2
What is the most common presenting complaint in someone with a vestibular schwannoma?
Although this is a vestibular nerve lesion, the ability of the vestibular system to accommodate, means that any balance problems are usually transient. Progressive sensorineural hearing loss accompanied by tinnitus is therefore the most common presenting complaint.
What are the clinical features of a vestibular schwannoma (acoustic neuroma)?
8th nerve:
Hearing Loss
Vertigo
Tinnitus
7th nerve: facial palsy
5th nerve: absent corneal reflex
Where are the most common sites for a vestibular schwannoma to develop?
Just before the nerve exits the internal auditory meatus
In the cerebellopontine angle
How is a vestibular schwannoma diagnosed?
Gadolinum-enhanced MRI scan of the internal auditory meatus and cerebellopontine angle will reveal an enhancing lesion.
How do you manage someone with a diagnosed vestibular schwannoma?
If it is slow growing, it might be more appropriate to watch and wait. If not the options are surgical removal or targeted radiotherapy.
What is a sign that vertebrobasilar insufficiency/ischaemia could be the cause of vertigo?
Dizziness on extension of the neck
