Vertigo

Question 1

What are the two most common causes of isolated vertigo?

Answer 1

BPPV

Acute vestibular neuritis (Sustained vertigo)

Question 2

Recent viral infection
Sudden onset
Nausea and vomiting
Hearing may be affected

Answer 2

Viral labyrinthitis

Usually resolves in 2-3 weeks - refer if >6 weeks.

Prochloperazine or promethiazine.

(Gastric emptying may be slow if an acute attack - consider Buccastem or IM)

Question 3

Recent viral infection
Recurrent vertigo attacks lasting hours or days
No hearing loss

Answer 3

Vestibular neuritis

Inflammation of the vestibular nerve.

Reassure it will resolve in a few weeks. Buccastem helpful.

Advise not to drive.

Refer if no improvement for > 1 week or perists for >6 weeks.

Question 4

Gradual onset
Triggered by change in head position
Each episode lasts 10-20 seconds

Answer 4

Benign paroxysmal positional vertigo

Dix Hallpike to diagnose

Epley to resolve.

Refer if 1/No benefit after Epley 2/Symptomatic for >4 weeks 3/ >3 periods of BPPV

Question 5

Associated with hearing loss, tinnitus and sensation of fullness or pressure in one or both ears

Answer 5

Meniere’s disease

Refer to ENT as routine.

Inform the DVLA - cease driving.

Attacks - buccastem.

Prevention - betahistine.

Question 6

Elderly patient
Dizziness on rotation/extension of neck

May be history of cervical spondylosis

Answer 6

Vertebrobasilar basilar insufficiency

Advise on lifestyle changes.

Cervical collar

Question 7

Hearing loss, vertigo, tinnitus
Absent corneal reflex is important sign
Associated with neurofibromatosis type 2

Answer 7

Acoustic neuroma

Question 8

What are some other causes of vertigo?

Answer 8

• Trauma
• Multiple sclerosis
• Ototoxicity e.g. gentamicin

Question 9

Migrainous symptoms associated recurrently with unsteadiness or vertigo.

Symoptoms may occur oustide classic ‘aura’ timing.

Possible tinnitus. Hearing can sound muffled but is mostly unaffected.

Largely a diagnosis of exclusion

Answer 9

Vestibular migraine

May need referral if presenting acutely.

Question 10

What should you do if someone presents with sudden unilateral deafness?

Answer 10

Admit under ENT to exclude acute labyrinthine ischaemia or brainstem cause.

Question 11

Episodic vertigo for a few seconds to minutes?

Answer 11

BPPV

Question 12

Episodic vertigo for minutes to hours?

Answer 12

Meniere’s disease (Hearing loss-tinnitus)

Question 13

Prolonged vertigo

Answer 13

Viral labyrinthitis (Mild hearing loss)

Vestibular neuritis (No hearing loss)

Trauama or central lesion

Question 14

What are the red flags for vertigo?

Answer 14

• Acute unilateral hearing loss
• Abnormal neurological symptoms (diplopia, CN palsy, Dysarthria, ataxia.
• New headache
• Normal vestibulo-ocular on head impulse testing.
• Vertical nystagmus.

Question 15

What can you do to ensure the vertigo is not due to a central cause?

Answer 15

HINTS (Head impulse test/Nystagmus/Test of Skew)

• Head impulse - corrective saccade = peripheral.
• Nystagmus - change of direction of nystagmus when change from looking straight on to look to the side = central
• Test of skew(Eye cover test) - skew deviation = central/posterior

Question 16

Describe the Head impulse Test.

Answer 16

Which ever side the saccade occurs on, that is the ear that is affected. And a brainstem cause can be ruled out.

Question 17

Which one of the following is least recognized as a cause of vertigo?

• Gentamicin
• Meniere’s disease
• Acoustic neuroma
• Multiple sclerosis
• Motor neuron disease

Answer 17

Motor neuron disease

Question 18

What are some central causes of vertigo?

Answer 18

• Demyelination
• Vascular
• Vertebrobasilar occlusion
• Tumour