Vertigo

Question 1

Vestibular Neuronitis - Example Question

Answer 1

A 25-year-old man presents with a four-day history of anorexia, feverishness and vertigo. He has had intermittent difficulty balancing and staying upright when walking and has had episodes of mild vertigo lasting 10-20 minutes at a time. His hearing is unimpaired. On examination, he has some cervical lymphadenopathy. The examination is otherwise unremarkable. What is the likely diagnosis?

	Meniere's disease
	Benign Paroxysmal Positional Vertigo
	Otitis media
	> Vestibular neuronitis
	Multiple sclerosis

Vestibular neuronitis may be preceded by viral symptoms. Vestibular neuronitis is associated with spontaneous onset vertigo and imbalance often associated with nausea and vomiting. Unlike labyrinthitis, it does not cause tinnitus or hearing loss.

Urgent referral should be considered with any of the following red flags: Neurological symptoms or signs, acute deafness, a new type or new onset headache, vertical nystagmus.

Question 2

Viral Labrythinitis

Answer 2

Recent viral infection
Sudden onset
Nausea and vomiting
Hearing may be affected e.g. hearing loss/tinnitus

Question 3

Vestibular Neuritis

Answer 3

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

Red Flags:
Neurological symptoms or signs, acute deafness, a new type or new onset headache, vertical nystagmus.

Question 4

Benign Paroxysmal Positional Vertigo

Answer 4

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

Question 5

Meniere’s Disease

Answer 5

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

Question 6

Vertebrobasilar Ischaemia

Answer 6

Elderly patient

Dizziness on extension of neck

Question 7

Acoustic Neuroma

Answer 7

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

Question 8

Other Causes of Vertigo

Answer 8

Other causes of vertigo include
trauma
multiple sclerosis
ototoxicity e.g. gentamicin

Question 9

Benign Paroxysmal Positional Vertigo (BPPV)

Answer 9

= one of most common causes of Vertigo.

• characterised by sudden onset dizziness and vertigo triggered by changes in head position
• average age of onset > 55 (less common in younger patients)

Differential:

• Viral labrynthitis (shorter duration of Sx)
• Meniere disease (hearing loss + tinnitus + longer duration of vertigo)

Features:

• vertigo triggered by a change in head position e.g. rolling over in bed or gazing upwards
• may be associated with nausea
• each episode lasts 10-20secs

Diagnosis:
- positive Dix-Hallpike manœuvre

Mx:
- Good prognosis - usually resolves spontaneously after weeks/ months
- Symptomatic relief:
> Epley Manœuvre - 80% success rate
> Teaching patient Home exercises e.g. Brandt-Daroff
- Medication inc Beta Histamine is often prescribed but is of limited value

Question 10

BPPV Ix and Mx

Answer 10

Ix = DIX-HALLPIKE MANOEUVRE

Mx = EPLEY MANOUEVRE

Question 11

Meniere’s Disease - Mx

Answer 11

Betahistine may be of benefit

Question 12

Meniere’s Disease

Answer 12

= disorder of the inner ear, unknown cause
Characterised by excessive pressure and progressive dilation of endolymphatic system
More common in middle aged adults but may be seen at any age
Similar prevalence in both men and women

Features:
- recurrent episodes of vertigo, tinnitus, hearing loss (sensorineural)
NB Vertigo is usually prominent Sx!
- a sensation of aural fullness or pressure is now recognised as being common
- other Fx: nystagmus and a positive Romberg test
- episodes last mins to hours - typically Sx are unilateral but bilateral Sx stay develop over a number of years

Natural Hx:

• Sx resolve in majority of patients after 5-10 years
• Majority of patients will be left with a degree of hearing loss
• Psychological distress is common

Mx:

• ENT assessment to confirm diagnosis
• Acute attack: Buccal or IM prochlorperazine (dopamine receptor antagonist)
• Prevention: Betahistine may be of benefit

NB Patients should inform DVLA, advice = to cease driving until satisfactory control of Sx

Question 13

Vertigo - Red Flags

Answer 13

Urgent referral should be considered with any of the following red flags:

• Neurological symptoms or signs
• Acute deafness
• A new type or new onset headache
• Vertical nystagmus.