Vertigo Flashcards
Vertigo.
a) What is it?
b) 2 basic types (and likely cause/ referral)
c) Central causes (cortex, cerebellum, brain stem)
d) Peripheral (labyrinth, semicircular canals, CN VIII)
e) Differentiating central vs peripheral causes
f) Symptoms that may be confused with vertigo
a) Hallucination of movement
b) Horizontal - peripheral cause - ENT referral (inner ear dysfunction)
- Vertical - neurology referral (brainstem dysfunction)
c) - Exclude Stroke/TIA (PoCS) - esp. if sudden onset
- Migraine, multiple sclerosis, acoustic neuroma, diplopia, alcohol intoxication, SOL, head injury
d) Viral labyrinthitis/vestibular neuritis, BPPV, Ménière’s, motion sickness, ototoxicity (eg, gentamicin), herpes zoster (Ramsay Hunt syndrome)
e) - Central - focal neurology, CN palsies, headache, imbalance/gait ataxia, central nystagmus, HIT negative
- Peripheral - precipitated by head movement (BPPV), HIT positive, may be tinnitus or hearing loss (Meniere’s, labyrinthitis)
f) Dizziness, pre-syncope, syncope, imbalance, ataxia, acrophobia
Labyrinthitis/vestibular neuritis
a) Explain difference
b) Cause/risk factors
c) Usual presentation (vs. BPPV)
d) Examination and findings
e) Differentiating from stroke/central causes (stroke is most important differential to exclude)
f) If headache present before, during or after vertigo - likely diagnosis? (other serious DDs to rule out?)
g) Indications for admission
h) Management
a) Vestibular neuritis - affects vestibular nerve only, no hearing loss; common condition
- Labyrinthitis - also affects the labyrinth (semicircular canals and cochlea), has hearing loss; rarer than vestibular neuritis
b) - Both - URTI, causing reactivation of latent HSV-1
- Labyrinthitis - ototoxic drugs, ischaemia, trauma
- Otitis media can cause serous labyrinthitis
c) - Sudden, spontaneous, severe and often incapacitating vertigo (+/- hearing loss, tinnitus).
- Nausea/vomiting
- Exacerbated by movement (whereas BPPV is TRIGGERED by movement)
- Fever may be present (but if very high - consider meningitis or mastoiditis)
d) - External ear - should be normal
- Otoscopy - may show effusion (OME can cause serous labyrinthitis)
- Rinne’s/Webers - may show CHL/SNHL in labyrinthitis
- Romberg’s test positive
- Nystagmus
- Head impulse test (HIT) positive
e) HINTS:
- peripheral: head impulse +, nystagmus unidirectional, skew negative
- central: head impulse negative, nsytagmus bidirectional, skew positive
f) - Vestibular migraine
- Other: meningitis, mastoiditis, SOL, head injury
g) - Sudden-onset unilateral hearing loss or vertigo not triggered by movement
- Systemically unwell, high fever, meningism, mastoid tenderness, etc.
- Severe vomiting/ unable to take oral meds or fluids
h) - Prochlorperazine /other antihistamines
Red flags (differentials):
a) Otorrhoea, haemotympanum
b) Neck pain/stiffness
c) High fever
d) Facial weakness, or weakness elsewhere
e) Dysarthria, dysphagia, diplopia, ataxia
f) Sudden-onset vertigo, not provoked by position change
g) Unilateral sensorineural hearing loss
a) Basilar skull fracture
- may also have: periorbital ecchymosis (raccoon eyes), CSF rhinorrhoea, CSF otorrhoea, mastoid ecchymosis (Battle sign), CN VII/VIII palsy
b) Meningitis or vertebral artery dissection.
c) Mastoiditis, meninigitis
d) Herpes zoster (Ramsay Hunt), stroke/TIA
e) Stroke/TIA (PoCS)
f) Stroke/TIA, Meniere’s
g) Acoustic neuroma
Drug causes of vertigo (all the As)
- Aminoglycosides (eg. gentamicin) and other ototoxic medications.
- Antihypertensives, such as amlodipine.
- Antidepressants (e.g. abruptly discontinuing SSRI).
- Anxiolytics (e.g. benzodiazepines)
- Anti-epileptics.
Examination of vertigo.
a) ENT
b) To rule out meningitis / mastoiditis
c) Neurological
d) Gait - patients tend to fall towards…?
e) Inability to stand or walk unassisted is suggestive of..?
f) Special tests
g) Secondary care investigations
a) - External ear: vesicles suggestive of herpes zoster
- Otoscopy: cholesteatoma, effusion (serous labyrinthitis)
- Hearing (Rinne’s/Webers)
b) - Meningism and fever/ mastoid tenderness and fever
c) - CN exam: palsies, nystagmus and hearing loss.
- Assessment of gait.
- Weakness
d) Patients tend to fall towards the affected side when standing or walking (also in Romberg test)
e) Cerebellar disease: ?ischaemia
f) - Romberg test: +ve = proprioceptive/vestibular disease
- Head impulse test: test vestibular function
- Dix-Hallpike test: can confirm BPPV
g) - Audiology: pure tone audiometry/ tympanometry
- Vestibular: electronystagmography (ENG)
- Neurological: CT, MRI, EEG
Weber’s and Rinne’s test
a) Procedure
b) Explain
a)
b) Find paeds notes
Head impulse test (HIT).
a) Procedure
b) Positive test
c) Contraindications
a) - Always start by asking the patient to sit upright and to turn their head to either side to assess any limitation of movement and ensure it is safe to proceed.
- Advise the person to fix their gaze on your nose.
- Using your hands, turn the head rapidly 10-20° and then rapidly turn it back to face you and watch the eyes for saccades.
b) If the vestibulo-ocular reflex is impaired, as it is in vestibular neuritis and labyrinthitis, patients will not be able to maintain focus on your nose and then a ‘catch-up’ reflexive saccade will occur
c) Neck pain/disease, vertebrobasilar insufficiency
HINTS examination
a) Stands for…?
b) Differentiates between…?
c) Explain results
a) Head Impulse - HIT test
- Nystagmus Type - unidirectional means fast beat is always in same direction irrespective of direction of gaze. Bidirectional means the fast beat changes depending on gaze direction
- Skew - when eyes are alternately covered and uncovered, the affected (skewed) eye moves vertically
b) Vestibular neuritis/labyrinthitis vs. acute stroke
c) - Vestibular - HI positive, NT unidirectional, no skew
- Stroke - HI negative, NT bi-directional, vertical skew
Dix-Hallpike test
a) Procedure
b) Used to diagnose…?
c) If positive, should then be followed by what manoeuvre that could cure BPPV?
a) - With patient sat up, turn their head 45 degrees to one side
- Lie them down quickly and extend their head 20 degrees over the end of the couch
- Positive test: vertigo +/- nystagmus
b) BPPV - causes vertigo and nystagmus
c) Epley manoeuvre
Vertigo differentials:
a) Characteristic nystagmus and vertigo are brief and triggered by changes of position but between movements they may have few or no symptoms. Dix-Hallpike positive
b) Accompanied by headache
c) Sudden onset, vertigo at rest, hearing loss, nausea, preceding URTI
d) Sudden onset, vertigo at rest, no hearing loss, preceding URTI
e) Suddent onset, vertigo at rest, head impulse test negative
a) BPPV
b) Vestibular migraine
c) Acute labyrinthitis
d) Vestibular neuritis
e) Stroke/TIA
Vertigo: red flags
- Sudden onset (?stroke)
- Unilateral hearing loss or tinnitus
- new-onset headache
- focal neurological signs
- cerebellar signs (gait ataxia, down-beating/ other atypical nystagmus)
- high fever (?mastoiditis, meningitis)
Vertigo: management
a) General
b) Positional
c) Physiotherapy
d) Medical - when should they be stopped?
e) Surgical
a) Advise against driving when dizzy - inform DVLA if necessary
- If severe N/V and unable to tolerate food/fluids/medication - to hospital
b) Epley manoeuvre or Brandt-Daroff exercises
c) Balance rehabilitation, e.g. Cawthorne-Cooksey exercises
d) Antihistamines (eg. prochlorperazine, cyclizine, promethazine, cinnarizine)
e) e.g. labyrinthectomy
Index conditions
BPPV
Meniere’s
Vestibular neuritis/labyrinthitis
BPPV.
a) Pathophysiology
b) Causes and risk factors
c) Presentation - common triggers
d) How long do episodes last?
e) What symptoms should NOT be present (suggest alternative diagnosis)
f) Examination and findings (main 1)
g) Management
a) Otoliths dislodge in the semicircular canals, causing dysfunctional endolymph flow and resultant vertigo
b) - Idiopathic (60%), other - middle ear disease, previous labyrinthitis/VN, head injury
- Risk factors - age 40-60, female, migraine, anxiety, Meniere’s
c) - Vertigo triggered by movement: rolling over in bed, lying down, sitting up, leaning forward, turning the head
- May be a delay of 5-20 seconds between movement and vertigo
- Nausea common, vomiting rare
- May be worse in the mornings
d) Usually last seconds to mins. Sudden onset and offset
e) Hearing loss, tinnitus, ear/mastoid pain or tenderness, headache, meningism, vomiting, gait ataxia
f) - Romberg’s - may be positive
- Dix-Hallpike test positive: vertigo and nystagmus reproduced (should only be positive on one side)
- Hearing, balance, CNs, etc. should be normal
g) - Immediate treatment: Epley manoeuvre
- Driving: Not to drive when they are dizzy, or if they are likely to experience an episode of vertigo while driving.
- Reassure that self-limiting usually
- Brandt-Daroff exercises/ vestibular rehab
- AVOID medication
- Investigate/refer if conservative measures don’t help
- Surgery rarely, for intractable symptoms
Meniere’s.
a) What is it?
b) Cause
c) Presentation - 4 core symptoms
d) How long do attacks last?
e) Other possible associated symptoms
f) Examinations/investigations
g) Management (conservative, prophylaxis, acute attacks, further interventions)
a) Episodic vertigo that lasts from minutes to 24 hours, usually characterised by unilateral (in 90%) hearing loss, tinnitus and aural fullness
b) - Disorder of the inner ear caused by a change in fluid volume;
- RFs - age 40-60, female, FHx, autoimmune (RA, SLE), food allergy
c) Spontaneous attacks of: VERTIGO, usually (90%) with unilateral TINNITUS, SNHL and AURAL FULLNESS
(note: as the disease progresses, the vertigo may improve while the SNHL and tinnitus worsen)
d) Minutes to hours; often occur in clusters
e) Drop attacks (4%), altered balance
f) - Romberg’s - may be positive
- Otoscopy - exclude earwax and other causes of hearing loss
- Neurology - CNs normal
- CV: BP (lying, standing), carotid bruits, ECG
- Dix-Hallpike manoeuvre for BPPV - negative
- Bloods: FBC, ESR, TFTs, glucose, UEs/creatinine
- Imaging: MRI (if unilateral signs ?acoustic neuroma, SOL), etc.
- Special tests: audiology (PTA/tympanometry), electronystagmography (ENG)
g) 1st line.
- Salt/caffeine restriction, alcohol and tobacco cessation
- DVLA - notify; don’t drive if dizzy
- Acute attacks: antihistamine (relieve nausea/vertigo) +/- IM steroids
- Prophylaxis: betahistine
- Hearing loss: hearing aids
- Tinnitus: sound therapy, distraction techniques
2nd line.
- local gentamicin treatment (may cure vertigo, but risk of worsening SNHL)
- local steroid injection
- surgery - e.g. micropressure therapy via grommet
