Vertigo Flashcards
Differentials for dizziness
Can be categorised into 4 subgroups: vertigo, pre-syncope, disequilibrium and lightheadedness (or non-specific dizziness).
- Benign paroxysmal positional vertigo
- Meniere’s disease
- Vestibular neuritis
- Labyrinthitis
- Cereballar (ataxia, stroke)
- Neoplasm - acoustic neuroma
other causes of vertigo: posterior circulation stroke, trauma, multiple sclerosis, ototoxicity e.g. gentamicin
What is vertigo?
- Vertigo is the sensation that the environment is spinning around relative to oneself (objective vertigo) or vice versa (subjective vertigo).
- Vertigo may result from diseases of the inner ear or disturbances of the vestibular centres or pathways.
Benign paroxysmal positional vertigo (BPPV) - definition
- Dysfunction of posterior semicircular canals
- A peripheral vestibular disorder characterised by sudden-onset, severe attacks of vertigo usually lasting <30 seconds and precipitated by specific head movements (e.g., looking up or bending down, getting up, turning the head, or rolling over to one side in bed).
Benign paroxysmal positional vertigo (BPPV) - cause
Most cases result from the migration of free-floating endolymph canalith particles (thought to be displaced otoconia from the utricular otolithic membrane) into the semicircular canals, rendering them sensitive to gravity
BPPV - clinical features
more common in women > 50 y/o specific provoking positions brief duration of vertigo (<30 s) episodic vertigo severe episodes of vertigo sudden onset of vertigo nausea, imbalance, and lightheadedness absence of associated neurological or otological symptoms (eg hearing loss, tinnitus) normal neurological and otological examination
BPPV - investigations
Clinical Dx
- positive “positional” tests: Dix-Hallpike manoeuvre and supine lateral head turn
(positive = get vertigo and nystagmus)
Dix-Hallpike testing lies the patient down quickly as the eyes are observed. Nystagmus will occur on the side tested. There will be a brief delay then nystagmus will occur for less than one minute. Repeating the manoeuvre shows the effect is weaker with subsequent attempts.
BPPV - management
- 1st line: pt education and reassurance
- repositioning manoeuvre (Epleys manoeuvre) - lie pt down head 45 degree to the right, then after 30 seconds to the left, then turn pt to left lateral decubitus for 30 seconds, then sit up
- autonomic dysfunction: vestibular suppressant medication (eg lorazepam, diazepam, cyclizine)
- betahistine
- vestibular rehabilitation exercises
Meniere’s Disease - definition
- Auditory disease characterised by an episodic, sudden onset of vertigo; hearing loss and roaring tinnitus; and a sensation of pressure or discomfort in the affected ear.
- Meniere’s Disease = idiopathic
- Meniere’s syndrome = 2ary (allergies, syphilis, lyme disease, hypothyroidism)
Meniere’s Disease - clinical features
RF: recent viral illness, autoimmune disorders.
Occupation –> construction and driving put at risk
vertigo (recurrent attacks, minutes to hours and may have N+V)
hearing loss (unilateral, fluctuating and worsens around the vertigo spells in initial stages, then constant)
tinnitus (unilateral)
aural fullness in affected ear
Meniere’s triad
- Recurrent vertigo
- Fluctuating SNHL (sensorineural hearing loss)
- Tinnitus
(These symptoms mimic Acoustic Neuroma)
Meniere’s - management
- Lifestyle: Dietary salt restriction, avoid alcohol, caffeine and stress/fatigue/overwork
- vestibular rehabilitation exercises
- acute attacks: buccal or IM prochlorperazine (buccastem) - antiemetic and vestibular suppressant
- betahistine for prevention- H3 antagonist and weak H1 agonist (vestibular vasodilation = relieves pressure)
- intratympanic injections (dexamathasone OR gentamicin)
- surgery: endolymphatic sac procedure (sac is decompressed), labyrinthectomy and vestibular nerve section
- Other: hearing aids for hearing loss, meniett device (delivers pressure pulses), grommet insertion
- inform DVLA
Vestibular Neuritis - definition
Acute peripheral vestibulopathy due to reactivation of a viral infection, most commonly herpes simplex virus, which affects the vestibular ganglion, vestibular nerve, labyrinth, or a combination of these sites.
Vestibular Neuritis - clinical features
Sudden onset of peripheral vertigo Usually without hearing loss Lasts a few days, resolves over weeks dizziness, balance issues, N+V Spontaneous, complete symptomatic recovery with supportive treatment
Labyrinthitis
inflammatory disorder of the membranous labyrinth, affecting both the vestibular and cochlear end organs
Patients typically present with an acute onset of:
vertigo: not triggered by movement but exacerbated by movement
nausea and vomiting
SNHL: may be unilateral or bilateral
tinnitus
preceding or concurrent symptoms of upper respiratory tract infection
Vestibular Neuronitis vs Labyrinthitis
Labyrinthitis should be distinguished from vestibular neuritis as there are important differences: vestibular neuritis is used to define cases in which only the vestibular nerve is involved, hence there is no hearing impairment; Labyrinthitis is used when both the vestibular nerve and the labyrinth are involved, usually resulting in both vertigo and hearing impairment.
