Vertigo

Question 1

What is vertigo?

Answer 1

Sensation that the body or the environment is moving or spinning

Question 2

What is vestibular/peripheral vertigo? What accompanies it?

Causes?

Answer 2

Severe 
Loss of balance
Nausea vomiting
Hearing loss
Tinnitus
Nysteagmus - usually horizontal
Diaphoresis (sweating)

Meineries
Benign paroxysmal positional vertigo
Vestibular failure
Labyrinthitis
Superior semi-circular canal dehiscence

Question 3

What is central vertigo? What accompanies it?

Causes?

Answer 3

Usually less severe
Nystagmus may be horizontal or vertical

Acoustic neuroma
MS
head injury
Migraine
Vertebrobasilar insufficiency

Question 4

What should you ask about the dizziness?

Answer 4

Did the world seem to spin
Which way were things going
Thos with vertigo often know without hesitation

Duration:
Seconds to minutes - BPPV
30min to 30h - meniere’s migraine
30h to week - acute vestibular failure

Question 5

What tests for dizziness?

Answer 5

Assess CNs and ears
Test cerebellar function and reflexes
Nystagmus, gait, Romberg's test 
Hallpike test
Headthrust test

MRI

Question 6

What does a positive Romberg’s test indicate?

Answer 6

Balance is worse when eyes are shut, implying defective joint position sense or vestibular input.

Question 7

What is the Dix Hallpike test?

Answer 7

Ask patient to keep their eyes open and look straight ahead
Place patient sitting on couch so when they lay back, their head will be over edge of couch
Lie patient backwards, turn their head 45 towards the test ear (leads to maximal stimulation of the poster circular canal on lying)
Continue to hold patients head between hands
Ask them to lie backwards and then quickly lower their head 30 below the level of the couch
Ask if patient feels dizzy and look for nystagmus

If + there is vertigo and rotary nystagmus towards undermost ear after 5-10 secs
On sitting there is more vertigo

Question 8

What is benign paroxysmal positional vertigo?

Answer 8

Commonest cause of peripheral vertigo
Attacks of sudden rotational vertigo lasting > 30 seconds are provoked by changes in head position/head-turining
Displacement of otoconia stimulate the semicircular canals

Question 9

What are features of vertigo?

Answer 9

55 years
Vertigo triggered by change in head position
May be associated with nausea
10-20 second episodes
Positive Dix-Hallpike manoeuvre

No persistent vertigo
No speech, visual, motor or sensory problems
No tinnitus, headache, ataxia, facial numbness or dysphagia, no vertical nystagmus

Question 10

What is mangmgent for BPPV?

Answer 10

Usually resolves spontaneously after weeks/months

Epley manoeuvre
Home exercises - vestibular rehabilitation

Question 11

What is the Epley manoeuvre?

Answer 11

Move patients head through 4 sequential positions rising for 30 secs between each movement
Aim is to reposition otoconia war from the sensitive posterior canals

Avoid lying on affected side for 7 days
Upright head position for 48 hours post procedure.

Home Epley can be tough to patients

Question 12

What are Brandt-Daroff exercises?

Answer 12

Series of home exercises to reduce BPPV symptoms?

REpostion, disperse or dissolve inner ear debris

Question 13

What is Meniere’s disease

Answer 13

Dilatation of endolymphatic system of the membranous labyrinth causing sudden attacks of vertigo lasting 2-4 hours
Nystagmus is always present

Question 14

What are features of Meniere’s disease?

Answer 14

Recurrent vertigo, tinnitus and hearing loss (sensorineural)
Sensation of aural fullness
Nystagmus
Positive Romberg’s
Episodes last minutes to hours
Unilateral symptoms, can become bilateral

Question 15

What is management of Meniere’s disease?

Prevention?

Answer 15

ENT assessment

Acute: Prochlorperazine bucalo or IM

Prophylaxis: Betahistine and vestibular rehabilitation exercises

Inform DVLA, cease driving until satisfactory control of sympotms

Question 16

What is acute vestibular failure? Signs?

Answer 16

Vestibular neuronitis/labyrinthitis
Labyrinth = cochlea and semicircular canals

Sudden attacks of unilateral vertigo and vomiting in a previously well person
Often following a recent URTI
Lasts 1-2 days

Nystagmus away from affected side

Question 17

What is management of acute vestibular failure?

Answer 17

Vestibular suppressants:
Prochlorperazine
Cyclizine

Question 18

What is vestibular neuronitis? Features?

Answer 18

Vestibular neuronitis is a cause of vertigo that often develops following a viral infection of vestibular nerve

Young patient - sudden loss of balance

Features
Recurrent vertigo attacks lasting hours or days
Nausea and vomiting may be present
Horizontal nystagmus is usually present
No hearing loss or tinnitus

Question 19

Management for vestibular neuronitis

Answer 19

Vestibular rehabilitation exercises are the preferred treatment for patients who experience chronic symptoms

Prochlorperazine in the acute phase. but should be stopped after a few days as it delays recovery by interfering with central compensatory mechanisms. If the patient is vomiting, prochlorperazine can be given intramuscularly initially, and subsequently switched to oral.

Betahistine is often used although the evidence base suggests it is less effective than vestibular rehabilitation