Vertigo Flashcards
What is vertigo?
Vertigo is the illusion of movement and refers to a false sensation that oneself or the surroundings are moving or spinning.
What are the central (5) and peripheral (7) causes of vertigo? And how can you differentiate between central and peripheral causes?
Central causes refer to the abnormality being in the cerebral cortex, cerebellum or brainstem.
E.g: CVA, Migraine, MS, Acoustic Neuroma, alcohol intoxication
Peripheral causes refer to abnormalities outside of the central regions aka vestibular labryinth, semicircular canals or vestibular nn.
E.g: viral labyrinthitis, vestibular neuritis, benign paroxysmal positional vertigo (BPPV), Ménière’s disease, motion sickness, ototoxicity (eg, gentamicin), herpes zoster (Ramsay Hunt syndrome).
More likely to be central cause if:
- Prolonged/severe vertigo
- Prolonged severe imbalance (can’t stand even with open eyes)
- New onset headache
- Focal neurological signs
- Central nystagmus (vertical nystagmus)
- Abnormal response to Hallpike manoueuvre
What is the difference between vertigo and a syncopal attack?
Vertigo is an illusion of movement in which there is a false sensation that the person or the person’s surrounding are spinning.
Syncope is a temporary loss of consciousness. Vertigo may occur before syncope.
What is the likely diagnosis: a patient 30yo lady, who has been suffering from a severe attack of vertigo for the past 3 days. With this dizziness she has been feeling sick and vomited on several occasions. She has also noticed some hearing loss.
Labyrinthitis
What is the likely diagnosis: a 45yo man who complains of feeling dizzy out of the blue. ‘It felt like the room was spinning and gets worse if I move my head’. He also complains of nausea and vomiting. On examination you notice nystagmus.
Vestibular neuritis
The presence of any of the following would suggest it is NOT vestibular neuritis:
Nystagmus which fatigues.
Hearing loss.
Abnormalities of cranial nerves other than VIII.
Red tympanic membrane.
Cerebellar ataxia.
Mastoid tenderness, nuchal rigidity or high fever.
What is the likely diagnosis: a 23yo lady suffering from a severe unilateral headache and complains of feeling dizzy and nauseated this lasts for several hours.
Vestibular migraine.
Manage the same as a migraine, pain relief, avoid bright lights, anti emetics. Potentially Triptans.
What is the likely diagnosis: a 45yo lady who has been complaining of transient attacks of hearing loss, a ringing in her ear and dizziness.
Meniere’s disease.
Triad of symptoms (vertigo, hearing loss and tinnitus) which fluctuate.
What is the likely diagnosis: a 36 yo man complaining of the room spinning, he notices it most when he rolls over in bed.
Benign paroxysmal positional vertigo.
What is the likely diagnosis: a 85yo man complaining of feeling dizzy, you check his medication and there is nothing to suggest an issue. There is no postural hypotension drop, ECG normal, no cognitive deficit.
Presbystasis: aka disequilibrium associated with ageing when there is no other cause.
What is labyrinthitis and how is it managed?
Labyrinthitis is inflammation of the membranous labyrinth (utricle, saccule, semicircular canals and cochlea).
It can be caused by bacterial or viral infections. Although viral are more common.
Viral labyrinthitis is often preceded by an upper respiratory tract infection.
Management:
If the patient presents with sudden unilateral hearing loss, they need an assessment by an ENT specialist to explore the diagnosis.
If labyrinthitis is a clear diagnosis they can be managed at home, advise them to lay still as this will help symtoms, antiemetics can be given. Patient should be advised to seek help for worsening symptoms and paticularly the presences of any new neurological symptoms.
What is Ramsey Hunt Syndrome?
Ramsey Hunt syndrome is a paticular type of viral labyrinthitis caused by the varicella zoster virus. Symptoms of this will also include a deep burning auricular pain aswell as a vesicular rash in the external auditory canal and concha.
What is BPPV and how is it managed?
Benign Paroxysmal Positional Vertigo. It is the most common cause of vertigo.
Otoliths are the receptors in the semicircular canals responsible for detecting head position and movement. Embedded in otoliths there are hair cells which detect the movement of endolymph in the semicircular canals.
In BPPV otoliths become detached. Detached otoliths may continue to move after the head has stopped moving and vertigo results from the conflicting sensation of ongoing movement with other sensory inputs.
Management:
Attempt Epley’s manouvere.
Educate patient that BPPV is usually self limiting.
Advise patient against sudden head movements as this will help limit symptoms.
What is vestibular neuritis and how is it managed?
Etymology: Inflammation of the vestibular nn but in reality it is a vestibular nn neuropathy.
Presents with:
- Sudden severe vertigo
- Moving the head aggravates symptoms
- Nausea and Vomiting
- O/e: Nystagmus. (may only be present when gazing away from the affected side)
Management:
- Reassure patients symptoms usually resolve within a few weeks.
- Advise against alcohol as this can worsen symptoms.
- Advise about safety risks - driving, hazards at work
- Anti-emetics for symptom control
- A vestibular supressant such as prochlorperazine could be used for a few days to relieve symptoms but must be discontinued after a few days as it impedes the process of central vestibular compensation.
What is Romberg’s test?
Patient is asked to stand up with there feet together or at distance for them to be stable. They are then asked to stretch out there arms and close there eyes. If they fall to wither side this is a positive Romberg’s test (assess propioception)
What is the Dix-Hallpike manoeuvere?
A test to assess for BPPV.
The test is performed with the patient sitting upright on the examination table with the legs extended. The patient’s head is then rotated to one side by approximately 45 degrees. The clinician helps the patient to lie down backwards quickly with the head held in approximately 20 degrees of extension.
The patient’s eyes are then observed for 45 seconds, there is usually a 5-10 second latency period and then the patient will have a rotational nystagmus for the test to be positive.
