Vertigo

Question 1

Vertigo:

What must be differentiated when describing vertigo?

Answer 1

• vertigo (spinning)
• dysequilibrium (imbalance)
• Lightheaded or presyncope (feeling faint)

Question 2

Vertigo:

Types of vertigo?

Answer 2

1) Peripheral

2) Central

Question 3

Vertigo:

What are the central causes that need to be considered?

Answer 3

• CVA (look for vascular risk factors to increase level of suspicion for this diagnosis)
• MS
• Space occupying lesions
• Vestibular migraine (headache but 50% associated with vertigo - can be vertigo without headache - lasts 5min and up to 72hrs)
• may be associated a with other neurological signs*

headache with vertigo warrants further investigation

Question 4

Vertigo:

Peripheral causes to consider?

Answer 4

BPPV
Vestibular neuronitis
Labyrinthitis
Menieres disease
Perilymphatic fistula (if history of trauma)
Hyperventilation with anxiety
often associated with nausea, vomiting and hearing loss

Question 5

Vertigo:

Essential examination and strategy?

Answer 5

1) Otoscopy
2) Rule out a central cause
- cranial nerves
- cerebellar (coordination, gait, balance)
- HINTS (see other questions)
- Nystagmus (vertical = central, any direction nystagmus that does not disappear with gaze fixing = central
3) Tragus pressure looking for nystagmus or vertigo stimulation (perilymphatic fistular)
4) hearing assessment (free field voice testing - individual ear with contralateral masking, words spoken at a whisper at arms length and 15cm from ear)
5) cardiovascular (pulse, rhythm, carotid bruits, BP)
6) glucose level

Special test

1) Orthostatic BP
2) Dix-Hallpike or lateral side lying test
3) Head impulse (Vestibular Ocular Reflex)
4) neck torsion test (10sec rotation) - cervical pathology
5) Fukuda stepping test

Question 6

Vertigo:

What is the HINTS exam?

Answer 6

• only perform if
  1) persistent (NOT episodic) active vertigo and nystagmus combined
  2) normal neurological examination
  3) symptoms are acute

Head Impulse (VOR - correctional saccade = suggestive of peripheral cause [should be unilateral] -IF no saccade = consider central cause)
Nystagmus (unidirectional = peripheral, biphasic = central)
Test of Skew (eye cover test - any correctional movement = central)

Can add in hearing if want to - new hearing loss = central cause likely AICA CVA

Central cause = if any components suggest central cause
Peripheral cause = when all components suggest peripheral cause

Question 7

Vertigo:

How to delineate peripheral causes?

Answer 7

hearing loss -> Yes

• vertigo last >20minutes to hours = Menieres
• vertigo last seconds = Labyrinthitis

hearing loss -> No

• Dix Hall pike positive = BPPV
• Dix Hall Pike negative = Vestibular neuronitis

Question 8

Vertigo:

How often is the Epley manoeuvre effective?

Answer 8

77% on the first attempt and 100% on subsequent attempts

IF Posterior Canal BPPV (the most common form)

Question 9

Vertigo:

Post Epley manoeuvre instructions?

Answer 9

• rest for 7 days; no straining
• no shaking headache or neck extension
• do not sleep on affected side

Question 10

Vertigo:

Meniere’s treatment?

Answer 10

1) Diuretics - HCT, HCT/amiloride, HCT/triamterene
2) Surgery
- intratympanic injections
- positive pressure therapy

Question 11

Vertigo:

Vestibular Neuronitis mangement/treatment?

Answer 11

1) CT or MRI if strong risk factors for CVA
2) betahistine for acute vertigo (not long term)
3) vestibular rehabilitation with physiotherapist
4) 5 days of prednisolone 50mg (not large evidence base but anecdotal evidence)