Vertigo Flashcards
What is vertigo?
The abnormal sensation of movement
What are the central causes of vertigo?
- Vestibular neuronitis
- Tumours eg acoustic neuroma
- Multiple sclerosis
- Head inury
- Vascular occlusion
- Drug induced
What are the peripheral causes of vertigo?
- Benign paroxysmal positional vertigo (BPPV)
- Ménière’s disease
- Labyrinthitis
- Middle ear diseases
- Post ear surgery
- Post trauma
- Vascular insufficiency
When taking a history, how can you dissociate true vertigo from dizziness?
Give non-vertigo causes of dizziness
Vertigo is often described as the room spinning. There must be a real sense of movement. In contrast, dizziness is often described as feeling light headed or having a funny turn.
- Cardiac insufficiency
- Cervial spine disease
- Migraine
- Epilepsy
- Neurological disorders
- Metabolic disorders eg diabetes
- Anaemia
How might the length of time that vertigo last for help you narrow down your differential diagnoses?
- If it lasts for seconds - likely to be BPPV
- If it lasts for minutes to hours - likely to be Menieres disease
- If it lasts for days to weeks - likely to be vestibular neuritis
What special tests should you perform in someone with vertigo?
- Gait assessment
- Romberg’s test - vestibular lesions the patient will tend to fall to that side
- Unterberger’s test - Patient walks on the spot for 30 seconds with eyes closed Rotation greater than 30 degrees suggests vestibular pathology
- Dix-Hallpike test
What are the features of benign paroxysmal positional vertigo (BPPV)?
How long does BPPV last?
Episodic vertigo that occurs when the head is moved in certain positions. Classically, it is brought on by turning in bed or looking up at an object and usually only lasts for minutes, but it can remain for hours.
The episodes of BBPV may occur regularly for weeks or months before settling slowly.
What is the pathophysiology of benign paroxysmal positional vertigo (BPPV)?
Thought to be due to debris in the inner ear
What age group are more commonly affected by benign paroxysmal positional vertigo (BPPV)?
Average age of onset is 55. Very rare to affect younger patients.
What is the special test used to diagnose benign paroxysmal positional vertigo (BPPV)?
Dix-Hallpike test - aims to replicate the symptoms by a rapid change in head movement
(The patient sits on a couch facing the examiner. The patient then quickly lies flat and the examiner, supporting the patient’s head, turns the head through 30 degrees and inclines it downward. The examiner watches for 30 second to 1 minute for nystagmus and to see if symptoms are reproduced. It is repeated on the other side. Watch geeky medics demonstration.)
The nystagmus of BPPV has specific characteristics: it is rotatory towards the underlying affected ear, it has a latent period before starting, the nystagmus fatigues (slowly settles) and shows adaption (lessens with consecutive tests).
How do you treat benign paroxysmal positional vertigo (BPPV)?
- Epley maneuver (watch geeky medics video)
- Settles spontaneously
What is Meniere’s disease?
It is poorly understood but it appears to be due to recurrent increases in endolymph pressure within the vestibule with progressive dilation of the endolymphatic system. This leads to bouts of otological and vestibular hyperstimulation.
What age group are most commonly affected by Meniere’s disease?
Middle aged adults but may be seen at any age
What are the symptoms of Meniere’s disease?
Triad of:
- Vertigo (lasting hours and associated with nausea and vomitting and nystagmus)
- Sensorineural hearing loss (in early stage of disease it affects the lower frequencies and returns to normal after the attack)
- Tinnnitus and sensation of fullness in the effected ear may precede the attack
Over the course of the condition the tinnitus and hearing loss become permanent.
Are symptoms of Meniere’s disease such as tinnitus and sensorineural hearing loss typically unilateral or bilateral?
Unilateral but bilateral symptoms may develop after a number of years
What are the clinical signs of acute attack of Meniere’s disease?
- Lying in bed reluctant to move head
- Nystagmus
- Positive Romberg’s tests
How do we manage someone with Meniere’s disease?
- Treatment of acute attacks: vestibular sedatives
- Long term:
- Diuretics, betahistine (a vasodilator) and avoidance of caffeine and salt (are used to counteract the increased endolymphatic pressure)
- Patients should inform the DVLA. The current advice is to cease driving until satisfactory control of symptoms is achieved
If Ménière’s disease becomes debilitating, what treatment may be considered?
Destroying the affected labyrinth chemically with gentamicin injection, or surgically by drilling out the inner ear or cutting the VIII nerve.
This brings an end to the fluctuations in vestibular function however one must hope that the condition does not affect the other ear in the future.
What is the natural history and prognosis of Meniere’s disease?
With each attack, it is likely that hearing will deteriorate a little, with the lower frequencies being most affected. Eventually the attacks will cease as the disease “burns out”. The other ear may also become involved at any time.
What is the other name for vestibular schwannoma?
Acoustic neuroma
What is a vestibular schwannoma?
A benign, slow growing tumour which originates from the Schwann cells surrounding the vestibular division of the 8th cranial nerve. The 7th and 5th cranial nerves can also be affected adding to the symptoms it causes.
How common are vestibular schwannomas (acoustic neuromas) relative to other brain tumours?
They account for 5% of all intracranial tumours and 90% of all cerebellopontine angle tumours
What disease is associated with bilateral vestibular schwannoma?
Neurofibromatosis type 2
What is the most common presenting complaint in someone with a vestibular schwannoma?
Unilateral progressive sensorineural hearing loss accompanied by tinnitus is the most common presenting complaint.
(Although this is a vestibular nerve lesion, the ability of the vestibular system to accommodate, means that any balance problems are usually transient.)
What are the clinical features of a vestibular schwannoma (acoustic neuroma)?
8th nerve: hearing loss, tinnitus, vertigo
7th nerve: facial palsy
5th nerve: absent corneal reflex
How is a vestibular schwannoma diagnosed?
MRI scan of the internal auditory meatus and cerebellopontine angle
How do you manage someone with a diagnosed vestibular schwannoma?
If it is slow growing, it might be more appropriate to watch and wait. If not the options are surgical removal or targeted radiotherapy.
What is a sign that vertebrobasilar insufficiency/ischaemia could be the cause of vertigo?
Dizziness on extension of the neck
Sudden onset vertigo
Recent viral infection
Nausea and vomiting
Hearing may be affected
What is the diagnosis?
Viral labyrinthitis
Recurrent vertigo lasting hours or days
Recent viral infection
No hearing loss
Vestibular neuritis
Gradual onset vertigo triggered by a change in head position
Each episode lasts 10-20 seconds
Benign paroxysmal positional vertigo
Vertigo associated with hearing loss, tinnitus and sensation of fullness or pressure in one or both ears
Ménière’s disease
Elderly patient
Dizziness on extension of neck
Vertebrobasilar ischaemia
Hearing loss, vertigo, tinnitus, absent corneal reflex
Acoustic neuroma
