Vertigo & BPPV Flashcards
Define vertigo
Sensation that there is movement between the patient and their environment.
May feel they are moving or that the room is moving.
Often this is a horizontal spinning sensation.
What are the 3 sensory inputs responsible for maintaining balance & posture?
1) vision
2) proprioception
3) signals from vestibular system
Vertigo is caused by a mismatch between these sensory inputs.
What is the vestibular apparatus?
Located in the inner ear.
Consists of 3 loops (semicircular canals) that are filled with endolymph.
These semicircular canals are oriented in different directions to detect various movements of the head.
Describe how the vestibular system lets the brain know that the head is moving in a particular direction.
1) Head turns and endolymph fluid shifts within semicircular canals
2) Fluid shift is detected by tiny hairs (stereocilia) found in the ampulla (a section of the canal)
3) Sensory input of shifting fluid is transmitted to the brain by the vestibular nerve
4) The vestibular nerve carries signals from the vestibular apparatus to the vestibular nucleus in the brainstem and the cerebellum
Vertigo can be caused by peripheral or central problems.
What are problems with the peripheral system usually affecting?
Central?
Peripheral problem - usually affecting the vestibular system
Central problem - usually involving the brainstem or the cerebellum
Give 5 major causes of peripheral vertigo
1) Viral labyrinthritis
2) Vestibular neuronitis
3) BPPV
4) Meniere’s disease
5) Acoustic neuroma
What is BPPV characterised by?
Sudden onset dizziness and vertigo triggered by changes in head position .
Average age of onset of BPPV?
> 55 y/o
Prognosis of BPPV?
BPPV has a good prognosis and usually resolves spontaneously after a few weeks to months.
Features of BPPV?
1) vertigo triggered by change in head position (e.g. rolling over in bed or gazing upwards)
2) may have nausea
3) episodes last 10-20 seconds
How long do BPPV attacks last?
10-20 seconds
Does BPPV cause hearing loss or tinnitus?
No
Cause of BPPV?
Crystals of calcium carbonate (otoconia) become displaced into the semicircular canals.
The crystals disrupt the normal flow of endolymph through the canals, confusing the vestibular system.
Head movement creates the flow of endolymph in the canals, triggering episodes of vertigo.
What manoeuvre can be used to diagnose BPPV?
The Dix-Hallpike manoeuvre
(Dix for dx - diagnosis)
Describe the Dix-Hallpike manoeuvre
Involves moving the patient’s head in a way that moves endolymph through the semicircular canals and triggers vertigo in patients with BPPV.
What should you check before performing the Dix-Hallpike?
Ensuring they have no neck pain or pathology.
How to perform the Dix-Hallpike?
1) The patient sits upright on a flat examination couch with their head turned 45 degrees to one side (turned to the right to test the right ear and left to test the left ear)
2) Support the patient’s head to stay in the 45 degree position while rapidly lowering the patient backwards until their head is hanging off the end of the couch, extended 20-30 degrees
3) Hold the patient’s head still, turned 45 degrees to one side and extended 20-30 degrees below the level of the couch
4) Watch the eyes closely for 30-60 seconds, looking for nystagmus
5) Repeat the test with the head turned 45 degrees in the other direction
What is a positive result of Dix-Hallpike?
In patients with BPPV, the Dix-Hallpike manoeuvre will trigger rotational nystagmus and symptoms of vertigo.
The eye will have rotational beats of nystagmus TOWARDS the affected ear (clockwise with left ear and anti-clockwise for right ear BPPV).
Most common semicircular canal to be affected by crystals in BPPV?
Posterior semicircular canal
What manoeuvre is used to treat BPPV?
Epley manoeuvre
The idea is to move the crystals in the semicircular canal into a position that does not disrupt endolymph flow.
Describe the Epley manouevre
1) Follow the steps of the Dix-Hallpike manoeuvre, having the patient go from an upright position with their head rotated 45 degrees (to the affected side) down to a lying position with their head extended off the end of the bed, still rotated 45 degrees
2) Rotate the patient’s head 90 degrees past the central position
3) Have the patient roll onto their side so their head rotates a further 90 degrees in the same direction
4) Have the patient sit up sideways with the legs off the side of the couch
5) Position the head in the central position with the neck flexed 45 degrees, with the chin towards the chest
6) At each stage, support the patient’s head in place for 30 seconds and wait for any nystagmus or dizziness to settle
What exercises can be performed by patients at home to improve symptoms of BPPV?
Brandt-Daroff exercises
What do Brandt-Daroff exercises involve?
Sitting on the end of a bed and lying sideways, from one side to the other, while rotating the head slightly to face the ceiling.
The exercises are repeated several times a day until symptoms improve.
What cause of vertigo is associated with hearing loss, tinnitus and sensation of fullness or pressure in one or both ears?
Meniere’s disease
What cause of vertigo has:
- Recent viral infection
- Recurrent vertigo attacks lasting hours or days
- No hearing loss
Vestibulra neuronitis
What cause of vertigo has:
- Recent viral infection
- Sudden onset
- Nausea and vomiting
- Hearing may be affected
Viral labyrinthitis
Cause of Meniere’s disease?
An excessive buildup of endolymph in the semicircular canals, causing a higher pressure than normal, disrupting the sensory signals.
It causes attacks of hearing loss, tinnitus, vertigo and a sensation of fullness in the ear.
How long do attacks last in Meniere’s?
Can last several hours
Is attacks of vertigo in meniere’s triggered by movement?
No
Is hearing affected in Meniere’s?
Yes - over time the patient’s hearing will gradually deteriorate.
What is acute vestibular neuronitis?
Inflammation of the vestibular nerve e.g. due to viral infection
Typically, the history is of acute onset of vertigo that improves within a few weeks.
What is labyrinthitis?
inflammation of the structures of the inner ear e.g. due to viral infection
How can labyrinthitis be differentiated from vestibular neuronitis?
Labyrinthitis can cause hearing loss, vestibular neuronitis does not.
Give 4 central causes of vertigo
1) Posterior circulation infarction (stroke)
2) Tumour
3) Multiple sclerosis
4) Vestibular migraine
All the central causes of vertigo will cause sustained, non-positional vertigo.
Featuers of a posterior circulation infarction?
1) sudden onset
2) may be associated with other symptoms, such as ataxia, diplopia, cranial nerve defects or limb symptoms.
What can a vestibular migraine be triggered by?
- Stress
- Bright lights
- Strong smells
- Certain foods (e.g. chocolate, cheese and caffeine)
- Dehydration
- Menstruation
- Abnormal sleep patterns
Key features that may point to a specific cause of vertigo:
1) Recent viral illness (labyrinthitis or vestibular neuronitis)
2) Headache (vestibular migraine, cerebrovascular accident or brain tumour)
3) Typical triggers (vestibular migraine)
4) Ear symptoms, such as pain or discharge (infection)
5) Acute onset neurological symptoms (stroke)
What exam can be used to distinguish between central and peripheral vertigo?
HINTS examination:
HI – Head Impulse
N – Nystagmus
TS – Test of Skew
What mx may be used to help reduce the attacks in patients diagnosed with Ménière’s disease?
Betahistine
What is viral labyrinthitis?
An inflammatory condition of the inner ear, specifically affecting the labyrinth, which comprises the vestibular system and the cochlea.
What does the labyrinth consist of?
Vestibular system & cochlea
What does viral labyrinthitis typically follow?
Viral infection
Spreads from the respiratory tract or middle ear to the inner ear.
Featuers of labyrinthitis?
Sudden onset:
1) vertigo
2) hearing loss
3) tinnitus
Describe direction of nystagmus in labyrinthitis
Spontaneous unidirectional horizontal nystagmus towards the UNAFFECTED side
Describe direction of nystagmus in BPPV
Rotational beats of nystagmus towards the AFFECTED ear (clockwise with left ear and anti-clockwise for right ear BPPV).
Hearing loss in labyrinthitis?
Sensorineural
What is vestibular neuronitis?
An inflammatory condition that affects the vestibular nerve
What is vestibular neuronitis thought to be primarily caused by?
Viral infection
What are the most commonly implicated viruses in vestibular neuronitis?
Herpes viruses e.g. HSV, VZV
Clinical features of vestibular neuronitis?
1) Vertigo
2) Imblance
3) Nystagmus
NO hearing loss and tinnitus (unlike viral labyrinthitis - as cochlea not affected.
Describe nystagmus in vestibular neuronitis
A spontaneous, unidirectional, horizontal nystagmus.
Mx of vestibular neuronitis?
1) Buccal or IM prochlorperazine –> rapid relief for severe cases
2) Short oral course of prochlorperazine, or an antihistamine (cinnarizine, cyclizine, or promethazine)
3) Vestibular rehabilitation exercises
