Week 1 - Vertigo Flashcards
What could “dizzy” mean?
- Pre-syncopal symptoms - light-headed, pale, about to faint, relieved by lying - postural hypotension
- Unsteady
- in the legs
- in the head
- Vertigo - room spinning
- Psychogenic - associatied with and exacerbates organic dizziness. Fear of falling, ↓ confidence, anxiety, somatisation
What is Vertigo?
Vertigo = the false sense that the body or environment is moving in any direction
- Often described as “sensation of room spinning”
- Is suggestive of a problem with vestibulo-labyrinthine system
- i.e. anywhere between the ear (peripheral vertigo)
- and the central vestibular pathways (central vertigo)
Name 4 causes of peripheral vertigo
- Benign Paroxysmal Vertigo
- Meniere’s disease
- Acute vestibular neuronitis
What are the common features of an attack of Meniere’s disease?
What signs might you see?
Symptoms:
- Hearing loss
- Vertigo
- Tinnitus
- Sensation of fullness/pressure in one or both ears
Signs:
- Nystagmus during attacks
- +ive Rhomberg’s (balance issues) / can’t heel-toe
What is the disease course of Meniere’s disease?
First presents with attacks (20 mins to several hours <24) of symptoms. Attacks may occur in clusters.
After several years symptoms may resolve, but can leave the patient with permenant hearing loss and tinnitus. the social and psychological effects can be severe (e.g. cannot drive)
What must you tell anyone who is experiencing episodes of vertigo regularly?
Do not drive! May have to inform DVLA
People who have frequent, sudden attacks should be advised to keep medication readily accessible, and to consider the risks before starting potentially dangerous activities like driving, swimming, or operating machinery.
What is the name of the balance test when a pt is asked to march on the spot with their eyes closed?
Unterberger’s test
What is the cause of Benign Paroxysmal Positional Vertigo (BPPV)?
Crystals (called otoconia) displaced into the semicircular canals, disrupt the normal flow of endolymph and cause symptoms
What medications can be given buccal/IM in severe nausea and vomiting and orally in less severe?
→ To rapidly relieve severe nausea and vomiting administer buccal prochlorperazine or a deep IM injection of the same or cyclizine.
→ A short course of prochlorperazine or cyclizine can help alleviate symptoms over days.
What treats BPPV?
Epley manouvre
What are the symptoms of BPPV?
- Positional symptom of vertigo
- Triggered by movement e.g. rolling over in bed
- Lasts around a minute
- Occurs over several weeks and then resolves, but can reoccur
What test confirms BPPV?
Dix-Hallpike manoeuvre
How do you do the “head impulse test”?
- Advise the person to sit upright and to fix their gaze on the examiner.
- Then rapidly turn the head 10–20 degrees to one side and watch the person’s eyes. In a normal response (indicating a normal peripheral vestibular system), the eyes stay fixed on the examiner. If the eyes are dragged off target by the head turn, a corrective abnormal movement (saccade) occurs as the eyes move back to fix on the examiner.
- Repeat several times to the same or opposite side, randomly and unpredictably, until satisfied as to the consistent presence or absence of the corrective saccade.
What is vestibular neuronitis?
→ acute, isolated, spontaneous and prolonged vertigo that often develops following a viral infection
NB/ has been used interchangeably with labyrinthitis but they are not the same - hearing loss is a feature of labyrinthitis, but hearing is not affected in vestibular neuronitis.
What does a positive test look like on the head impulse test?
What does it imply?
A corrective saccade represents a positive test (= disrupted vestibulo-ocular reflex) and implies moderate to severe loss of function of the horizontal semi-circular canal on the side to which the test is positive.
What are the symptoms of vestibular neuronitis?
What is their time course?
Symptoms:
- recurrent vertigo attacks lasting hours or days
- vertigo may be worsened due to position changes BUT remains constant when still (unlike BPPV)
- nausea and vomiting may be present, often with other autonomic symptoms e.g. malaise, pallor, sweating
- Balance may be affected - ↑risk of falls. May veer to the affected side
Time course:
- Acute symptoms resolve in a few days
- Recovery in ~6weeks is gradual through CNS compensation
- What neurological sign is present in vestibular neuronitis?
- What 2 signs are cruicially absent to differentiate from labyrinthitis?
- horizontal nystagmus is usually present
- no hearing loss or tinnitus
What is Ramsay Hunt syndrome?
- a complication of shingles. It is the name given to describe the symptoms of a shingles infection affecting the facial nerve. Important to distinguish from Bell’s Palsy
What does the head impulse test examine?
the vestibular ocular reflex - the reflex that allows you to keep your eyes focused on an object while your head (vestibular system) moves
What safety issues should you consider with a patient with vestibular neuronitis?
-
Driving - Advise the person not to drive when they are dizzy, or if they are likely to experience an episode of vertigo while driving.
- The DVLAstates that people with ‘liability to sudden and unprovoked or unprecipitated episodes of disabling dizziness’ should stop driving and inform the DVLA.
- Workplace — the person should inform their employer if their vertigo poses a risk in the workplace (for example people using ladders, operating heavy machinery, or driving).
- Falls in the home — discuss the risk of falling in the home during an episode of vertigo and suggest measures to reduce this.
What is the difference between labyrinthitis and vestibular neuronitis?
vestibular neuritis is used to define cases in which only the vestibular nerve is involved, hence there is no hearing impairment;
Labyrinthitis is used when both the vestibular nerve and the labyrinth are involved, usually resulting in both vertigo and hearing impairment.
What is the most common cause of central vertigo?
Vestibular migraine
Name 4 causes of central vertigo
- Vestibular migraine
- Posterior circulation stroke
- Cerebellar or brainstem tumour
- MS
How would you differentiate a central cause of vertigo from a peripheral one in the history?
central causes will lead to sustained, non-positional vertigo, because they are not related to disruption in the semi-circular canal but in the brain’s interpretation of the signals.
- Prolonged, severe vertigo (although this can also indicate vestibular neuronitis or Meniere’s disease).
- New-onset headache or recent trauma.
- Cardiovascular risk factors.
- Stroke symptoms
What are some features of a vestibular migraine?
- Patient may have had these symptoms before
- Will last minutes to hours.
- ataxia,
- visual disorders,
- occipital pressure / pain
- nausea and vomiting.
It can be difficult to distinguish from early Meniere’s disease.
What condition is this: Elderly patient; dizziness on extension of neck due to both compression and stenosis of the vertebral and basilar arteries?
Vertebrobasilar insufficiency
What are 4 features of acoustic neuroma?
Acoustic neuroma
- Hearing loss
- Tinnitus
- Absent corneal reflex
- Associated with neurofibromatosis type 2
How is benign paroxysmal position vertigo diagnosed and what does the diagnosis involve?
Dix-Hallpike manoeuvre
https://www.youtube.com/watch?time_continue=135&v=8RYB2QlO1N4
- Sit upright, straight legged on a couch, with arms folded across chest
- Put your hands on either side of their head and turn it 45 degrees towards you, ask them to stare at your nose
- Lower patient smoothly backwards so their head is extended roughly 20 degrees over the back of the couch
- If patient has BPPV –> nystagmus within 20-30 secs (can take up to 1 min)
- Do on both sides (with head turned left/right), do asymptomatic side first
- Patient must keep eyes OPEN!!
How is Benign paroxysmal positional vertigo treated?
Epley manoeuvre
https://www.youtube.com/watch?time_continue=32&v=jBzID5nVQjk
- Perform the Dix-Hallpike manoeuvre
- Then once nystagmus has resovled, turn pts head 90 degrees so that it is now tilted by 45 degrees facing the opposite side
- Ask patient to roll onto the side they are now tilted towards, as they do this rotate their head so that it continues to be rotated 45 degrees to that side
- Take control + weight of patient’s head, then ask patient to sit up with legs over side of couch and finish with their head facing downwards in the midline
