Vertigo

Vertigo is the illusion of movement, which includes sensation of rotation of self (internal spinning) or environment as well as sensation of being pulled downwards/sideways or the room tilting. It can be classified into:

• Peripheral – Problem with vestibular system

• Central – Problem with brainstem/cerebellum

Dizziness is the generic term that may refer to light-headedness, faintness, giddiness, floating sensation, unsteadiness, imbalances.

The vestibular system are the motion sensors of the head for rotation, linear acceleration, and gravity. It functions to stabilise gaze, maintain head and body posture, get subjective sense of movement, and get orientation in space.

Peripheral vestibular dysfunction can mimic a Stroke.

N.B. These pts are 12x more likely to fall, therefore is the most common cause of accidental death in 75+

Central causes

• Stroke (Posterior circulation infarction)

• Tumour

• MS

• Vestibular Migraine

Peripheral causes

• Benign Paroxysmal Positional Vertigo (BPPV)

• Vestibular Neuronitis (VN)

• Labyrinthitis

• Meniere’s Disease

Benign Paroxysmal Positional Vertigo (BPPV)

Most commonly affects the Posterior SCC (semi-circular canal) as debris forms inside. 50% occur spontaneously, but can occur secondary to Head injury, Whiplash injury, or Post-VN.

It presents with brief (20-30 secs) episodes of vertigo induced by moving head position. The patient will not have HL or Tinnitus.

Diagnosis - Dix-Hallpike manoeuvre - Positive result leads to the reproduction of the vertigo, and the observation of a rotational nystagmus

Management - Epley manoeuvre (or Semont)

N.B. Brandt Daroff exercises are commonly used by GP’s to enable patients to treat BPPV at home.

Vestibular Neuronitis (VN)

This is inflammation of the Vestibular nerve, and is usually associated with a preceding viral URTI.

It presents with a sudden onset of Vertigo, which is worse at the beginning and gradually improves with time. The patient will not have HL or Tinnitus as the cochlear nerve isn't affected, which allows it to be differentiated from Labrynthitis.

N.B. These patients don’t have any focal neurological symptoms (e.g. diplopia or dysarthria).

Patient may develop BPPV after.

Management - Symptomatic relief of N+V with Prochlorperazine or an Antihistamine

Labyrinthitis

Presents with Acute Vertigo, associated with HL, Tinnitus, and Ear fullness, and is usually associated with a viral URTI.

N.B. These patients don’t have any focal neurological symptoms (e.g. diplopia or dysarthria).

Diagnosis is mainly clinical, but it's important to rule out the central causes of acute vertigo e.g. stroke, with a Head Impulse Test. A positive result (corrective saccade seen) here indicates a peripheral cause i.e. labyrinthitis or vestibular neuronitis.

Management:

• Acute - Prochlorperazine, Antihistamine for N+V symptoms

• Prophylactic – Betahistine

Meniere’s Disease

Due to endolymphatic hydrops (build-up in inner ear), leading to recurrent attacks of vertigo lasting 12-24 hours with unilateral hearing loss, tinnitus, and ear fullness.

The disease progresses in stages:

• Early stages – Vestibular/cochlear symptoms may occur in isolation. Hearing loss (low frequency) and tinnitus recede fully

• After 1-2 yrs – Complete set of symptoms

• Late stages – Progressive deterioration of hearing

Managament:

• Acute - Prochlorperazine, Antihistamine for N+V symptoms

• Prophylactic – Betahistine

Investigations

History should include:

• Room spinning or Light-headedness?

• Sudden or Gradual?

• Intermittent or Persistent?

• Positional or not?

• HL or Tinnitus?

  • NO, think BPPV or VN

  • YES, think Labyrinthitis or Meniere’s

Red flags:

• Neurological symptoms

• Headache

Examination

• Otoscopy

• Neurological

• Cerebellar

• Cardiovascular

The special test that should be done is HINTS Plus (Head Impulse Nystagmus Test of Skew plus Hearing), which helps to distinguish between Central and Peripheral vertigo:

• Head Impulse - The normal (-ve) response is for the eyes to remain focused on the examiners nose. The abnormal (+ve) response is for there to be a Corrective saccade once the head is turned, which indicates a peripheral cause.

• Nystagmus

  • Unilateral horizontal nystagmus → Peripheral cause

  • Bilateral/vertical nystagmus → Central cause

• Test of Skew - Examiner covers one eye of the patient and then takes it away while looking for a vertical corrective movement as an indication of vertical misalignment → Central cause