Approach to vertigo

Amina Tighilt
Asma Mohammad
Lubna Ahmad
Mariam Waleed
Introduction
Vertigo is a symptom, not a diagnosis.

It arises because of asymmetry in the
vestibular system due to damage to or
dysfunction of the labyrinth, vestibular
nerve, or central vestibular structures in
the brainstem.

In most cases history and examination
distinguish between central and
peripheral etiologies identifying those
patients that require urgent diagnostic
evaluation.
History taking
A. Chief complain:
Vertigo
Description:
Patient can interpret it as self motion or motion of the environment.
It can be spinning , swaying , or tilting.
Not all patients are able to describe their vertigo in such concrete terms.
Vague dizziness, imbalance, or disorientation may eventually prove to be due to
a vestibular problem.
Time duration
(seconds minutes hours days )
Central adapts within days to weeks , constant dizziness up to months is not
vestibular.

Attacks are they single or recurrent
Aggravating and provoking factors
All causes are worse with head movements , if not then its a different type of
dizziness.
BPPV is provoked with certain movements and posture .(ex , rolling over bed,
neck extension).
Vertigo aggravated with coughing , sneezing , exertion , loud noises should rise
a suspicion of perilyphmatic fistula.
Associated symptoms
Nausea and vomiting : typical with acute attacks unless its mild and brief like in
BPPV.
Postural instability: vertigo of central origin impairs gait and posture to a
greater degree than does vertigo of peripheral origin.
Auditory symptoms : hearing loss , tinnitus.
Ask about recent viral symptoms
ROS
Diplopia , dysarthria , dysphasia, numbness stroke
Neurological symptoms MS
Headaches , photopia migrainoiues vertigo



B. Past Medical and Surgical History:
Migraine
Stroke risk factors
DM , HTN , Hx of vascular disease
History of trauma
Previous ear surgery

C. Drug history :
Cisplatin , aminoglycosides vestibular toxicity
Phenytoin cerebellar toxicity

D. Family history
A family history of vertigo may suggest a rare hereditary channelopathy.
E. Social History

Physical examination
Differentiate between central and peripheral vertigo:

Nystagmus:
o Freznel lenses
o Dix Hallpike
o Head thrust
o Head shaking
o Caloric testing
Gait instability
Rinne and Webber tests
Other neurologic signs

Diagnostic testing
The need for diagnostic testing in vertigo is a clinical
decision made based on certain patient characteristics.
Examples of indications for neuroimaging:

Findings in history and examination suggestive of a central cause
(new onset headache, focal neurological signs and symptoms,
vertical nystagmus)
Unilateral vertigo of gradual progression to rule out a vestibular
shwanomma
Multiple risk factors of stroke or co-morbidities
Lack of response to conservative treatment





Tests to rule out central causes:
MRI or MRA
CT scan
Tests to assess vestibular function and ocular motility:
Electronystagmography
video nystagmography

Vestibular evoked myogenic potentials (VEMPs) are a new means of assessing otolith
function
Audiometry
Pure tone audiometry
Speech audiometry( SRT and speech discrimination test)
Impedance audiometry( tympanogram)

Brainstem auditory evoked potentials (BAEPs) have a 90 to 95 percent sensitivity for
detecting acoustic neuromas.


Vertigo
Peripheral Causes Central causes
Benign paroxysmal positional vertigo Migrainous vertigo
Vestibular neuritis Brainstem ischemia
Meniere disease Cerebellar infarction and hemorrhage
Labyrinthine concussion Chiari malformation
Acoustic neuroma Multiple sclerosis
Aminoglycoside toxicity Toxic (Alcohol, hypnotics)
Otitis media
Tumors (CPA, Posterior fossa, Glomus
tumor)
Perilymphatic fistula Inflammation (meningitis, abscess)
Peripheral vs. Central Vertigo
Symptoms Peripheral Central
Imbalance Mild to moderate Severe
Nausea and Vomiting Severe Variable
Auditory Symptoms Common Rare
Neurological symptoms Rare Common
Compensation Rapid Slow
Nystagmus Horizontal or Rotatory Vertical or Horizontal
Differential Diagnosis of Vertigo
based on HX
Condition Duration Hearing loss Tinnitus Aural
Fullness
others
BPPV Seconds to minutes - - - -
Menieres Dx Minutes to hours Uni\bilateral
fluctating
+ Pressure
\
warmth
Vestibular
neuroritis
Hours to days Unilateral - -
Labyrinthitis Days Unilateral whisteling
Benign Paroxysmal Positional
Vertigo (BPPV)
Definition: acute attacks of transient vertigo lasting seconds to
minutes initiated by certain head positions.
Etiology: due to canalithiasis or cupulolithiasis
Hx, Examination, Dix-Hallpike Positional Testing
Management:
Reassure patient that process resolves spontaneously
Particle repositioning maneuvers
Epley maneuver
Brandt-daroff exercises (performed by patient)
Anti-emetics for nausea/vomiting
Drugs to suppress the vestibular system delay eventual recovery
and are therefore not used
Meniere's Disease
Definition: episodic attacks of tinnitus, hearing loss, aural fullness, and vertigo lasting
minutes to hours
Proposed Etiology: inadequate absorption of endolymph leads to endolymphatic hydrops
(over accumulation) that distorts the membranous labyrinth
Treatment
Acute management may consist of bed rest, antiemetics, antivertiginous drugs [e.G.
Betahistine and low molecular weight dextrans (not commonly used)
Long term management may include:
Medical:
Low salt diet, diuretics (e.G. Hydrochlorothiazide, triamterene, amiloride)
Sere'" prophylactically to decrease intensity of attacks
Local application of gentamicin to destroy vestibular end-organ, results in complete
SNHL
Surgical:
Selective vestibular neurectomy or transtympanic labyrinthectomy
Vestibular implants have recently been introduced, experimentally
Must monitor opposite ear as bilaterality occurs in 35% of cases
Vestibular Neuronitis
Acute onset of disabling vertigo often accompanied by
nausea, vomiting and imbalance withouthearing loss that
resolves over days leaving a residual imbalance that lasts days
to weeks.
Treatment:
Treatment
, and Acute phase:
Bed rest, vestibular sedatives (gravole), diazepam
Convalescent phase:
Progressive ambulation especially in the elderly
Vestibular exercises: involve eye and head movements, sitting,
standing and walking

Labyrinthitis

Acute infection of the inner ear resulting in vertigo and hearing loss
Causes
May be serous (viral) or purulent (bacterial)
Occurs as a complication of acute and chronic otitis media, bacterial meningitis,
cholesteatoma,
And temporal bone fractures
Bacterial: S. Pneumoniae, H, influenzae, M. Catarrhalis, P. Aeruginosa, P. Mirabilis
Viral: rubella, CMV, measles, mumps, varicella zoster
Clinical features
Sudden onset of vertigo, nausea, vomiting, tinnitus, and unilateral hearing loss,
with no
Associated fever or pain
Meningitis is a serious complication
Investigations
Cthead
If meningitis is suspected: lumbar puncture, blood cultures
Treatment
Treat with IV antibiotics, drainage of middle ear mastoidectomy
Reference:
Furman, JM. . Approach to the patient with vertigo. In:
UpToDate, Aminoff, MJ (Ed), UpToDate, Waltham, MA, 2013.
Retrieved from:
http://www.uptodate.com/contents/approach-to-the-patient-
with-vertigo