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Vertigo

Chris Edwards, DO
Wednesday, 2/6/2007

four types of dizziness

Vertigo
lightheadedness,
presyncope,
dysequilibrium

accounts for 54% of all dizziness

The big question

Central
Or
Peripheral?

Central causes
Cerebellopontine angletumor
Vestibular schwannoma (acoustic neuroma) as well as
infratentorial ependymoma, brainstem glioma,
medulloblastoma or neurofibromatosis

Cerebrovascular disease (TIA or


stroke)
Arterial occlusion causing ischemia or infarct,
especially of VBS)

Central Causes
Migraine
Vertigo preceded by HA that is throbbing, unilateral, aura,
NV, photophobia, phonophobia

Multiple sclerosis
Demyelination of white matter in CNS

Peripheral Causes
Acute labyrinthitis
Inflammation of the labyrinthine organs caused by
viral orbacterial infection

Acute vestibular neuronitis (vestibular


neuritis)
Inflammation of the vestibular nerve, usually caused
by viral infection

Benign positional paroxysmal vertigo


Transient vertigocaused by stimulation of vestibular
sense organs, usually in middle age or older, women
2x that of men

Peripheral Causes
Cholesteatoma
Cyst like lesion filled with keratin debris, most often involving middle
ear and mastoid

Herpes zoster oticus (Ramsay Hunt syndrome)


Vesicular eruption affecting ear

Meniere's disease
Recurrent vertigo, hearing loss, tinnitus, or aural fullness caused by
increased volume of endolymph in semicircular canals

Otosclerosis
Hardening or thickening of tympanic membrane caused by age or
recurrent infections

Perilymphatic fistula
Breech between middle and inner ear often caused by trauma or
excessive straining

Other causes
Cervical vertigo
Triggered by somatosensory input from head and neck
movement

Drug induced vertigo


(EtOH, aminoglycosides, anticonvulsants,
antidepressants, antihypertensives, barbiturates,
cocaine, diuretics, NTG, quinine, salicylates,
sedative/hypnotics

Psychological
Mood, anxiety, somatization, personality, EtOH abuse

Start with a good history


Hx alone will dx 3 out of 4 patients
Start by asking When you feel dizzy, do
you feel lightheaded, or do you feel like the
world is spinning around you?

History
Next, is it peripheral or central
Timing and duration
What provokes or aggravates
Associated sxs
Rotatory illusions (peripheral)
Nausea, vomiting (peripheral)
Nystagmus

History
Timing and duration
The longer the sxs last, the more likely it is
central
Sudden onset more suggestive of peripheral
Early morning vertigo may be more suggestive
of peripheral

History
Provoking Factors
Positional changesusually BPPV
Turning in bed, bending at waist and then straightening, or
extending neck

Recent viral illness acute vestibular neuronitis, acute


labyrinthitis
Same provokers as those of migrainous HA
Trauma, excessive straining (perilymphatic fistula)
Psychosocial stress anxiety, hyperventilation

History
Associated sxs
Hearing loss (usually peripheral cause)
Exception is CVA involving internal auditory artery or inferior
cerebellar artery

Pain
Acute middle ear, invasive of temporal bone, or meningeal irritation

Nausea/vomiting
Usually less severe in central disease

Neuro Sxs
Weakness, dysarthria, vision or hearing changes, change in
consciousness, ataxia, motor/sensory changes

Migrainous
(21-35% of pts with migraines have vertigo)s

Medical History

Medications
Trauma
Toxins
Age related illness
Diabetes, HTN

Family Hx
Migraines, CVA risk

Physical Examination
Most importantly
Neurological
Head and Neck
Cardiovascular

Physical Examination
Head and Neck
Tympanic membranes
Vesicles suggest Ramsey Hunt Syndrome (herpes zoster
oticus)
Cholesteatoma

Henneberts sign
Vertigo caused by pushing on tragus or external auditory
meatus of affected side perilymphatic fistula

Valsalva maneuver
Forced exhalation with mouth and nose closed again ?
perilymphatic fistula or semicircular canal dehiscence

Physical Examination
Cardiovascular
Orthostatic changes
Drop of 20 mmHg or increase of 10 BPM may
suggest dehydration or autonomic dysfunction

Arrhythmias
Carotid Bruits
or other signs of atherosclerosis

Physical Examination
Neurological
Cranial nerves
Palsies, sensorineural hearing loss

Nystagmus
Vertical 80% sensitive for vestibular nuclear or
cerebellar lesions
Horizontal with or without rotatory component
suggests peripheral cause

Physical Examination
Gait and balance
If peripheral, pt will be able to walk
Central pt usually will be severely impaired in
walking

Psych
Hyperventilation for 30 s may help in ruling out
psychogenic causes, though this can exacerbate
vertigo if it is a perilymphatic fistula or acoustic
neuroma

Dix-Hallpike Maneuver
MOST HELPFUL TEST!!!
PPV of 83%, NPV of 52% in diagnosing BPPV
Intensity of induced sxs should decrease with
each maneuver if peripheral in origin
Combo of +DH and hx of vertigo or N/V
strongly suggests peripheral cause
If provokes purely vertical (downbeating) or
torsional w/o latent period, suggests central

THE QUESTION

SO, HOW DO I DO IT?

Dix Hallpike
Pt sits upright, warn pt, turn head 30-45 degrees to side
being tested,
pt keeps eyes open and focused on examiners eyes or
forehead.
Then, supporting head, pt quickly lies supine (<2 s),
allowing head to hyperextend 20-30 degrees past
horizontal
After 2-20 s latent period, onset of torsional upbeat or
horizontal nystagmus denotes positive test.
Sxs can last for 20 to 40 seconds.
Nystagmus will change direction when returning to upright

Dix Hallpike

Dix Hallpike

Nystagmus
What does it look like?

Laboratory Evaluation
Electrolytes, glucose, CBC, TSH?
NO, they will identify the etiology of vertigo in
less than 1 percent of patients with dizziness

Radiologic Studies
Consider imaging if there are
neurological sxs
CVD risk factors
Progressive unilateral hearing loss

One study quoted by AAFP found that 40%


of pts with neuro findings had relevant
abnormalities on imaging

Radiologic Studies
The preferred study is MR imaging of head
Superior visualization of posterior fossa, where
most CNS disease causing vertigo is found

MRA or angiography

Vertebrobasilar insufficiency
Thrombosis of labyrinthine artery
AICA or PICA insufficiency
Subclavian steal syndrome

Treatment
BPPV
Caused by calcium debris in semicircular canals
Canalith repositioning (Epley Maneuver)
displaces debris back to vestibule
Pts may need to remain upright for 24 hrs post
procedure to prevent recurrence
Contraindications includes: severe carotid
stenosis, unstable heart disease, severe neck
disease (cervical spondylosis or advanced RA)

Treatment of BPPV
Initial studies suggested 80% success rate
with Epley Maneuver first time, and 100%
success rate with repeated treatments
Repeat studies suggested 50-90% success
Cochrane Review concluded EM is safe Rx
that will likely improve sxs of BPPV
Recurrence rate is about 15% per year

Epley Maneuver
Pt sits on table with eyes open and head 45 degrees to right
Pts head is supported and lies back quickly as in DixHallpike
Pts head is rotated 90 degrees to left and held for 30
seconds
Pts head is rotated additional 90 degrees to left while pt
rotates his or her body 90 degrees in same direction. This
position is held for 30 seconds
Pt sits up on left side of table
This can be repeated on either side until symptomatic relief
occurs

Epley Maneuver

Epley Maneuver

Rx of Vestibular Neuronitis and


Labyrithitis
Many cases are self limited viral illnesses
Rx sxs with vestibular suppressants
Meclizine (Antivert)
Dimenhydrinate (Dramamine)

N/V
Promethazine (phenergan)
Metoclopramide (Reglan)

Menieres disease
Treatment involves lowering endolymphatic
pressure
Low salt diet and diuretics (usually dyazide
[HCTZ+triamterene] improve vertigo, but not
tinnitus and hearing loss
Surgical intervention
Endolymphatic shunt
Ablation of vestibular hair cells by intratympanic
injection of gentamycin

Migrainous Vertigo
Treatment
Dietary (avoid caffeine, chocolate, aspartamate,
EtOH)
Lifestyle (exercise, stress reduction, sleep
patterns)
Vestibular rehabilitation exercises
Medications (benzos, TCAs, BB, SSRI, Ca
Channel blockers, antiemetics)

Psychiatric Causes
Anxiety as would treat anxiety (hard to
separate which causes which sometimes)
Vestibular suppressants, benzos provide
temporary relief
SSRIs may be better
CBT

CVA
Treat by preventing future events (BP
control, cholesterol, smoking cessation,
ASA, antiplatelet therapy)
Minimize head mvement and treat with
vestibular suppressant meds for first day
When tolerated, taper meds, initiate
vestibular rehab exercises

Take Home points


Benign Paroxysmal Positional Vertigo
Easily diagnosed with hx and Dix Hallpike
Easily treated with Epley Maneuver

Vertigo
93% of primary care cases are
BPPV
Acute vestibular neuronitis
Menieres Disease

Do not need extensive lab workup


Imaging not indicated unless PE suggests central cause
of vertigo

Thats it!
Sources
AAFP, Volume 71, number 6, 3/15/2005
AAFP, Volume 73, number, 1/15/2006
www.dizzinessandbalance.com

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