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Vertigo

Vertigo. Dr. Thamara Gunasekera GPST3. Definition - sensation of movement , either of the patient in relation to the their environment or environment in relation to the patient Symptom rather than a disease. Usually caused by the dysfunction of the middle ear.

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Vertigo

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  1. Vertigo • Dr. Thamara Gunasekera • GPST3

  2. Definition - sensation of movement , either of the patient in relation to the their environment or environment in relation to the patient • Symptom rather than a disease. • Usually caused by the dysfunction of the middle ear. • Means different things to different people. • Often has a rotational or spinning component. • Vertigo is not a general imbalance or a light headedness or faint like disorientation

  3. What is ? • Dizziness – difficult to define, may result form conditions of the inner ear or non ear conditions. Key - a good history to differentiate whether its vertigo or not • Disequilibrium - the sense of feeling off balance without any actual sensation of movement • Presyncope - the feeling of light headedness, often without any sensation of movement and often accompanied by a sense of impending loss of consciousness

  4. Anatomy and physiology • Inner ear is about 2cm long and has 2 main parts • The cochlea and the vestibular system • The vestibular system comprised of - 3 semicircular canals -3 diff planes - otolith organs • The cochlea is concerned with hearing while the vestibular system deals with balance

  5. History • Onset of the symptoms • Describe the symptoms - Tell me what it feels like ? - Avoid leading Q. • Patient might make a gesture using the hand or the finger often a rotational movement ( This usually suggest U/L disease.) • Time course : Is it worsening resolving or fluctuating ?

  6. Diagram of the inner ear

  7. Persistence : Is it constant or episodic ? • Quantify the episodes : length, frequency • Associated symptoms - Nausea - Anxiety - Neurological symptoms • Are the episodes spontaneous or provoked ( eg: Head movement)

  8. H/O ear symptoms: earache, discharge, tinnitus, hearing loss • Neurological symptoms • Ophthalmological symptoms • Family history • Other RF for inner ear disease - Head injury - whiplash injury - Ototoxic medication

  9. Examination - How sure am I that this is only a peripheral vestibular disorder? - Should I seek ENT / Neuro/ Medical advise? - Is this BPPV ? Is Epley’s manoeuvre indicated?

  10. Examination • Balance • Gait- pt with vestibular pathology may veer towards the side of the lesion and use a wide based gait • Otoscopy and tuning folk test for hearing • Eyes- eye movements, nystagmus • CNS examination- cerebellar signs, CN,

  11. Peripheral causes of Vertigo • Vestibular neuronitis • BPPV • Meniere's Disease • Recurrent vestibulopathy

  12. Vestibular neuronitis and labrynthitis • Cause unknown • Could be due to viral infection, therefore could have preceding URTI. • Typically pt present with features of vertigo which lasts for days to weeks . • Nystagmus is usually present • Acute labrynthitis is form of vestibular neuronitis, which involves a single attack of vertigo, with hearing loss and often tinnitus. • Hearing loss and tinnitus is often helpful to lateralise the lesion. • Note- sudden onset hearing loss is an emergency.

  13. . • Rx - Vestibular sedatives - prochloroperazine , - should not be prescribed more than a week as prolonged vestibular sedation interrupts the process of recalibration process and hinder the recovery.

  14. BPPV • Self limiting , resolves spontaneously. • Episodes of vertigo with nausea and general imbalance, lasting up to a minute. • Usually precipitated by certain head movements • Often lasting no longer than few months • Dix- Hallpike positional testing is diagnostic and is treated with performing Epley’s manoeuvre.

  15. Meniere's Disease • Triad of vertigo, hearing loss and tinnitus • Often describes an association of the feeling fullness in ear canal • Episodes lasts for 30minutes to several hours. • Difference with vestibular neuronitis - vestibular neuronitis : single attack - Meniere's : multiple attacks

  16. Meniere's Disease • Mx - all new cases need to be referred to ENT - regulating salt and fluid intake, caffeine and smoking reduction has shown some benefit. - Vestibular sedatives - prochloroperazine for acute phase - Betahistine - for maintenance -

  17. Recurrent vestibulopathy • Recurrent vertigo , • episodes which last from 5 minutes to 24 hours, • occur in the absence of auditory or neurological symptom or signs. • The spells occur without a prodrome and with not provoked particular movement.

  18. Central vestibular Disorders • CVA, brain tumours, MS • Do not exhibit vertigo as their only presenting symptom • Often present with associated neurological deficits • CN examination, fundoscopy , neuro examination mandatory

  19. Vestibular migraine • Migraine associated with dizziness • Often incorrectly diagnosed as Meniere's • Presents with the classic symptoms of Meniere's • only difference is presence of other classic signs of migraine ( aura, photophobia and headache)

  20. Key points • Good history • 3 common peripheral vestibular disorders , distinguished from history by identifying the duration of the symptoms and associated symptoms • R/O important central causes for vertigo

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