Vertigo Simplified

1. Vertigo Simplified Gary Kroukamp Kingsbury Hospital Tygerberg Hospital

4. At the end of this talk… • Define vertigo • Diagnose - just by the history • Refer • Investigate • Manage

5. Definitions Dizziness/lightheadedness: A distorted sense of one’s spatial relationship Vertigo: Hallucination of rotatory motion Unsteadiness: Difficulty with gait/Tendency to fall to one side Blackouts: Loss of consciousness Giddiness – Who the hell knows?

6. Anatomy and Physiology Input Output Cortical awareness Visual adaptation Vision Central integration Musculosceletal Proprioception Autonomic nervous system Vestibular labyrinth

8. Anatomy and Physiology

10. Anatomy and Physiology

12. History 1. Describing character of symptoms 2. Onset – Sudden or Gradual 3. Frequency 4. Duration 5. Severity • Aggravating factors (activity, darkness) • Associated symptoms (N+V, Tinnitus, • Hearing loss) 8. Medical history (CVS, Psych, CNS) • Trauma 10. Medications/Alcohol

13. History

14. Examination 1. General 2. Vital signs 3. ENT -Middle ear disease, hearing(audiogram) • Neurologic -Cranial nerves, Cerebellum, • Nystagmus • Cardiovascular -postural hypotension, pulse, • carotid bruits, Cardiac murmurs 6. Manoeuvers -Hallpike

15. Special Investigations 1. FBC (Infection, leukemia) 2. VDRL, Bloodglucose, Thryroid functions 3. ECG (Arythmias, previous MI) • Electronystagmography, Videonystagmo- • graphy 5. MRI

16. Causes Otological (Peripheral) vs Non-otological (Central)

17. Otological causes • External ear (Foreign body, impacted wax) 2. Middle ear disease 3. Trauma -Temporal bone fracture) • Menière’s disease 5. BPPV 6. Labyrinthitis • Vestibular neuronitis (Viral) • Other -Syphilis, Ototoxic drugs, Acoustic • neuroma

18. Characteristics of Inner Ear Disorders • Dysequilibrium, not fainting • Definite attacks/episodes • “True vertigo” • Severe • Often with N & V • Other Inner Ear symptoms

19. Clinical Scenario 1 • Mrs JW • 59 years old • 3 week h/o dizziness • Some nausea, no vomiting • Wakes her up at night • Worse on rolling over to the left • Worse on reaching up to high shelf

20. BPPV Episodic Vertigo on position change Pathology: Otoliths in semicircular canals Diagnosis: Dix-Hallpike manoeuvre with rotational nystagmus Treatment: Repositioning manoeuvres, Epley

21. Clinical Scenario 2 • Mr SP • 43 yo • Dizzy “attacks” for 3 years • 4 to 5 per year • Last 2 to 3 hours • N&V • Has to lie down • Tinnitus and muffled hearing left ear

22. Menière’s disease Endolymphatichydrops 1. Young to middle age 2. Episodic attacks • Cardinal features -Vertigo, Tinnitus, Hearing • loss, Fullness • Management - Reassurance and Vestibularsedatives - Reduction of Caffeine, smoking, salt, 3L water - Medical -Serc, mild diuretics

24. Menière’s disease • Surgery now largely abandoned in favour of • Middle ear installation of Gentamycin • Middle ear installation of Steroids

25. Clinical scenario 3 • Mrs RvW • 36 yo • Sudden onset severe dizziness 2 days ago • N&V • Unable to stand/falls over • Normal hearing • Blurring of vision • Left beating nystagmus

26. VestibularNeuronitis • Viral labyrinthitis • Nonspecific viral illness followed 6/52 by a sudden onset of vertigo, nausea + vomiting • Initially severe- gradual resolution over 10 days • Rx: Steroids • Vestibular suppressants

27. Labyrinthitis Infection of Vestibular labyrinth, associated with URTI Rapid onset vertigo with nystagmus and hearing loss First 24 hrs worse, normally resolve after 36 hrs

28. Clinical Scenario 4 • Mr AD • 74 yo man • Gradual onset hearing loss R ear – for years • Also tinnitus R ear • Vague poor balance • 1 episode vertigo 4 years ago • Hearing worse after this

29. Acoustic/Vestibular Schwannoma • Benign, slow-growing tumor in vestibular division of eighth cranial nerve • Not episodic vertigo • MRI with gadolinium is reliable +cost-effective • Rx: “Radiosurgery”Gamma knife/ Surgery

30. Characteristics of Central Causes • Continuous • Dysequilibrium more vague, not “True Vertigo” • Less severe imbalance, can still function

31. Non-otological (Central) • Vascular -Vertebrobasilar insufficiency, TIA, • postural hypotension, Cardiac dys- • rythmias, Valvular lesions,Wallenberg • syndrome, Medullary infarction,Inter- • nal auditory artery obstruction, Verte- • brobasilar migraine, Subclavian Steel • syndrome 2. Trauma -Head injury 3. Ageing -multifactorial • Infectious -Meningitis, Ramsay Hunt • Syndrome

32. Non-otological (Central) • Demyelinating diseases eg. MS 6. Epilepsy 7. Toxic -Alcohol, Anticonvulsants 8. Psychogenic –Hyperventilation,Anxiety 9. Tumour • Metabolic -thyroid, hypo- and hyperglycaemia, • Addison’s disease • Congenital -Familial episodic ataxia, Hydro- • cephalus, Arnold-Chiari malformation)

33. Clinical Scenario 5 • Mrs TH • 28 yo • Poor balance and swaying 6 months • After a cruise Durban to Cape Town • Better with exercise • Better with alcohol

34. Mal de Debarquement Syndrome • After travel by ship • Improvement with exercise/alcohol • Psychogenic?/Anxiety • Overly focused on balance correction • Reassurance/exercise

36. Conclusion • History! • Clinical Picture • Not everyone has Meniere’s • Appropriate referral • Management according to diagnosis