Vertigo
Diagnosis and treatment
Paul Redman
Fimley Park ED
Vertigo
Definition
- A sensation of rotation or movement of one's self (subjective vertigo) or of one's surroundings (objective vertigo) in any plane.
- The term is sometimes used erroneously as a synonym for dizziness or lightheadedness.
- 5 months pregnant
- Fit and healthy
- Awoken from sleep with intense dizzyness.
- When lays still, goes off
- Tries to sit up - returns ++
- Retching, no vomit
- Cant walk to bathroom - falls to left side.
- Lethargy and vomiting after diagnostic cardiac catheterization.
- Symptoms were attributed to sedation but failed to improve four hours post investigation despite treatment with opioid antagonists.
- Examination:
- SPB >180 mmHg
- Lethargy
- Dysarthria
- Bilateral upper extremity ataxia
- Bilateral inferomedial gaze deviation
Central Vertigo
Basically a stroke - cause to be defined...
Red flag symptoms:
- Isolated, persistent (>24 hours) vertigo of hyperacute (seconds) onset.
- Normal head impulse test.
- New onset headache.
- New onset unilateral deafness.
- Cranial nerve weakness or sensory loss, or limb weakness or sensory loss.
- Severe ataxia.
Peripheral Vertigo
Differential:
- Benign Paroxysmal Positional Vertigo (BPPV)
- Labyrinthitis / Vestibular Neuronitis
- Meniere's Disease
Benign
Paroxysmal
Positional
- Triggered by head movement
Vertigo
BPPV
- Transient episodes
- Brought on by head movement
- Tinnitus NOT a feature
- ENT examination to exclude other causes...
Clinical Diagnosis
Dix-Hallpike Manoeuvre
Diagnosis
Makes a 'formal' diagnosis
Look for nystagmus
May vomit - watch your shoes!
Epley Manoeuvre
Treatment
Sucessful in 80%
BPPV - 90% Posterior canal
- 8% Lateral canal
- 2% Anterior canal
- Medication not a substitute for repositioning procedures
- Adverse effects of drugs outweighs benefits
Inflammatory Vertigos
Inflammatory Vertigo
Labyrintitis
- Inflammation of the inner ear
- Related to URTI
- Increased fluid production in SCCs / increased pressure
Vestibular neuritis
- Inflammation of the nerve (CN VIII)
- Viral
Meniere's Disease
Meniere's
Triad of:
- Sensorineural hearing loss +
- Tinnitus +
- Vertigo
Rx for inflammatory conditions / meniere's
Prochlorperazine - PO, Buccal, IM
Cinnarazine - PO
Cyclizine - PO, IM
BDZ - little evidence for but may help
Other treatments
Should settle in 24 hours.
Reassess diagnosis if it hasn't by day 5.
- Vertigo is a symptom, not a diagnosis
- Most balance problems are not true rotatory vertigo.
- It is important to differentiate peripheral from central vertigo
- A central cause of vertigo should be suspected when the signs and symptoms do not match the features of any of the peripheral causes with reasonable accuracy.
Summary