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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.

Cases

Cases

34 yo F

  • 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.

78 yo M

  • 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

Causes

Central

Causes

Peripheral

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.

Needs HINTS exam

HINTS exam

HINTS

Peripheral Vertigo

Differential:

  • Benign Paroxysmal Positional Vertigo (BPPV)
  • Labyrinthitis / Vestibular Neuronitis
  • Meniere's Disease

Benign

  • Not malignant

Paroxysmal

  • Out of nowhere

Positional

  • Triggered by head movement

Vertigo

  • Room spinning

BPPV

Pathology

  • 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

Epley

Epley Manoeuvre

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.

BMJ Practice Pointer

  • 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

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