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Evaluation of Vertigo
Jeff Robichaud BSc MD FRCSC Diplomate American Board of Otolaryngology Head & Neck
SurgeryAssistant Clinical Professor Dept of Surgery
McMaster University
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Vertigo
The hallucination of movementTypically described as a spinning and circling sensationThis generally reflects an abnormality of peripheral and or central vestibular pathways.
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Dizziness
An altered sense of well being
Light headedness, giddiness, floating, weakness, difficulty concentrating
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Physiology
Vestibular information provided thorugh linear ( Otolithic) and angular (semicircular) acceleration receptors of the inner ear.Impulses from the inner ear synapse with central vestibular nuclei of the brainstem and form specific second-order vestibulospinal tract (VST) and Vestibulocerebellar (VCT) tracts and the VOR Vestibulo-ocular-reflex.
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VOR
The vestibular system, allows crisp clear vision by compensating for head movements almost immediately.To achieve this , signals from the semicircular canals are sent in a fairly direct route to the extra ocular muscles via a three neuron arc.Via these direct connections, eye movements will lag head movements by less than 10ms in a healthy individual.
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Vestibulo-ocular reflex (VOR)
Three Neuron Arc. During a head movement to the right, 8th cranial nerve from the vestibular nerve system to the vestibular nuclei Vn in the brainstem to the V1 abducens nucleus. The mlf projects then to the III oculomotor nucleus. The left lateral rectus lr, and right medial rectus mr, contract turning the eyes to the left.
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Classification of Dizziness
Psychogenic Nonvestibular organicVestibular causes
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History
90% of vertigo diagnosed by history alone.Physical examDiagnostic testingImaging
Useful adjuncts at times to the history
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History
Attacks of true vertigo from the peripheral vestibular system tend to be described crisply with a clear
onset,DurationAssociated symptomsAggravating, alleviating factors
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History
Associated symptoms suggestive of inner ear disease
Hearing lossTinnitusAural pressure or fullness
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History
Central nervous system disorders causing vertigo: look for associated focal deficit
DysphagiaDiplopiaParesies, paresthesiaIncontinenceLoss of Consciousness (rule out cardiac arrythmia) effects of medications
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History
Psychogenic dizzinessLong meandering historyDifficult to decipherAssociated depression or anxiety
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Physical Exam
OtoscopyCranial nerve assessmentOculomotor testingCerebellar testsSpecial tests: look for Tullio phenomenon, or Hennebert signPresence of nystagmus
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Testing
Complete Audiogram ENG: ElectronystagmographyABRImaging: MRI, CTECOG
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Five common causes of peripheral vestibular dysfunction
Menieres diseaseBenign positional vertigoVestibular neuronitisRecurrent vestibulopathyAcoustic neuroma
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Meniere’s Disease
Vertigo lasts minutes to hoursAssociated tinnitus and/or aural fullness at the time, or preceding the vertigoFluctuating low frequency sensorineural hearing loss
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Menieres Disease
Treatment: DietMedication Serc, HCTZ, Supportive, medical ablation of vestibular labrynth. Surgical: Singular Neurectomy, labrinthectomyremember; 50% of patients will develop bilateral disease80% of pateints will get better with medical therapy.
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Recurrent Vestibulopathy
Vertigo lasts minutes to hours.No associated otologic symptomsNo hearing loss
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Benign positional vertigo
Vertigo lasting several secondsNo associated otologic symptomsPositional Paroxysmal.FatigueableTreatment: repositioning maneuver, Brandt exercises, posterior semiciurcular canal occlusion.
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BPPV Diagnosis
Hallpike ManeuverLay the patient with head 45 degrees from the earth vertical plane, and 30 degrees to the affected side.There will be a geotropic nystagmus seen lasting for 5-30 seconds
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BPPV Treatment
Particle Repositioning maneuver
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BPPV Treatment
Brandt Exercises.Do up to three times per day, each taking up to five minutes.For recurrent disease. Patients who can’t tolerate the repositioning maneuverUp to ten percent will recur in a year.
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BPPV Treatment
Posterior Canal Occlusion
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Vestibular Neuronitis
Vertigo is intermittent lasting for days , and rarely weeksImbalance can take up to 6 months to resolve. Will occasionally be permanent.Generally no associated otologic symptoms.Treatment: supportive.
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Acoustic Neuroma
Patient complains of imbalanceNo rotational illusionAssociated hearing loss, and tinnitus, are progressivetreatment: observation, surgical excision, Gamma Knife.
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Traumatic Vertigo
Diffuse Axonal injuryPerilymphatic fistulaConcussive labrinthitisCervical VertigoSecondary benign positional vertigo is common.Psychogenic dizzinessTemporal bone fracture
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Traumatic Vertigo
Diffuse Axonal injuryPerilymphatic fistulaConcussive labrinthitisCervical VertigoSecondary benign positional vertigo is common.Psychogenic dizzinessTemporal bone fracture
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Psychogenic vs Organic vestibular Dizziness
Feature Organic Vestibular Anxiety
Duration Seconds, minutes or hours Variable , from a flash to days or months
Frequency Except for BPPV, rarely more than once a day
Constant or several times per day
Head movement Intensifies symptoms Symptoms usually not affected to any degree
Ataxia during spell Usually prominent Insignificant
Effect of hyperventilation Not like the attack Often reproduces symptoms of the attack.
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When to Refer?
The problem seems to be peripheral in nature, and requires further testing, or treatmentTo confirm a diagnosis.Patient requestAsymmetric hearing lossPersistent unilateral tinnitus