Vertigo

Dr Tharaka Chandrakumar GPST2Dr Emma Humphreys GPST1

The Mill Medical Practice, Godalming

Case discussion

Case discussion

• 58 yr old lady

Case discussion

• 58 yr old lady • Awoke feeling room was spinning

Case discussion

• 58 yr old lady • Awoke feeling room was spinning • Vomited twice

Case discussion

• 58 yr old lady • Awoke feeling room was spinning • Vomited twice • Seemed anxious

Case discussion

• 58 yr old lady • Awoke feeling room was spinning • Vomited twice • Seemed anxious • Slightly unsteady on her feet

Case discussion

• 58 yr old lady • Awoke feeling room was spinning • Vomited twice • Seemed anxious • Slightly unsteady on her feet • Hyperventilating

Case discussion

• 58 yr old lady • Awoke feeling room was spinning • Vomited twice • Seemed anxious • Slightly unsteady on her feet • Hyperventilating • No fever, but had sore throat

Case discussion

• 58 yr old lady • Awoke feeling room was spinning • Vomited twice • Seemed anxious • Slightly unsteady on her feet • Hyperventilating • No fever, but had sore throat • Slight difficulty swallowing

Case discussion

On examination

• Red throat • Positionally induced nystagmus was sustained

Case discussion

On examination

• Red throat

Case discussion

On examination

• Red throat • Positionally induced nystagmus was sustained

“I felt dizzy Doctor”

“I felt dizzy Doctor”

Light-headedness• Presyncope, eg

transient hypotension• Disequilibrium of

elderly• Anxiety or

hyperventilation

“like I’d just got off a roundabout”

“like I’d just got off a roundabout”

Vertigo • illusory sense of movement or orientation• disorder of labyrinth or brainstem

“like I’d just got off a roundabout”

Vertigo • illusory sense of movement or orientation• disorder of labyrinth or brainstem

But which?

Differential Diagnosis

Peripheral

Central

Differential Diagnosis

Peripheral– Benign Positional Paroxsymal Vertigo (BPPV)– Acute Vestibular Neuritis– Meniere’s Disease

Central

Differential Diagnosis

Peripheral– Benign Positional Paroxsymal Vertigo (BPPV)– Acute Vestibular Neuritis– Meniere’s Disease

Central– Brainstem stroke / tumour / demyelination– Vertiginous Migraine (dx of exclusion)

History

• Headache?

History

• Headache?• Hearing?

History

• Headache?• Hearing? • Tinnitus?

History

• Headache?• Hearing? • Tinnitus?• Positional vertigo?

History

• Headache?• Hearing? • Tinnitus?• Positional vertigo?• Vision?

History

• Headache?• Hearing? • Tinnitus?• Positional vertigo?• Vision?• Swallowing?

Examination

• Cranial nerves

Examination

• Cranial nerves• Eye movements (?nystagmus)

Examination

• Cranial nerves• Eye movements (?nystagmus)• Ears

Examination

• Cranial nerves• Eye movements (?nystagmus)• Ears• Hearing

Examination

• Cranial nerves• Eye movements (?nystagmus)• Ears• Hearing• Gait (?unsteady)

Examination

• Cranial nerves• Eye movements (?nystagmus)• Ears• Hearing• Gait (?unsteady)• Coordination

Examination

• Cranial nerves• Eye movements (?nystagmus)• Ears• Hearing• Gait (?unsteady)• Coordination• Head Thrust test or Hallpike Manouevre

(positional provocation tests)

Red flags

• Neurological symptoms or signs• New headache (esp occipital)• Acute deafness• Vertical nystagmus

Anatomy and pathophysiology

Tharaka Chandrakumar

Objectives

• Labyrinthine cavity (inner ear) - osseous labyrinth - membranous labyrinth • Membranous labyrinth - endolymph - vestibular - cochlear - semicircular canals • Hair cells • Pathology

Middle and inner ear

Vestibule

Bony Vestibule - lateral wall - medial wall - roof - posterior - anteriorMembranous vestibule - utricle (close to

semicircular canals - saccule (close to cochlea)

Hair cells within membranous vestibule

Kinetic labyrinth; semicircular canals

Pathology

• Meniere’s disease • Meniere’s syndrome • BPPV • Vestibular neuritis • Labyrinthitis ; viral/bacterial

Acute Vestibular Neuritis

Acute Vestibular Neuritis

• Common• ?preceding viral infection• Sustained vertigo• Unsteady gait• Unidirectional horizontal nystagmus• Positive ocular reflex (“head thrust”)

Halmagyi Head Thrust

Halmagyi Head Thrust

• http://www.youtube.com/watch?feature=player_detailpage&v=CZXDNLLGG8k

Acute Vestibular Neuritis

• Self-limiting• Acute illness up to a week• Several weeks to resolve completely• Symptomatic relief Prochlorperazine

(Stemetil) • Vestibular rehab exercises BD

Benign Paroxysmal Positional Vertigo(BPPV)

• Common• Female: male = 2:1• Brief episodes (<1 min)• Specific positions• Posterior canal common• Intense vertigo +/- nausea• Prolonged dizziness may last hours

Benign Paroxysmal Positional Vertigo(BPPV)

Risk Factors:• Advancing age• Head trauma• Migraine• Inner ear disease• General anaesthesia

BPPV – How to diagnose

• Hallpike Manouevre

• http://www.youtube.com/watch?v=ttgaqpIv_wM

• Typical rotatory nystagmus • Careful explanation

BPPV – How to Treat

• Epley Manoeuvre• http://www.youtube.com/watch?v=LsPURdtM

jac

BPPV – How to Treat• Semont Manoeuvre

Final Part of Case

• More careful questioning elicited facial numbness and slight clumsiness of left hand

• On admission to hospital the patient;

• Sustained nystagmus on positioning

Take-Home Messages

• Vestibular problems common• Ensure no red flags• Vestibular sedatives short term use only• Learn Hallpike and Epley or Semont

AKT QUESTIONS

QUESTION 1

• A 45-year-old man presents with dizziness and right-sided hearing loss to his GP. Which one of the following tests would most likely indicate an acoustic neuroma?

A.Jerky nystagmus• B.Left homonymous hemianopia• C.Tongue deviated to the left• D.Fasciculation of the tongue• E.Absent corneal reflex

QUESTION 2

• Which one of the following medications is most useful for helping to prevent attacks of Meniere's disease?

A.Promethazine• B.Prochlorperazine • C.Betahistine• D.Chlorphenamine • E.Cinnarizine

QUESTION 3• Which one of the following statements regarding Meniere's

disease is correct?

A.More common in patients from the Indian Subcontinent• B.Symptoms resolve in the majority of patients after 6-12

months• C.It is very rare that patients develop permanent hearing loss• D.More common in children• E.Approximately equal incidence in males and females

References

• Barraclough & Bronstein Vertigo:diagnosis in general practice, BMJ 2009; 339:b3493 http://www.bmj.com/content/339/bmj.b3493

• Bronstein BPPV - Diagnosis and Physical Treatment, ACNR Vol 5 No 3, July/Aug 2005 http://www.acnr.co.uk/pdfs/volume5issue3/v5i3revbbpv.pdf

references

• Anatomy and Physiology, 7th edition, Seeley, Stephens, Tate 2005

• http://projects.cbe.ab.ca/Diefenbaker/Biology/Bio%20Website%20Final/notes/nervous_system/9_the_ear.html

• Clinical Medicine 5th edition, Kumar and Clark • Vertigo: A Review of Common Peripheral and Central Vestibular

Disorders Timothy L. Thompson, MD and Ronald Amedee, MD Ochsner J. 2009 Spring; 9(1): 20–26.

• http://emedicine.medscape.com/article/1948907-overview• Vertigo, K.Barraclough, A Bronstein, Diagnosis in General

practice, BMJ Sept 2009 Vol 339 • Lateral medullary infarct, West Indian med. j. vol.61 no.7 Mona

Oct. 2012

Manoeuvres

• Epley http://www.youtube.com/watch?v=59EIKztATiw

• Semont http://www.youtube.com/watch?v=pg_SjWG-L9c

• Brand-Daroff exercises http://www.youtube.com/watch?v=NWuEJxJ5s7c

• Have a practice!