Vertigo

Definition

  • Illusion of movement

  • True rotatory spinning sensation

Pathophysiology

  • Vestibular Ocular Reflex different on each side

  • Generated nystagmus

  • Generates sensation of movement

Balance

  • Psychological

  • Vision

  • Circulation

  • Proprioception

  • Inner ears

  • Brain

Peripheral vs Central

  • Peripheral is much more common

  • HINTS testing useful

  • Patients with central causes often just not quite right

    • Palsies

    • CN changes

    • Gait changes

    • Limb numbness

    • Nystagmus is not right, doesn’t fit a pattern

Red Flags

  • Truncal ataxia

  • Inability to stand

  • Sudden loss of hearing (rare but can happen in peripheral)

  • Five Dead D’s of Dizziness

    • Dizziness

    • Diploplia

    • Dyarthria

    • Dysmetria

    • Dysphagia

Causes

First episode

  • Triggered

    • Drugs / Exposures

    • Headache

  • Random

    • Vestibular Neuronitis

    • Stroke

Multiple episodes

  • Triggered

    • Postural Hypotension

    • BPPV

  • Random

    • Meniere’s disease

    • Vestibular Migraine

How long

Lasts seconds to a minute

  • BPPV

  • Test with Dix-Hallpike test

  • Epley’s manoeuvre is 95% effective for 6 months relief

  • Brandt-Daroff is 50% effective

  • Increases fall risk

  • 6 movements that trigger

    • Turning left or right in bed

    • Lying down or up in bed

    • Tipping head back or forward

  • Comes in waves and resolves from seconds to a minute

Lasts 20 minutes to 24 hours

  • Meniere’s

  • Nausea and vomiting

  • Tinnitus in one ear

  • Aural fulness in one ear

  • Fluctuating hearing loss

  • Raised pressure in inner ear structures

  • Classic presentation

  • Spontaneous

Days to weeks

  • Vestibular Neuronitis

  • 4 to 6 days of dizziness

  • Then not quite right weeks later

  • Nerves of balance affected

  • Post URTI

  • Once vestibular loss, never the same since

  • Head impulse test

  • Can improve functional balance, confidence, and strength

  • No real treatment

  • Don’t use vestibular suppressants (long-term stemetil)

  • Be active, do vestibular exercises

  • Labirynthitis comes with hearing loss

  • Vestibular neuronitis just balance

HINTS

Testing horizontal semicircular canals reflex

  • Head impulse

    • Hold head, move side to side with a sudden movement

    • Eyes should remain fixed

    • If one side not functioning, catch up cascade, eyes will zip away from nose and then catch up

    • This continues to happen with 3 or 4 tests

Meniere’s Disease

  • Stepwise treatment

  • Medication

  • Intratympanic Dexamethasone = 90% effective for 6 months +

  • 10% no benefit

Vestibular Neuronitis

  • Vestibular rehab

BPPV

  • Vestibular Rehab

PPPD

  • Chronic dizziness after the initial event

  • Anxious response, usually premorbid anxiety or acute anxious response

  • Maladaptation

Reference:

  • Vertigo - Primary Care Knowledge Booooost

Resources:

  • HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE . Nov 2009, Stroke: https://pubmed.ncbi.nlm.nih.gov/19762709/

            https://www.youtube.com/watch?v=psyPED6anPo

            https://www.youtube.com/watch?v=XpghlvnrREI