Vertigo Dr. Thamara Gunasekera GPST3

Definition - sensation of movement , either of the patient in relation to the their environment or environment in relation to the patient Symptom rather than a disease. Usually caused by the dysfunction of the middle ear. Means different things to different people. Often has a rotational or spinning component. Vertigo is not a general imbalance or a light headedness or faint like disorientation

What is ? Dizziness – difficult to define, may result form conditions of the inner ear or non ear conditions. Key - a good history to differentiate whether its vertigo or not Disequilibrium - the sense of feeling off balance without any actual sensation of movement Presyncope - the feeling of light headedness, often without any sensation of movement and often accompanied by a sense of impending loss of consciousness Dizziness- 3 components, syncope, vertigo and nonvertigo-non syncopal 3

Anatomy and physiology Inner ear is about 2cm long and has 2 main parts The cochlea and the vestibular system The vestibular system comprised of - 3 semicircular canals -3 diff planes - otolith organs The cochlea is concerned with hearing while the vestibular system deals with balance

History Onset of the symptoms Describe the symptoms - Tell me what it feels like ? - Avoid leading Q. Patient might make a gesture using the hand or the finger often a rotational movement ( This usually suggest U/L disease.) Time course : Is it worsening resolving or fluctuating ? Aim – to find out its vertigo, disequllibrium (postural hypo), presyncope. Then the cause 5

Diagram of the inner ear

Persistence : Is it constant or episodic ? Quantify the episodes : length, frequency Associated symptoms - Nausea - Anxiety - Neurological symptoms Are the episodes spontaneous or provoked ( eg: Head movement)

H/O ear symptoms: earache, discharge, tinnitus, hearing loss Neurological symptoms Ophthalmological symptoms Family history Other RF for inner ear disease - Head injury - whiplash injury - Ototoxic medication

Examination - How sure am I that this is only a peripheral vestibular disorder? - Should I seek ENT / Neuro/ Medical advise? - Is this BPPV ? Is Epley’s manoeuvre indicated?

Examination Balance Gait- pt with vestibular pathology may veer towards the side of the lesion and use a wide based gait Otoscopy and tuning folk test for hearing Eyes- eye movements, nystagmus CNS examination- cerebellar signs, CN, start obeserving while patient walks into the room ( patient with a vestibular D, often stares at the floor to keep the balance especially in an unfamiliar setting.) 10

Peripheral causes of Vertigo Vestibular neuronitis BPPV Meniere's Disease Recurrent vestibulopathy

Vestibular neuronitis and labrynthitis Cause unknown Could be due to viral infection, therefore could have preceding URTI. Typically pt present with features of vertigo which lasts for days to weeks . Nystagmus is usually present Acute labrynthitis is form of vestibular neuronitis, which involves a single attack of vertigo, with hearing loss and often tinnitus. Hearing loss and tinnitus is often helpful to lateralise the lesion. Note- sudden onset hearing loss is an emergency.

Rx - Vestibular sedatives - prochloroperazine , . Rx - Vestibular sedatives - prochloroperazine , - should not be prescribed more than a week as prolonged vestibular sedation interrupts the process of recalibration process and hinder the recovery. , as prolonged vestibular sedation interrupts the process of recalibration process and hinder the recovery. 13

BPPV Self limiting , resolves spontaneously. Episodes of vertigo with nausea and general imbalance, lasting up to a minute. Usually precipitated by certain head movements Often lasting no longer than few months Dix- Hallpike positional testing is diagnostic and is treated with performing Epley’s manoeuvre.

Meniere's Disease Triad of vertigo, hearing loss and tinnitus Often describes an association of the feeling fullness in ear canal Episodes lasts for 30minutes to several hours. Difference with vestibular neuronitis - vestibular neuronitis : single attack - Meniere's : multiple attacks

Meniere's Disease Mx - all new cases need to be referred to ENT - regulating salt and fluid intake, caffeine and smoking reduction has shown some benefit. - Vestibular sedatives - prochloroperazine for acute phase - Betahistine - for maintenance -

Recurrent vestibulopathy Recurrent vertigo , episodes which last from 5 minutes to 24 hours, occur in the absence of auditory or neurological symptom or signs. The spells occur without a prodrome and with not provoked particular movement.

Constant for many hours / even a day Viral illness Nausea , vomiting Onset Duration Precipitants Associations Vestibular neuronitis Sudden Constant for many hours / even a day Viral illness Nausea , vomiting BPPV Intermittent Up to 60 seconds Head movements None Meniere's disease Unpredictable , may hours Tinnitus Deafness Aural fullness Recurrent vestibulopathy Episodes last minutes to hours

Central vestibular Disorders CVA, brain tumours, MS Do not exhibit vertigo as their only presenting symptom Often present with associated neurological deficits CN examination, fundoscopy , neuro examination mandatory

Vestibular migraine Migraine associated with dizziness Often incorrectly diagnosed as Meniere's Presents with the classic symptoms of Meniere's only difference is presence of other classic signs of migraine ( aura, photophobia and headache)

Key points Good history 3 common peripheral vestibular disorders , distinguished from history by identifying the duration of the symptoms and associated symptoms R/O important central causes for vertigo