1. Vertigo Simplified
Gary Kroukamp
Kingsbury Hospital
Tygerberg Hospital

4. At the end of this talk… Define vertigo Diagnose - just by the history
Refer
Investigate
Manage

5. Giddiness – Who the hell knows?
Definitions
Dizziness/lightheadedness: A distorted sense of
one’s spatial relationship
Vertigo: Hallucination of rotatory motion
Unsteadiness: Difficulty with gait/Tendency to fall
to one side
Blackouts: Loss of consciousness
Giddiness – Who the hell knows?

6. Anatomy and Physiology
Input
Output
Cortical awareness
Visual adaptation
Vision
Central integration
Musculosceletal
Proprioception
Autonomic nervous
system
Vestibular labyrinth

8. Anatomy and Physiology

10. Anatomy and Physiology

12. History 1. Describing character of symptoms
2. Onset – Sudden or Gradual
3. Frequency
4. Duration
5. Severity
Aggravating factors (activity, darkness)
Associated symptoms (N+V, Tinnitus,
Hearing loss)
8. Medical history (CVS, Psych, CNS)
Trauma
10. Medications/Alcohol

13. History Peripheral Central Syncopal Psychogenic Vertigo Dizziness
Blackout
‘Out of body’
Episodic
Continuous
Variable
N+V
Other CNS Simptoms
+- CVS history
Anxiety
Visual fixation

14. Examination 1. General 2. Vital signs
3. ENT -Middle ear disease, hearing(audiogram)
Neurologic -Cranial nerves, Cerebellum,
Nystagmus
Cardiovascular -postural hypotension, pulse,
carotid bruits, Cardiac murmurs
6. Manoeuvers -Hallpike

15. Special Investigations
1. FBC (Infection, leukemia)
2. VDRL, Bloodglucose, Thryroid functions
3. ECG (Arythmias, previous MI)
Electronystagmography, Videonystagmo-
graphy
5. MRI

16. Causes
Otological (Peripheral) vs
Non-otological (Central)

17. Otological causes External ear (Foreign body, impacted wax)
2. Middle ear disease
3. Trauma -Temporal bone fracture)
Menière’s disease
5. BPPV
6. Labyrinthitis
Vestibular neuronitis (Viral)
Other -Syphilis, Ototoxic drugs, Acoustic
neuroma

18. Characteristics of Inner Ear Disorders
Dysequilibrium, not fainting
Definite attacks/episodes
“True vertigo”
Severe
Often with N & V
Other Inner Ear symptoms

19. Clinical Scenario 1 Mrs JW 59 years old 3 week h/o dizziness
Some nausea, no vomiting
Wakes her up at night
Worse on rolling over to the left
Worse on reaching up to high shelf

20. BPPV Episodic Vertigo on position change
Pathology: Otoliths in semicircular canals
Diagnosis: Dix-Hallpike manoeuvre with rotational
nystagmus
Treatment: Repositioning manoeuvres, Epley

21. Clinical Scenario 2 Mr SP 43 yo Dizzy “attacks” for 3 years
4 to 5 per year
Last 2 to 3 hours
N&V
Has to lie down
Tinnitus and muffled hearing left ear

22. - Reassurance and Vestibular sedatives
Menière’s disease
Endolymphatic hydrops
1. Young to middle age
2. Episodic attacks
Cardinal features -Vertigo, Tinnitus, Hearing
loss, Fullness
Management
- Reassurance and Vestibular sedatives
- Reduction of Caffeine, smoking, salt, 3L water
- Medical -Serc, mild diuretics

24. Menière’s disease Surgery now largely abandoned in favour of
Middle ear installation of Gentamycin
Middle ear installation of Steroids

25. Clinical scenario 3 Mrs RvW 36 yo
Sudden onset severe dizziness 2 days ago
N&V
Unable to stand/falls over
Normal hearing
Blurring of vision
Left beating nystagmus

26. Vestibular Neuronitis
Viral labyrinthitis
Nonspecific viral illness followed 6/52 by a sudden onset of vertigo, nausea + vomiting
Initially severe- gradual resolution over 10 days
Rx: Steroids
Vestibular suppressants

27. Labyrinthitis Infection of Vestibular labyrinth, associated with URTI
Rapid onset vertigo with nystagmus and hearing loss
First 24 hrs worse, normally resolve after 36 hrs

28. Clinical Scenario 4 Mr AD 74 yo man
Gradual onset hearing loss R ear – for years
Also tinnitus R ear
Vague poor balance
1 episode vertigo 4 years ago
Hearing worse after this

29. Acoustic/Vestibular Schwannoma
Benign, slow-growing tumor in vestibular division of eighth cranial nerve
Not episodic vertigo
MRI with gadolinium is reliable +cost-effective
Rx: “Radiosurgery”Gamma knife/ Surgery

30. Characteristics of Central Causes
Continuous
Dysequilibrium more vague, not “True Vertigo”
Less severe imbalance, can still function

31. Non-otological (Central)
Vascular -Vertebrobasilar insufficiency, TIA,
postural hypotension, Cardiac dys-
rythmias, Valvular lesions, Wallenberg
syndrome, Medullary infarction, Inter-
nal auditory artery obstruction, Verte-
brobasilar migraine, Subclavian Steel
syndrome
2. Trauma -Head injury
3. Ageing -multifactorial
Infectious -Meningitis, Ramsay Hunt
Syndrome

32. Non-otological (Central)
Demyelinating diseases eg. MS
6. Epilepsy
7. Toxic -Alcohol, Anticonvulsants
8. Psychogenic –Hyperventilation,Anxiety
9. Tumour
Metabolic -thyroid, hypo- and hyperglycaemia,
Addison’s disease
Congenital -Familial episodic ataxia, Hydro-
cephalus, Arnold-Chiari malformation)

33. Clinical Scenario 5 Mrs TH 28 yo Poor balance and swaying 6 months
After a cruise Durban to Cape Town
Better with exercise
Better with alcohol

34. Mal de Debarquement Syndrome
After travel by ship
Improvement with exercise/alcohol
Psychogenic?/Anxiety
Overly focused on balance correction
Reassurance/exercise

36. Conclusion History! Clinical Picture Not everyone has Meniere’s
Appropriate referral
Management according to diagnosis