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Vertigo

Vertigo is derived from Latin word – vertere ( turn ) & igo ( a condition ). 
Vertigo is a false sense of motion.

Terminology to help differentiate other causes
 Pre-syncope – a sensation of impending loss of consciousness , usually caused by CV disorders , peripheral neuropathy , hyperventilation , postural hypotension and vasovagal reactions ( underlying event is thought to be a decrease in global cerebral blood flow )
 Disequilibrium or postural unsteadiness – sense of imbalance not strictly associated with motion happens when the brain is processing less information about the body’s position in space. Common causes include
decreased lower limb strength ( e.g pseudoparkinsonism )
peripheral neuropathy
visual loss
poorly compensated peripheral vestibular disorders
 Light-headedness ( also described as giddiness or wooziness ) has no clear definition and no clear associated diagnosis.

How common – Vertigo accounts for 54 % of reports of dizziness in primary care Most cases of vertigo ( 93 % ) happen due to 3 conditions
benign paroxysmal positional vertigo ( BPPV )
acute vestibular neuritis 
Meniere’s disease Vertigo is amongst the commonest symptoms presented to doctors with a lifetime prevalence of around 20-30 % Patients may present and seek help from specialties as
primary care ( GPs )
ENT
Neurologists
Ophthalmologists.

History-Patients use terms as “spinning” or “whirling” or they or their surrounding are moving in a circular fashion Onset , duration and accompanying symptoms Eg Nausea, vomiting , hearing disturbance , tinnitus
duration may last from seconds or minutes ( as in vestibular paroxysms ) to hourse ( as in Meniere’s disease or vestibular migraine ) Visual symptoms , Falling , Headache , Otalgia H/O Trauma ? Recent viral illness ? Flying → ? Barotrauma Provoking and aggravating factors Past medical history ( eg Acoustic neuroma and Nuerofibromatosis type 2 , MS and brainstem demyelination ) Current and Past drug hx (eg use of aminoglycosides )

Examination –Check the ear drums Hearing ( tuning fork test ) CNS – full neurological examination Vision , nystagmus Test of skew ( r/o brainstem involvement ) Gait and Romberg test Dix – Hallpike maeuver ( diagnostic of BPPV ) Unterberg’s test ( to identify labyrinth dysfunction ) CVS exam Laboratory tests – usually not helpful

See videos of specialist tests under links and resources.

Red flags –Nystagmus that is down beating and continuous Unremitting headache and nausea Ataxia , cerebeallar signs Progressive hearing loss Loss of consciousness Signs of suppurative ( Purulent ) labyrinthitis
▬ bulging erythematous tympanic membrane
▬ fever
▬ balance disturbance.

Diplopia , sensory disturbances , dysphagia , dysarthria and paralysis of arms and legs indicate a central origin Headache or a h/o migraine may point to the diagnosis of vestibular migraine but can also be caused by brainstem ischaemia or posterior fossa haemorrage Please see the box- red flags.

Triggered by change in head position –Acute labyrinthitis BPPV Cerebellopontine angle tumour MS Perilymphatic fistula.Spontaneous –Acute vestibular neuronitis Cerebrovascular dis ( CVA/TIA) Meniere’s dis Migraine MS.Associated hearing loss –Acute vestibular neuronitis Cerebrovascular dis ( CVA/TIA) Meniere’s dis Migraine MS. Acute labyrinthitis Acoustic neuroma Meniere’s disAcute labyrinthitis Acoustic neuroma Meniere’s dis. ear or mastoid pain Acoustic neuroma Acute middle ear disease.

Benign paroxysmal positional vertigo –Most common cause of dizziness Sudden attacks of rotatory vertigo lasting seconds often precipitated by head turning Vertigo → turning over in bed , lying down or sitting up from supine position Vertigo on looking ↑ or bending forward Displacement of otoconia in semicircular canal.No aural symptoms Peripheral positional nystagmus
( Using Hallpike’s manouevere is diagnostic of BPPV ) Normal CNS exam.Recovery usually over several weeks but → symptoms can recur and last longer ( months ) Repositioning manouveres ( Epley , Semont’s , Brandt-Daroff positional exercise ) are effective in 80-90 % cases Advice about safety ( Not to drive when they are dizzy) DVLA→ people liable to “sudden attacks of unprovoked or unprecipitated disabling giddiness’ should stop driving. Get out of bed slowly and avoid tasks that involve looking upwards Advice to return in 4 weeks if symptoms have not settled.Majority of cases are self limiting CKS NHS →symptomatic drug treatment usually not helpful for people with BPPV ( but this is widely used )
Options include Prochlorperazine 5 mg tds ( Stemetil ) Betahistine 8-16 mg tds ( Serc ) Promethazine up to 25 mg qds ( Avomine ).Severe nausea or vomiting ( admit ) Epley manoeuvre has been performed and symptoms persist Atypical symptoms or signs ( lateral canal BPPV ) Symptoms have not settled in 4 weeks ( ? Wrong diagnosis ).

labyrinthitis –Inflammatory disorder if inner ear or labyrinth Causes severe vertigo and total loss of hearing Can be viral or bacterial Most common complication of otitis media Acute symptoms of vertigo & nausea resolve after several days to weeks Haring loss is variable

menieres disease –Violent paroxysmal vertigo → often rotatory associated with deafness and tinnitus Often preceded by sensation of aural fullness ↑ or change in character of tinnitus , pain in the neck or ↑ deafness Low frequency hearing loss and tinnitus is low pitch Deafness is sensorineural and fluctuates Attacks in clusters – can last for hrs ( 20 mins to 24 hrs ) ↑ ed vol of endolymph in semicircular canals (endolymphatic hypertension ) Can be unilateral at first-becomes b/l in 25-45 % ↑ common in females.

Consider admission if patient has severe nausea and vomiting and is unable to tolerate oral fluids or symptomatic drug treatment Very sudden onset of vertigo
( within seconds ) that is not triggered by positional change and is persistent – ie it indicates a more sinister pathology Symptoms suggest a central cause -for e.g new type headache , gait disturbance , truncal ataxia , vertical nystagmus Patient reports acute deafness but has no other symptoms to support a diagnosis of Meniere’s disease Vertigo of undetermined cause.

References ; Further reading
 CKS NHS Vertigo Initial evaluation of Vertigo AAFP http://www.aafp.org/afp/2006/0115/p244.html Emedicine Dizziness, Vertigo, and Imbalance Author: Hesham M Samy, MD, PhD; Chief Editor: Robert A Egan, MD A Delicate balance : Managing vertigo in General Practice http://www.bpac.org.nz/BPJ/2012/september/vertigo.aspx Vertigo and Imbalance ABC of Ear Nose and Throat 6th Edition Dizziness and Vertigo Debara L. Tucci , MD , MS via http://www.merckmanuals.com/professional/ear,-nose,-and-throat-
disorders/approach-to-the-patient-with-ear-problems/dizziness-and-vertigo Dignosis and Treatment of Vertigo and Dizziness by Michael Strupp , Thomas Brandt A systematic review of vertigo in primary care by Karena Hanley , Tom O’Dowd and Niall Considine BJGP 2001 Vertigo – Diagnosis and management in primary care Daljit Singh Sura and Stephen Newell BJMP 2010 ; 3(4) : a351,Management of vertigo from evidence to clinical practice Paola Gnerre et al Italian Journal of Medicine 2015 from https://www.italjmed.org/index.php/ijm/article/download/itjm.2015.437/644/2527

LINKS AND RESOURCES

PATIENT INFORMATION

BPPV patient information from Guy’s and St Thomas https://www.guysandstthomas.nhs.uk/resources/patient-information/therapies/physiotherapy/benign-paroxysmal-positional-vertigo.pdf

NHS Inform on vertigo https://www.nhsinform.scot/illnesses-and-conditions/ears-nose-and-throat/vertigo

ENT UK on vertigo https://www.entuk.org/vertigo

American Academy of Otolaryngology-Head and Neck Surgery info on BPPV https://www.entnet.org/sites/default/files/uploads/PracticeManagement/Resources/_files/eng-bppv_faq.pdf

Meniere’s disease charity Menieres society https://www.menieres.org.uk/

Dizziness, vertigo and work

DVLA https://www.gov.uk/dizziness-and-driving
Fit for work https://support.fitforwork.org/app/answers/detail/a_id/766/~/vertigo

INFORMATION FOR CLINICIANS

BPPV a simple explainerhttps://vestibular.org/understanding-vestibular-disorders/types-vestibular-disorders/benign-paroxysmal-positional-vertigo

Fit for work https://support.fitforwork.org/app/answers/detail/a_id/766/~/vertigo

HINTS exam video https://www.youtube.com/watch?v=VwmrjYuvqtQ

Dix Hallpike from BMJ Learning https://www.youtube.com/watch?v=8RYB2QlO1N4

Unterberg test https://www.youtube.com/watch?v=ljGJbokAOXM

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