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History-Pts 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 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 )

Disequilibrium is a sense of being off balance without dizziness or vertigo , particularly when walking.

Deafness , Tinnitus , ear discharge or pain , ear fullness.Presence of aural symptoms suggests that the lesion is peripheral

Examination-CNS exam- for palsies, sensorineural hearing loss Eye movements and nystagmus →should be horizontal only Check for facial weakness , dysphagia or dysphonia Bedside hearing tests Gait and limb ataxia Head and neck exam ( otoscopy ) CVS exam → r/o autonomic dysfunction Blood tests Specialised tests ( eg Hallpikes manoeuvere )

Investigations-Based on suspicion Vestibular function studies 
( test vestibular portion of inner ear ) Brainstem evoked responses 
( mainy when Acoustic neuroma suspected ) Audiometry ( helpful in Menieres dis ) Tympanometry 
(identify problems with middle ear & mobility of ear drum ) otosclerosis , perforations , glue ear etc Caloric tests ( running cold and then warm water into the external auditory meatus ) Electronystagmography ECG / Echo if cardiac cause suspected MRI- if central cause suspected CT-cannot visualise well the posterior fossa ( area where most CNS lesions causing vertigo are located )

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

Benign Paroxysmal Positional Vertigo – BPPV.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

Majority of cases are self limiting CKS NHS →symptomatic drug treatment usually not helpful for people with BPPV
Options include Prochlorperazine 5 mg tds ( Stemetil ) Betahistine 8-16 mg tds ( Serc ) Promethazine up to 25 mg qds ( Avomine )

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

When to refer-.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 )

Vestubular neuronitis-Acute sustained dysfunction of the peripheral vestibular system Leads to nausea , vomiting and vertigo Viral infection considered as major cause Some cases thought 2ary to rectivation of latent herpes simplex virus type 1 in vastibular gangli Hearing usually not affected ( unlike labyrinthitis ) Tinnitus is also a feature of labyrinthitis but not vestibular neuronitis No focal neurological symptoms Spontaneous unidirectional horizontal nystagmus is the most important physical finding

Symptoms settle over several weeks ( even if no Rx taken ) Advice on safety ( driving , work place ) Buccal prochlorperazine ( to alleviate severe nausea , vomiting or vertigo ) has ↑ onset of action Medication for 3 days → then PRN basis If taken > 1 week → may delay recovery by affecting the body’s compensatory mechanism Return if symptoms deteriorate or have not fully recovered after 1/52 of treatment If symptoms persist more than 6 weeks→ Investigations to exclude other causes or vestibular rehabilitation may be required

Menieres Disease ( Idiopathic Endolymphatic hydrops )-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 tinnitis 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

Histamine agonists ( eg Serc ) Vasodilator drugs ( eg Nicotinic acid ) Diuretics → combined with ↓ Na diet Operative options include

Decompression of endolymphatic sac
Vestibular neurectomy
Labyrinthectomy ( leads to complete hearing loss )

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

References ; Further reading
 CKS NHS Vertigo Initial evaluation of Vertigo AAFP 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 Vertigo and Imbalance ABC of Ear Nose and Throat 6th Edition Dizziness and Vertigo Debara L. Tucci , MD , MS via,-nose,-and-throat-

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