• Nalaka de Silva

Vertigo: an outline

Please note that the following is a general guideline only. For a full assessment, exclusion of any other underlying cause for your symptoms and an individualised treatment approach, you will need to be seen by a qualified specialist.





Vertigo Definition

Illusion of Rotation due to asymmetry in neural activity between the L and R vestibular systems (Halmagi)







Taking a History

First familiarize your self with the specific features of the above 6 causes of vertigo. These are discussed in the later part. What helps tell these apart are the differences in their onset, length of the symptoms and associated features.


History taking should be fairly directed ie “ do you feel light headed (not vertigo) or is the roof spinning around (true vertigo)”. How quickly does it come on, in a second or over long period. When it comes on does it last for hours/ or days with out stopping, or only a few seconds but keeps coming back over days when you move for example?


Following are the main aspects of history



1 Characterize “dizziness”-is it true vertigo not light headedness, True vertigo has a clear sense of motion.


If true vertigo determine if its central (central vertigo has neurological features) OR... Peripheral vertigo- know the specific features in history that characterizes each type of peripheral vertigo well (conditions discussed in the latter part)

2 Following are the important aspects of history which helps you differentiate

Onset/ predisposing factors

time course,

temporal pattern


3 Associated symptoms (think of DDs)

CNS symptoms-Central vertigo

Migraine features

Ear symptoms





Examination (the most important ones)


1 Nystagmus

Central features- Vertical nystagmus, direction changing

Peripheral features; horizontal or in BPPV rotatory


2 Head pulsion test-only positive in peripheral vertigo, -ve in central vertigo types

Get the patient to fixate on an object 2 m in front of him/ her

keep the head Flexed down by about 3o degrees

rapid flick-movement of the head to the right then repeat the same to the left

if the labyrinth is dysfunctional the eyes will not stay fixed on the object (ie eyes will move with the head and flick back)

see the following video





3 Dix Hallpike

If symptoms suggest BPPV do Dix Hallpike to confirm. see the following video




4- Romberg

Balance depends on a tripod

A the input from the eyes,

B the proprioceptors of feet and

C tone by the vestibular spinal tracts

stand pt with feed together/ or on cushions (proprioceptors are removed)

ask the pt to close the eyes- visual input is removed (ensure you are ready to catch them)

now the patient relies on their vestibular tone alone- if one side is affected they will sway to that side


note a cerebellar tumor will also have a positive Romberg, however with other central signs as follows



Look for central signs-


- Finger-nose test (dysmetria past-pointing, intention tremor)

- Ataxia (heel-toe)

- Head Titubation

- Dysarthria

- Otological

- Neurological

- Visual

- Autonomic

-Other cranial nerves affected








Vertigo Main Conditions




Vestibular Neuronitis



History

Onset: within minutes to hours) onset of severe,

Time course: 24 hrs or more prolonged rotatory vertigo, nausea, and postural imbalance.

No Hearing Loss (helps differentiate from labyrinthitis)


NO central features





Examination


Peripheral vestibular signs

Horizontal spontaneous nystagmus


Head pulsion test is positive (indicates it is NOT a central process)

Romberg positive to affected side

No other neurological findings

NO evidence of a central vestibular lesion- no other neurological findings

No hearing loss

Treatment

Supportive

Rx-Steroids





Labyrinthitis


History

Onset:Over hours


Time course: Goes on for a day or more-then slowly subsides

Other: patient is very unwell-vomiting severely, and severe vertigo

Sensory hearing loss in the affected ear (different from V neuronitis)


Examination

Peripheral signs i.e.

Nystagmus- horizontal

head pulsion positive

Romberg positive- falls to affected side

also may have a middle ear infection


Sensory neural hearing loss


Rx

short course of vestibular sup presents i.e. Diazepam and Stemetil/ steroids

Stop after about 2 days- allow compensation

if middle ear infection- antibiotics





Meniere's Disease


Over diagnosed (vestibular Migraine)

History

Onset:Vertigo only hours, pt may feel unwell for days

Has associated features ; Aural fullness, Rumbling tinnitus , Hearing loss and vertigo


Examination

Peripheral vestibular symptoms as above ie


Nystagmus- horizontal

head pulsion positive

Romberg positive- falls to affected side


..for more details






BPPV


History


Very common

Onset-Short duration vertigo (seconds), with head movement, rolling in bed

Time course: Patient may call it days- as short duration episodes vertigo keeps over many days- need to specifically ask this

Movement brings it on i.e. turning in bed- wakes up with vertigo, or turning the head


Examination

Positive Dixhallpike test to the affected ear (see the above clip)


Treatment

Epley manoeuvre (not medical treatment)



for more details see the BPPV presentation






Vestibular Migraine (very common)


Usually comes on over minutes to hours


Usually lasts over a day


Has other migraine features i.e.


Photophobia, Phonophobia

may have an aura

May have a headache not always

responds to migraine medications

can have other neurology i.e. ataxia, tinnitus, other cranial nerve/ neurology






....dizziness exercises...




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