2. Vertigo Dr Tharaka Chandrakumar GPST2 Dr Emma Humphreys GPST1
The Mill Medical Practice, Godalming

3. Case discussion

4. Case discussion
58 yr old lady

5. Case discussion
58 yr old lady
Awoke feeling room was spinning

6. Case discussion 58 yr old lady Awoke feeling room was spinning
Vomited twice

7. Case discussion 58 yr old lady Awoke feeling room was spinning
Vomited twice
Seemed anxious

8. Case discussion 58 yr old lady Awoke feeling room was spinning
Vomited twice
Seemed anxious
Slightly unsteady on her feet

9. Case discussion 58 yr old lady Awoke feeling room was spinning
Vomited twice
Seemed anxious
Slightly unsteady on her feet
Hyperventilating

10. Case discussion 58 yr old lady Awoke feeling room was spinning
Vomited twice
Seemed anxious
Slightly unsteady on her feet
Hyperventilating
No fever, but had sore throat

11. Case discussion 58 yr old lady Awoke feeling room was spinning
Vomited twice
Seemed anxious
Slightly unsteady on her feet
Hyperventilating
No fever, but had sore throat
Slight difficulty swallowing

12. Case discussion On examination Red throat
Positionally induced nystagmus was sustained

13. Case discussion
On examination
Red throat

14. Case discussion On examination Red throat
Positionally induced nystagmus was sustained

16. “I felt dizzy Doctor”

17. “I felt dizzy Doctor” Light-headedness
Presyncope, eg transient hypotension
Disequilibrium of elderly
Anxiety or hyperventilation

18. “like I’d just got off a roundabout”

19. “like I’d just got off a roundabout”
Vertigo
illusory sense of movement or orientation
disorder of labyrinth or brainstem

20. “like I’d just got off a roundabout”
Vertigo
illusory sense of movement or orientation
disorder of labyrinth or brainstem
But which?

21. Differential Diagnosis
Peripheral
Central

22. Differential Diagnosis
Peripheral
Benign Positional Paroxsymal Vertigo (BPPV)
Acute Vestibular Neuritis
Meniere’s Disease
Central

23. Differential Diagnosis
Peripheral
Benign Positional Paroxsymal Vertigo (BPPV)
Acute Vestibular Neuritis
Meniere’s Disease
Central
Brainstem stroke / tumour / demyelination
Vertiginous Migraine (dx of exclusion)

24. History
Headache?

25. History
Headache?
Hearing?

26. History
Headache?
Hearing?
Tinnitus?

27. History
Headache?
Hearing?
Tinnitus?
Positional vertigo?

28. History
Headache?
Hearing?
Tinnitus?
Positional vertigo?
Vision?

29. History Headache? Hearing? Tinnitus? Positional vertigo? Vision?
Swallowing?

30. Examination
Cranial nerves

31. Examination
Cranial nerves
Eye movements (?nystagmus)

32. Examination
Cranial nerves
Eye movements (?nystagmus)
Ears

33. Examination
Cranial nerves
Eye movements (?nystagmus)
Ears
Hearing

34. Examination Cranial nerves Eye movements (?nystagmus) Ears Hearing
Gait (?unsteady)

35. Examination Cranial nerves Eye movements (?nystagmus) Ears Hearing
Gait (?unsteady)
Coordination

36. Examination Cranial nerves Eye movements (?nystagmus) Ears Hearing
Gait (?unsteady)
Coordination
Head Thrust test or Hallpike Manouevre (positional provocation tests)

37. Red flags Neurological symptoms or signs New headache (esp occipital)
Acute deafness
Vertical nystagmus

38. Anatomy and pathophysiology
Tharaka Chandrakumar

39. Objectives Labyrinthine cavity (inner ear) - osseous labyrinth
- membranous labyrinth
Membranous labyrinth - endolymph
- vestibular
- cochlear
- semicircular canals
Hair cells
Pathology

40. Middle and inner ear

41. Vestibule
Bony Vestibule - lateral wall - medial wall - roof - posterior - anterior Membranous vestibule - utricle (close to semicircular canals - saccule (close to cochlea)

43. Hair cells within membranous vestibule

44. Kinetic labyrinth; semicircular canals

45. Pathology Meniere’s disease Meniere’s syndrome BPPV
Vestibular neuritis
Labyrinthitis ; viral/bacterial

46. Acute Vestibular Neuritis

47. Acute Vestibular Neuritis
Common
?preceding viral infection
Sustained vertigo
Unsteady gait
Unidirectional horizontal nystagmus
Positive ocular reflex (“head thrust”)

48. Halmagyi Head Thrust

49. Halmagyi Head Thrust

50. Acute Vestibular Neuritis
Self-limiting
Acute illness up to a week
Several weeks to resolve completely
Symptomatic relief Prochlorperazine (Stemetil)
Vestibular rehab exercises BD

51. Benign Paroxysmal Positional Vertigo (BPPV)
Common
Female: male = 2:1
Brief episodes (<1 min)
Specific positions
Posterior canal common
Intense vertigo +/- nausea
Prolonged dizziness may last hours

52. Benign Paroxysmal Positional Vertigo (BPPV)
Risk Factors:
Advancing age
Head trauma
Migraine
Inner ear disease
General anaesthesia

53. BPPV – How to diagnose Hallpike Manouevre
Typical rotatory nystagmus
Careful explanation

54. BPPV – How to Treat Epley Manoeuvre

55. BPPV – How to Treat
Semont Manoeuvre

56. Final Part of Case

57. More careful questioning elicited facial numbness and slight clumsiness of left hand
On admission to hospital the patient;
Sustained nystagmus on positioning

58. Take-Home Messages Vestibular problems common Ensure no red flags
Vestibular sedatives short term use only
Learn Hallpike and Epley or Semont

59. AKT QUESTIONS

60. QUESTION 1
A 45-year-old man presents with dizziness and right-sided hearing loss to his GP. Which one of the following tests would most likely indicate an acoustic neuroma? A.Jerky nystagmus
B.Left homonymous hemianopia
C.Tongue deviated to the left
D.Fasciculation of the tongue
E.Absent corneal reflex E

61. QUESTION 2
Which one of the following medications is most useful for helping to prevent attacks of Meniere's disease? A.Promethazine
B.Prochlorperazine
C.Betahistine
D.Chlorphenamine
E.Cinnarizine C

62. QUESTION 3
Which one of the following statements regarding Meniere's disease is correct? A.More common in patients from the Indian Subcontinent
B.Symptoms resolve in the majority of patients after 6-12 months
C.It is very rare that patients develop permanent hearing loss
D.More common in children
E.Approximately equal incidence in males and females E

64. References
Barraclough & Bronstein Vertigo:diagnosis in general practice, BMJ 2009; 339:b3493
Bronstein BPPV - Diagnosis and Physical Treatment, ACNR Vol 5 No 3, July/Aug

65. references
Anatomy and Physiology, 7th edition, Seeley, Stephens, Tate 2005
Clinical Medicine 5th edition, Kumar and Clark
Vertigo: A Review of Common Peripheral and Central Vestibular Disorders Timothy L. Thompson, MD and Ronald Amedee, MD Ochsner J Spring; 9(1): 20–26.
Vertigo, K.Barraclough, A Bronstein, Diagnosis in General practice, BMJ Sept 2009 Vol 339
Lateral medullary infarct, West Indian med. j. vol.61 no.7 Mona Oct. 2012

66. Manoeuvres Epley http://www.youtube.com/watch?v=59EIKztATiw
Semont
Brand-Daroff exercises
Have a practice!