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

Case discussion

Case discussion 58 yr old lady

Case discussion 58 yr old lady Awoke feeling room was spinning

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

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

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

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

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

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

Case discussion On examination Red throat Positionally induced nystagmus was sustained

Case discussion On examination Red throat

Case discussion On examination Red throat Positionally induced nystagmus was sustained

“I felt dizzy Doctor”

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

“like I’d just got off a roundabout”

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

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

Differential Diagnosis Peripheral Central

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

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

History Headache?

History Headache? Hearing?

History Headache? Hearing? Tinnitus?

History Headache? Hearing? Tinnitus? Positional vertigo?

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

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

Examination Cranial nerves

Examination Cranial nerves Eye movements (?nystagmus)

Examination Cranial nerves Eye movements (?nystagmus) Ears

Examination Cranial nerves Eye movements (?nystagmus) Ears Hearing

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

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

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

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

Anatomy and pathophysiology Tharaka Chandrakumar

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

Middle and inner ear

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

Hair cells within membranous vestibule

Kinetic labyrinth; semicircular canals

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

Acute Vestibular Neuritis

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

Halmagyi Head Thrust

Halmagyi Head Thrust http://www.youtube.com/watch?feature=player_detailpage&v=CZXDNLLGG8k

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

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

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

BPPV – How to diagnose Hallpike Manouevre http://www.youtube.com/watch?v=ttgaqpIv_wM Typical rotatory nystagmus Careful explanation

BPPV – How to Treat Epley Manoeuvre http://www.youtube.com/watch?v=LsPURdtMjac

BPPV – How to Treat Semont Manoeuvre

Final Part of Case

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

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

AKT QUESTIONS

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

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

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

References Barraclough & Bronstein Vertigo:diagnosis in general practice, BMJ 2009; 339:b3493 http://www.bmj.com/content/339/bmj.b3493 Bronstein BPPV - Diagnosis and Physical Treatment, ACNR Vol 5 No 3, July/Aug 2005 http://www.acnr.co.uk/pdfs/volume5issue3/v5i3revbbpv.pdf

references Anatomy and Physiology, 7th edition, Seeley, Stephens, Tate 2005 http://projects.cbe.ab.ca/Diefenbaker/Biology/Bio%20Website%20Final/notes/nervous_system/9_the_ear.html 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. 2009 Spring; 9(1): 20–26. http://emedicine.medscape.com/article/1948907-overview 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

Manoeuvres Epley http://www.youtube.com/watch?v=59EIKztATiw Semont http://www.youtube.com/watch?v=pg_SjWG-L9c Brand-Daroff exercises http://www.youtube.com/watch?v=NWuEJxJ5s7c Have a practice!