An Approach to the Patient with Vertigo Cynthia Phelan PGY

Vertigo A false sense of moving or spinning or of objects moving or spinning, usually accompanied by nausea and loss of balance.

Chief Complaint: “Dizziness” Vertigo Light Headedness WeaknessFaintness Mental Confusion Headache Gait disorder Paresthesias

Abnormalities of Auditory Canal  Benign Paroxysmal Positional Vertigo Labyrinthitis  Otitis Interna  Herpes zoster Meniere`s disease Vestibular nerve inflammation  Trauma Neurologic  Multiple sclerosis Neoplasm  Migraine Circulatory  CVA  Vertebrobasilar insufficiency Trauma  Skull # with labyrinth injury Psychiatric Panic disorder Pharmacological  Alcohol Aminoglycosides Illicit drugs Environmental Motion sickness

History Description of symptoms Timing Onset, duration, frequency, diurnal variation Onset, duration, frequency, diurnal variation Positional Dependence Associated symptoms Alleviating and Aggravating Factors Past Medical History Medications Recent trauma. Risk Factors for Causes of Central Vertigo

Physical Exam Vitals Pay attention to BP (orthostatic) and Pulse Pay attention to BP (orthostatic) and PulseHEENT EOMs - NYSTAGMUS EOMs - NYSTAGMUS Hearing HearingCVS Rate, rhythm, bruits, murmurs Rate, rhythm, bruits, murmursNeurologic Cranial nerves Cranial nerves Reflexes Reflexes Cerebellar Exam Cerebellar Exam Gait Gait Proprioception Proprioception

Peripheral VertigoCentral Vertigo Associated Symptoms  Nausea & vomiting, diaphoresis Associated Symptoms - Neurologic  Diplopia, dysphagia, facial numbness, ataxia, hemiparesis Auditory Complaints - tinnitus, hearing lossAuditory Complaints - infrequent Intense SymptomsLess Intense Symptoms Abrupt onsetGradual Onset Association with head traumaNot Usually Associated with Head Trauma Nystagmus  Horizontal or Rotary  by gaze fixation  Direction constant Nystagmus  Vertical or Multidirectional  by gaze fixation  Varies with direction of gaze

Causes of Peripheral Vertigo BPVBPV Due to deposition of calcium carbonate crystals in the posterior semi-circular canal Due to deposition of calcium carbonate crystals in the posterior semi-circular canal Repeated attacks of vertigo lasting a few seconds Repeated attacks of vertigo lasting a few seconds Aggravated by changes in posture, typically turning ones head while lying in bed Aggravated by changes in posture, typically turning ones head while lying in bed No hearing loss or tinnitus No hearing loss or tinnitus Usual onset in the 60s – 70s Usual onset in the 60s – 70s Dix-Hallpike diagnostic and often therapeutic Dix-Hallpike diagnostic and often therapeutic Rotary nystagmus Rx – Gravol, eply maneuver Rx – Gravol, eply maneuver

Causes of Peripheral Vertigo LabyrithitisLabyrithitis Viral infection of labyrinth, rarely associated with otitis media Viral infection of labyrinth, rarely associated with otitis media Severe vertigo associated with hearing loss Severe vertigo associated with hearing loss Tx - Self limited, Gravol, decongestants Tx - Self limited, Gravol, decongestants Meniere`s DiseaseMeniere`s Disease Due to endolymphatic system dilation and degeneration of cochlear hair cells. Due to endolymphatic system dilation and degeneration of cochlear hair cells. Recurrent attacks of severe vertigo, vomiting and tinnitus Recurrent attacks of severe vertigo, vomiting and tinnitus Associated with progressive deafness Associated with progressive deafness Typical presentation is patient with progressive hearing loss who develops sudden severe attacks of vertigo which last for 30min to several hours before abating Typical presentation is patient with progressive hearing loss who develops sudden severe attacks of vertigo which last for 30min to several hours before abating severity and frequency of attacks decrease as deafness increases severity and frequency of attacks decrease as deafness increases Tx - Bed rest acutely, ENT, surgical ablation of labyrinth Tx - Bed rest acutely, ENT, surgical ablation of labyrinth

Peripheral Vertigo Vestibular NeuronitisVestibular Neuronitis Illness of suspected viral origin, may be mild encephalitis usually follows URTI Illness of suspected viral origin, may be mild encephalitis usually follows URTI Vertigo without hearing loss +/- tinnitus Vertigo without hearing loss +/- tinnitus Abnormal caloric testing Abnormal caloric testing Tx - Time limited, residual symptoms may last for weeks. Tx - Time limited, residual symptoms may last for weeks. Vestibulococclear Nerve Lesions, CP angle tumorsVestibulococclear Nerve Lesions, CP angle tumors Acoustic schwannomas, meningiomas Acoustic schwannomas, meningiomas Preceded by hearing loss, associated neurologic symptoms - ipsilateral corneal reflex impairment, facial weakness, cerebellar signs Preceded by hearing loss, associated neurologic symptoms - ipsilateral corneal reflex impairment, facial weakness, cerebellar signs Patients complain of unsteadiness more than vertigo Patients complain of unsteadiness more than vertigo Tx – Neurology / Neurosurgery consult Tx – Neurology / Neurosurgery consult

Causes of Central Vertigo 1.Cerebellar Hemorrhage or infarction Vertigo, ataxia, headache Vertigo, ataxia, headache May have conjugate eye deviation to the opposite side of the lesion May have conjugate eye deviation to the opposite side of the lesion Patients unable to maintain body position Patients unable to maintain body position Neurology consult and MRI/CT head STAT Neurology consult and MRI/CT head STAT 2.Brainstem Infarction or hemorrhage of brainstem produces vertigo as one of a large constellation of symptoms...dysphagia, dysphonia, facial numbness, absent corneal reflex, ipsilateral Horner`s, deficits in CN VI, VII, VIII. Infarction or hemorrhage of brainstem produces vertigo as one of a large constellation of symptoms...dysphagia, dysphonia, facial numbness, absent corneal reflex, ipsilateral Horner`s, deficits in CN VI, VII, VIII. STAT neurology/neurosurgery consult…often little can be done for these patients STAT neurology/neurosurgery consult…often little can be done for these patients Prognosis poor Prognosis poor 3.Multiple Sclerosis Vertigo can be produced by demyelinating lesions in the brainstem Vertigo can be produced by demyelinating lesions in the brainstem Vertigo is the presenting symptom in 5% of cases Vertigo is the presenting symptom in 5% of cases

MISC Disequilibrium Syndrome Disequilibrium Syndrome ill-defined dizziness resulting from multiple sensory abnormalities Usually in elderly Hyperventilation Syndrome Hyperventilation Syndrome Anxiety Anxiety Near Syncope, hypoglycemia Near Syncope, hypoglycemia Migraine Aura Migraine Aura Drugs / Ototoxins Drugs / Ototoxins Aminoglycosides, saliculates, ethanol, phenytoin, quinine, benzene, arsenic

Treatment Therapy depends on the etiology of the vertigo. 1. Symptomatic relief Rehydration - esp. in patients with vomiting and the elderly Rehydration - esp. in patients with vomiting and the elderly Bed rest in comfortable position Bed rest in comfortable position Medications for symptomatic relief Medications for symptomatic relief antihistamines, anticholinergics, antiemetics and benzodiazapies 2. Eply Maneuver for BPPV First Dix-Hallpike test performed – patient’s head rotated 45 degrees to the right First Dix-Hallpike test performed – patient’s head rotated 45 degrees to the right Once nystagmus stops, rotate head until body is face down (hold sec) Once nystagmus stops, rotate head until body is face down (hold sec) Bring patient back to seated position with head turned over left shoulder Bring patient back to seated position with head turned over left shoulder  80% success rate in BPV 3. Reassurance…symptoms of vertigo though distressing are usuall benign and self limited.

Take Home Points 1.Determine what the patient’s symptoms truly are – vertigo vs lightheadedness 2.Central vs Peripheral origin 3.Symptomatic treatment for benign, self- limited conditions 4.Referral for any suspected intracranial lesions