VERTIGOVERTIGO

A guide to diagnosis of otologic A guide to diagnosis of otologic causes of dizzinesscauses of dizziness

Dr Nadina ThwaitesDr Nadina ThwaitesGeneral Practitioner and MOSS ORL CMDHBGeneral Practitioner and MOSS ORL CMDHB

Does the patient have vertigo?Does the patient have vertigo?

The sensation of moving or falling caused by an The sensation of moving or falling caused by an asymmetrical abnormality in the vestibular asymmetrical abnormality in the vestibular system. system.

Pathological vertigo arises due to damage or Pathological vertigo arises due to damage or dysfunction of the labyrinth, vestibular nerve or dysfunction of the labyrinth, vestibular nerve or central vestibular structures in the brainstem.central vestibular structures in the brainstem.

Minimum vertigo historyMinimum vertigo history

Duration of attack Duration of attack –– seconds, hours, daysseconds, hours, daysFrequency Frequency –– daily vs. monthlydaily vs. monthlyEffect of head movements Effect of head movements –– worse, better or nil worse, better or nil effecteffectSpecific positions that induce symptomsSpecific positions that induce symptomsOther triggers Other triggers –– ValsalvaValsalva, loud noise, trauma, loud noise, traumaAssociated aural symptomsAssociated aural symptomsConcomitant ear diseaseConcomitant ear disease

Are the symptoms episodic or Are the symptoms episodic or continuous?continuous?

Most vestibulopathies cause fluctuating or Most vestibulopathies cause fluctuating or episodic symptomsepisodic symptoms

However there may be a constant sense of However there may be a constant sense of dysequilibrium in addition to the variable dysequilibrium in addition to the variable symptomssymptoms

Does the patient have medical problems Does the patient have medical problems which contribute?which contribute?

Underlying medical problems may give clues to Underlying medical problems may give clues to causecause–– diabetesdiabetes–– vascular diseasevascular disease–– anaemiaanaemia–– thyroid diseasethyroid disease–– autoimmune diseaseautoimmune disease–– postural hypotensionpostural hypotension–– arrhythmiaarrhythmia–– migrainemigraine

Other contributing factorsOther contributing factors

Some medication can produce symptoms Some medication can produce symptoms mimicking vestibular disordersmimicking vestibular disorders–– Vestibulotoxicity :Vestibulotoxicity : aminoglycosides, aminoglycosides,

antiepileptics,methotrexateantiepileptics,methotrexate–– CNS depression :CNS depression : benzodiazepines, antihistamines, benzodiazepines, antihistamines,

tricyclics, Etohtricyclics, Etoh–– Hypotension :Hypotension : antihypertensives, diureticsantihypertensives, diuretics–– Inner ear haemorrhage :Inner ear haemorrhage : anticoagulantsanticoagulants

What other symptoms are What other symptoms are associated?associated?

Aural fullness, deafness and tinnitus in MeniereAural fullness, deafness and tinnitus in Meniere’’s s diseasedisease

Headache, photophobia and sonophobia in migrainous Headache, photophobia and sonophobia in migrainous vertigovertigo

Unilateral tinnitus and high frequency SNHL, with a Unilateral tinnitus and high frequency SNHL, with a history of sudden pressure change (barotrauma) may history of sudden pressure change (barotrauma) may indicate development of an acute traumatic perilymph indicate development of an acute traumatic perilymph fistula.fistula.

What other symptoms are What other symptoms are associated?associated?

Vertigo in MS may have other neurological symptoms or Vertigo in MS may have other neurological symptoms or signssigns

Dysarthria, dysphagia, diplopia, weakness or Dysarthria, dysphagia, diplopia, weakness or parasthesia may indicate vertebrobasilar CVA with parasthesia may indicate vertebrobasilar CVA with acute onset vertigo. acute onset vertigo.

NB vertigo can be only symptom in cerebellar infarctionNB vertigo can be only symptom in cerebellar infarction

Shortness of breath, palpitations and sweating may be Shortness of breath, palpitations and sweating may be panic attack or arrythmiapanic attack or arrythmia

Are there psychological factors Are there psychological factors involved?involved?

Anxiety and panic symptoms and agoraphobia can Anxiety and panic symptoms and agoraphobia can lead to episodic symptoms which mimic lead to episodic symptoms which mimic vestibulopathy.vestibulopathy.

Hyperventilation syndromeHyperventilation syndrome

True vertigo?

No Consider non ORL causes

Non vestibular causes to considerNon vestibular causes to consider

Postural hypotension Postural hypotension Arrhythmia Arrhythmia Hyperventilation syndrome Hyperventilation syndrome Migraine Migraine Hypertension Hypertension AnaemiaAnaemiaHypoglycaemiaHypoglycaemiaEpilepsy Epilepsy Presyncope (vasovagal) Presyncope (vasovagal) Psychogenic Psychogenic Acute drug induced (eg EtOH)Acute drug induced (eg EtOH)

True vertigo?

History•Duration•Frequency•Associated •features•Provocation

Yes No Consider non ORL causes

Neurological and cardiovascular examNeurological and cardiovascular exam

Postural BPPostural BPAuscultation for carotid bruitsAuscultation for carotid bruitsRomberg test, tandem walking and stepping testsRomberg test, tandem walking and stepping testsCoordination tests Coordination tests ––past pointingpast pointing

True vertigo?

History•Duration•Frequency•Provocation

Yes No Consider non ORL causes

Neurological and Cardiovascular examination normal ? No Consider central causes

Central vestibular causes to considerCentral vestibular causes to consider

Vertebrobasilar insufficiencyVertebrobasilar insufficiencyCerebellar infarctionCerebellar infarctionBrainstem tumourBrainstem tumourDemyelinating diseases Demyelinating diseases Migrainous vertigoMigrainous vertigo

True vertigo?

History•Duration•Frequency•Provocation

Yes No Consider non ORL causes

Neurological and Cardiovascular examination normal ?

ORL specific examination•Otoscopy•Tuning fork•Dix Hallpike•Nystagmus•Basic vestibulo ocular reflexes

No Consider central causes

If diagnosis still unclear refer to ORL for complex investigations

ORL examinationORL examination

Otoscopy Otoscopy Tuning fork tests Tuning fork tests –– Weber and RinneWeber and RinneNystagmus Nystagmus –– spontaneous directional or gaze spontaneous directional or gaze evokedevokedBasic vestibuloBasic vestibulo--ocular reflexes (VORs)ocular reflexes (VORs)Dix Hallpike manoeuvreDix Hallpike manoeuvre

Vestibuloocular reflexVestibuloocular reflex

Functions to keep vision steady during head Functions to keep vision steady during head movementsmovementsLoss of this function can be detected in 4 ways:Loss of this function can be detected in 4 ways:2 methods are suitable for simple testing2 methods are suitable for simple testing–– Head thrust Head thrust –– Head shaking VAHead shaking VA

Frenzel lenses and caloric testing for other 2Frenzel lenses and caloric testing for other 2–– Specialized clinicsSpecialized clinics

Vestibuloocular reflexesVestibuloocular reflexes

Head shaking visual acuityHead shaking visual acuity–– Compare normal VA to VA during head shakeCompare normal VA to VA during head shake–– Poor VOR if head shake VA is 4 lines or more worse Poor VOR if head shake VA is 4 lines or more worse

than head still VAthan head still VA

Head thrust test :Head thrust test :–– unidirectional rapid head movements while maintaining unidirectional rapid head movements while maintaining

visual fixationvisual fixation–– Abnormal result = eyes move from target = peripheral Abnormal result = eyes move from target = peripheral

lesion on side of head thrust directionlesion on side of head thrust direction

ORL causes to considerORL causes to consider

BPPVBPPVMeniereMeniere’’s diseases diseaseChronic OMChronic OMVestibular neuronitis/labyrinthitisVestibular neuronitis/labyrinthitisLabyrinthine concussionLabyrinthine concussionHerpes Zoster oticus (Ramsay Hunt)Herpes Zoster oticus (Ramsay Hunt)Perilymphatic fistulaPerilymphatic fistulaOtotoxic drug useOtotoxic drug useVestibular schwanomaVestibular schwanoma

Benign paroxysmal positional Benign paroxysmal positional vertigo vertigo -- BPPVBPPV

HistoryHistory

ReproducibleReproducible : provoked by stereotypical position : provoked by stereotypical position change change Recurrent Recurrent : episodes continuing for weeks or : episodes continuing for weeks or monthsmonthsBriefBrief : episodes of vertigo <1 minute : episodes of vertigo <1 minute Self limited : Self limited : episodes diminish over time but may episodes diminish over time but may recur in futurerecur in future

Poor response to antiPoor response to anti--vertigo drugsvertigo drugs

InvestigationInvestigation

Normal otoscopy, tuning fork tests and audiogramNormal otoscopy, tuning fork tests and audiogramDiagnostic positional manoeuvres Diagnostic positional manoeuvres –– Dix HallpikeDix Hallpiketesttest•• LatencyLatency of response 2of response 2--20 seconds20 seconds•• Short durationShort duration <1 minute<1 minute•• NystagmusNystagmus in one direction in one direction •• ReproducibleReproducible•• FatigabilityFatigability

Management of BPPVManagement of BPPV

EpleyEpley manoeuvre manoeuvre -- canalithiasis repositioning in canalithiasis repositioning in clinicclinic

Modified EpleyModified Epley –– self treatment of BPPVself treatment of BPPV

MeniereMeniere’’s Diseases Disease

Idiopathic endolymphatic hydropsIdiopathic endolymphatic hydrops–– Swelling of the endolymphatic compartment of Swelling of the endolymphatic compartment of

the inner ear with ? endolymphatic fluid the inner ear with ? endolymphatic fluid accumulationaccumulation

Hard to diagnose on first presentationHard to diagnose on first presentation

HistoryHistory

RecurrentRecurrent : episodes lasting hours to days: episodes lasting hours to days

SpontaneousSpontaneous onset : no provocationonset : no provocation

Aural fullnessAural fullness : may precede episode: may precede episode

Hearing loss and tinnitus : Hearing loss and tinnitus : may accompany episodemay accompany episode

InvestigationInvestigation

Normal otoscopyNormal otoscopy

Tuning fork tests Tuning fork tests –– Weber to contralateral ear Weber to contralateral ear

Unilateral low frequency sensorineural hearing loss, Unilateral low frequency sensorineural hearing loss, usually peaking at 2kHzusually peaking at 2kHz

Nystagmus Nystagmus -- horizontal / torsional, suppresses with horizontal / torsional, suppresses with fixation, no direction change with gazefixation, no direction change with gaze

ManagementManagement

Symptomatic relief : Symptomatic relief : antianti--emeticsemetics , sedatives, sedatives

Vasodilators : Vasodilators : BetahistineBetahistine

Dietary modification : Dietary modification : low salt dietlow salt dietOsmotic diuretics : Osmotic diuretics : ureaurea

Refer new cases non urgently for audiology and Refer new cases non urgently for audiology and specialist reviewspecialist review

Acute peripheral vestibulopathyAcute peripheral vestibulopathy

Aka vestibular neuritis or Aka vestibular neuritis or ““ labyrinthitislabyrinthitis””Unknown aetiology ? ViralUnknown aetiology ? ViralYounger adultsYounger adultsUnilateral lesion of peripheral vestibular pathway especially Unilateral lesion of peripheral vestibular pathway especially vestibular nerve or labyrinthvestibular nerve or labyrinth

Sudden severe vertigo with nausea and vomitingSudden severe vertigo with nausea and vomitingDirection fixed nystagmus, increases in intensity with gaze Direction fixed nystagmus, increases in intensity with gaze toward the affected ear.toward the affected ear.Some improvement in 24hrs , then more slowly over Some improvement in 24hrs , then more slowly over coming weekscoming weeks

Perilymph fistulaPerilymph fistula

Due to minute leak of fluid from perilymphatic compartment Due to minute leak of fluid from perilymphatic compartment of inner ear into middle earof inner ear into middle earHistory History –– congenital ear disease congenital ear disease –– significant strainingsignificant straining–– rapid descent without equalisation during divingrapid descent without equalisation during diving

Findings Findings –– unilateral SNHLunilateral SNHL–– direction fixed nystagmusdirection fixed nystagmus–– Fistula signFistula sign

Need urgent specialist referral Need urgent specialist referral

SummarySummary

50 % dizziness is vertigo50 % dizziness is vertigo80 % vertigo is peripheral80 % vertigo is peripheral–– 3535--40% is BPPV40% is BPPV–– 20% vestibular neuritis20% vestibular neuritis–– 55--10% Meniere10% Meniere’’s diseases disease

So have a go!So have a go!–– Only audiogram, Frenzel, calorics, MRI to be doneOnly audiogram, Frenzel, calorics, MRI to be done

Refer what doesnRefer what doesn’’t fit a pattern t fit a pattern Include as much information as possibleInclude as much information as possible

ACUTE SPONTANEOUS VERTIGOACUTE SPONTANEOUS VERTIGO

HISTORY

Viral illness, Otitis media, head traumaVascular disease, previous CVA/TIA

Systemic disease, syphilis

EXAMINATION

- Severe imbalance- Focal neurological signs- Nystagmus = direction changing

- Moderate imbalance- Normal hearing-Nystagmus = spontaneousunidirectional

- Moderate imbalance- Unilateral hearing loss-Nystagmus = spontaneousunidirectional

MRI Treat symptoms& observe

FBC,ESR & VDRL

Viral labyrinthitis, syphilitic labyrinthitis,mastoiditisLabyrinthine infarct, labyrinthine concussionAutoimmune inner ear disease

No betterin 48hrs

Much betterin 48hrs

Cerebellar infarct or haemorrhageBrainstem infarctMultiple sclerosis

MRI Vestibularneuritis

RECURRENT SPONTANEOUS ATTACKS OF RECURRENT SPONTANEOUS ATTACKS OF VERTIGOVERTIGO

HISTORY

Age of onset, duration of attacksAssociated hearing lossAssociated neurological symptomsMigraine history, Autoimmune disease

EXAMINATION

Focal neurologicalfindings

Unilateral hearing loss

Normal

MRIAudiogram

Asymmetrichearing

Normal

FBC,ESRVDRL Meniere’s

Autoimmune dxSyphilis

MigraineVertebrobasilar

ischaemia

VertebrobasilarIschaemia

Multiple sclerosis

RECURRENT EPISODES POSITIONAL VERTIGORECURRENT EPISODES POSITIONAL VERTIGOHISTORY

Prior ear infectionHead trauma

Neurological symptoms

EXAMINATION

- Fatigable torsionalpositioning nystagmus

- Normal hearing

- Non fatigable pure vertical positioning nystagmus

- Assoc neurological signs

Positioningmanoeuvres

MRI

Positional vertigo and nystagmus disappear

BENIGN POSITIONALPAROXYSMAL VERTIGO

Cerebellar tumourMultiple sclerosisCerebellar atrophy