Vertigo

What is Vertigo?

Definition:

Vertigo is sensation of movement , either of the patient in relation to the their environment or environment in relation to the patient.

What is the difference between Vertigo and Dizziness?

Dizziness:

Difficult to define, may result form conditions of the inner  ear or non ear conditions. Key – a good history to differentiate whether its vertigo or not.

Disequilibrium:

The sense of feeling off  balance without any actual sensation of movement.

Presyncope:

the feeling of light headedness, often without any sensation of movement and often accompanied by a sense of impending loss of consciousness.

Symptoms:

  • Usually caused by the dysfunctio Symptom  rather  than  a disease.
  • Usually caused by the dysfunction of the middle ear.
  • Means  different things to different people.
  • Often has a rotational or spinning component.
  • Means  different things to different people.
  • Often has a rotational or spinning component.
  • Vertigo is not a general imbalance or a light headedness or faint like disorientation n of the middle ear.

Anatomy and physiology:

  • Inner ear is about 2cm long and has 2 main parts.
  • The cochlea and the vestibular system.
  • The vestibular system comprised of
  • 3 semicircular canals -3 diff planes
  • Otolith organs
  • The cochlea is concerned with hearing while the  vestibular system deals with balance.

History:

  • Onset of the symptoms
  • Describe the symptoms
  • Tell me what it feels like ?
  • Avoid leading Q.
  • Patient might make a gesture using  the hand or the finger often a rotational movement ( This usually suggest U/L disease.)
  • Time course : Is it worsening resolving or fluctuating?

Associated Symptoms:

– Nausea

– Anxiety

– Neurological symptoms

Are the episodes spontaneous or provoked ( eg: Head movement).

H/O Ear Symptoms:

  • Earache, discharge, tinnitus, hearing loss
  • Neurological symptoms
  • Ophthalmological symptoms
  • Family history
  • Other RF for inner ear disease

– Head injury

– Whiplash injury

– Ototoxic medication

How to make sure that this is vertigo or something else?

– How sure  am I that this is only a peripheral  vestibular disorder?

– Should I seek ENT / Neuro/ Medical advise?

– Is this BPPV ?  Is Epley’s  manoeuvre indicated?

Examination:

  • Balance.
  • Gait- pt with vestibular pathology may  turn sharply  towards the side of the lesion and use a wide based gait.
  • Otoscopy and tuning folk test for hearing.
  • Eyes- eye movements, nystagmus.
  • CNS examination- cerebellar signs, CN.

Start observing while patient walks into the room ( patient with a vestibular D, often stares at the floor to keep the balance especially in an unfamiliar setting).

Peripheral causes of  Vertigo:

  • Vestibular Neuronitis
  • BPPV
  • Meniere’s Disease
  • Recurrent vestibulopathy

Vestibular Neuronitis and Labrynthitis:

  • Cause unknown.
  • Could be due to  viral infection, therefore could have preceding URTI.
  • Typically pt present with features of vertigo which lasts for days to weeks.
  • Nystagmus  is usually present.
  • Acute labrynthitis is form of vestibular neuronitis, which involves a single attack of vertigo, with hearing loss and often tinnitus.
  • Hearing loss and tinnitus is often helpful to lateralise the lesion.

Note – sudden onset hearing loss is an emergency.

  • Rx   – Vestibular sedatives – prochloroperazine ,
  • Should not be prescribed more than a week

as prolonged vestibular sedation interrupts the process of recalibration process and hinder the recovery.

BPPV:

  • Self limiting , resolves spontaneously.
  • Episodes of vertigo with nausea and general imbalance,  lasting up to a minute.
  • Usually precipitated by certain head movements.
  • Often lasting no longer than few months.
  • Dix- Hallpike positional testing is diagnostic and  is treated with performing Epley’s manoeuvre.

Meniere’s Disease:

  • Triad of vertigo, hearing loss and tinnitus
  • Often describes an association of the feeling fullness in ear canal
  • Episodes lasts for 30minutes to several hours.
  • Difference with vestibular neuronitis
  • Vestibular neuronitis :  Single Attack
  • Meniere’s   : multiple  attacks

Meniere’s Disease:

  • all new cases need to be referred to ENT.
  • regulating salt and fluid intake, caffeine and smoking reduction  has shown some benefit.
  • Vestibular sedatives – prochloroperazine for acute phase.
  • Betahistine – for maintenance.

Recurrent Vestibulopathy:

  • Recurrent vertigo ,
  • Episodes which last from 5 minutes to 24 hours,
  • Occur in the absence of auditory or neurological symptom or signs.
  • The spells occur without a prodrome and with not provoked  particular movement.

 

Onset Duration Precipitants Associations
Vestibular neuronitis Sudden Constant for many hours / even a day Viral illness Nausea , vomiting
BPPV Intermittent Up to 60 seconds Head movements None
Meniere’s disease Intermittent Unpredictable , may  hours Tinnitus

Deafness

Aural fullness

Recurrent vestibulopathy Intermittent Episodes last minutes to hours

Central vestibular Disorders:

  • CVA, brain tumours, MS.
  • Do not exhibit vertigo as their only presenting symptom.
  • Often present with associated  neurological deficits.
  • CN examination, fundoscopy , neuro examination mandatory.

Vestibular Migraine:

  • Migraine associated with dizziness.
  • Often incorrectly diagnosed as Meniere’s.
  • Presents with the classic symptoms of  Meniere’s.
  • Only difference is presence of other classic signs of migraine ( aura, photophobia and headache).

Can allergy cause Vertigo?

  • Yes, when associated with allergic rhinitis. when allergens enter the body through mouth and nose, then body tries to push it out with mucus.
  • Unfortunately body produces excess amount of mucus with some fluid. this build up of fluid and mucus in sinuses affects vestibular system.
  • The vestibular system and the eustachian tube are responsible of  sense of balance.
  • So if the eustachian tube is blocked then variety of symptoms develop  like these include  dizziness,  vertigo, nausea and   vomiting.

Key Points:

  • Good  history.
  • 3 common peripheral vestibular disorders , distinguished from history by identifying the duration of the symptoms and associated symptoms.
  • R/O important central causes for vertigo.

Can We Use Meclizine For Vertigo?

  • Yes, in case  of patients having vertigo with allergic rhinitis we can use  meclizine or any other.
  • Anti histamine  I.E
  • Meclizine or
  • Cinnarizine

Treatment:

  • Anti histamines
  • I.E
  • Meclizine
  • Cinnarizine

 

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