What is Vertigo?

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 of Vertigo

• 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.

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 of Vertigo

• 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