Vertigo and dizziness

Vertigo and DizzinessVertigo and Dizziness

Presented by A. Hillier, D.O.Presented by A. Hillier, D.O.

EM Resident EM Resident

St. John West Shore HospitalSt. John West Shore Hospital

Vertigo and DizzinessVertigo and Dizziness PrevalencePrevalence

1 in 5 adults report dizziness in last month1 in 5 adults report dizziness in last month Increases in elderlyIncreases in elderlyWorsened by decreased visual acuity, Worsened by decreased visual acuity,

proprioception and vestibular inputproprioception and vestibular input Dizziness Dizziness

Non-specific termNon-specific termDifferent meanings to different peopleDifferent meanings to different people

Could meanCould mean- VertigoVertigo - Syncope- Syncope - -

PresyncopePresyncope- WeakWeak - Giddiness- Giddiness - Anxiety- Anxiety- AnemiaAnemia - Depression- Depression - -

UnsteadyUnsteady


VertigoVertigoPerception of movementPerception of movementPeripheral or CentralPeripheral or Central

SyncopeSyncopeTransient loss of consciousness with loss of Transient loss of consciousness with loss of

postural tonepostural tone


PresyncopePresyncopeLightheadedness-an impending loss of Lightheadedness-an impending loss of

consciousnessconsciousnessPsychiatric dizzinessPsychiatric dizziness

Dizziness not related to vestibular dysfunctionDizziness not related to vestibular dysfunctionDisequilibriumDisequilibrium

Feeling of unsteadiness, imbalance or Feeling of unsteadiness, imbalance or sensation of “floating” while walkingsensation of “floating” while walking

Vestibular LabyrinthVestibular Labyrinth PathophysiologyPathophysiology

Complex interaction of visual, vestibular and Complex interaction of visual, vestibular and proprioceptive inputs that the CNS integrates as proprioceptive inputs that the CNS integrates as motion and spatial orientationmotion and spatial orientation

3 semicircular canals3 semicircular canals rotational movementrotational movement cupulacupula

2 otolithic organs 2 otolithic organs utricle & sacculeutricle & saccule linear accelerationlinear acceleration MaculaMacula


Normally there is balanced input from both Normally there is balanced input from both vestibular systemsvestibular systems

Vertigo develops from asymmetrical vestibular Vertigo develops from asymmetrical vestibular activityactivity

Abnormal bilateral vestibular activation results Abnormal bilateral vestibular activation results in truncal ataxiain truncal ataxia

Vertigo and DizzinessVertigo and Dizziness NystagmusNystagmus

Rhythmic slow and fast eye movementRhythmic slow and fast eye movement Direction named by fast component Direction named by fast component Slow component due to vestibular or brainstem activitySlow component due to vestibular or brainstem activity Slow component usually ipsilateral to diseased structureSlow component usually ipsilateral to diseased structure Fast component due to cortical correctionFast component due to cortical correction

Physiologic VertigoPhysiologic Vertigo ““motion sickness”motion sickness” A mismatch between visual, proprioceptive and A mismatch between visual, proprioceptive and

vestibular inputsvestibular inputs Not a diseased cochleovestibular system or CNSNot a diseased cochleovestibular system or CNS

Vertigo-Differential DiagnosesVertigo-Differential Diagnoses Etiologies of VertigoEtiologies of Vertigo

BPPVBPPV LabyrintitisLabyrintitis

Acute suppurativeAcute suppurative SerousSerous ToxicToxic ChronicChronic

Vestibular neuronitisVestibular neuronitis Vestibular ganglionitisVestibular ganglionitis Ménière’sMénière’s Acoustic neuromaAcoustic neuroma Perilymphatic fistulaPerilymphatic fistula Cerumen impactionCerumen impaction

CNS infection (TB, Syphillis)CNS infection (TB, Syphillis) Tumor (Benign or Neoplastic)Tumor (Benign or Neoplastic) Cerebellar infarctCerebellar infarct Cerebellar hemorrhageCerebellar hemorrhage Vertebrobasilar insufficiencyVertebrobasilar insufficiency AICA syndromeAICA syndrome PICA syndromePICA syndrome Multiple SclerosisMultiple Sclerosis Basilar artery migraineBasilar artery migraine HypothyroidismHypothyroidism HypoglycemiaHypoglycemia TraumaticTraumatic Hematologic (Waldenstroms)Hematologic (Waldenstroms)

Vertigo-HistoryVertigo-History Is it true vertigo?Is it true vertigo? Autonomic Autonomic

symptoms?symptoms? Pattern of onset and Pattern of onset and

durationduration Auditory Auditory

disturbances?disturbances? Neurologic Neurologic

disturbances?disturbances? Was there syncope?Was there syncope?

Unusual eye Unusual eye movements?movements?

Any past head or Any past head or neck trauma?neck trauma?

Past medical history?Past medical history? Previous symptoms?Previous symptoms? Prescribed and OTC Prescribed and OTC

medications?medications? Drug and alcohol Drug and alcohol

intake?intake?

Vertigo-Physical ExamVertigo-Physical Exam Cerumen/FB in EACCerumen/FB in EAC Otitis mediaOtitis media Pneumatic otoscopyPneumatic otoscopy Tympanosclerosis or TM Tympanosclerosis or TM

perforationperforation NystagmusNystagmus Fundoscopic exam Fundoscopic exam Pupillary abnormalitiesPupillary abnormalities Extraocular musclesExtraocular muscles Cranial nervesCranial nerves Internuclear ophthalmoplegiaInternuclear ophthalmoplegia

Auscultate for carotid bruitsAuscultate for carotid bruits Orthostatic vital signsOrthostatic vital signs BP and pulse in both armsBP and pulse in both arms Dix-Hallpike maneuverDix-Hallpike maneuver Gross hearingGross hearing Weber-Rinne testWeber-Rinne test External auditory canal vesiclesExternal auditory canal vesicles Muscle strengthMuscle strength Gait and Cerebellar functionGait and Cerebellar function

Dix-Hallpike ManeuverDix-Hallpike Maneuver

Figure 1.Figure 1. Dix-Hallpike maneuver (used to diagnose benign paroxysmal Dix-Hallpike maneuver (used to diagnose benign paroxysmal positional vertigo). This test consists of a series of two maneuvers: With the positional vertigo). This test consists of a series of two maneuvers: With the patient sitting on the examination table, facing forward, eyes open, the patient sitting on the examination table, facing forward, eyes open, the physician turns the patient's head 45 degrees to the right (A). The physician physician turns the patient's head 45 degrees to the right (A). The physician supports the patient's head as the patient lies back quickly from a sitting to supports the patient's head as the patient lies back quickly from a sitting to supine position, ending with the head hanging 20 degrees off the end of the supine position, ending with the head hanging 20 degrees off the end of the examination table. The patient remains in this position for 30 seconds (B). examination table. The patient remains in this position for 30 seconds (B). Then the patient returns to the upright position and is observed for 30 Then the patient returns to the upright position and is observed for 30 seconds. Next, the maneuver is repeated with the patient's head turned to seconds. Next, the maneuver is repeated with the patient's head turned to the left. A positive test is indicated if any of these maneuvers provide vertigo the left. A positive test is indicated if any of these maneuvers provide vertigo with or without nystagmus. with or without nystagmus.

Vertigo-CharacteristicsVertigo-CharacteristicsPeripheralPeripheral CentralCentral

OnsetOnset SuddenSudden Usually slowUsually slowSeverity of VertigoSeverity of Vertigo IntenseIntense Usually mildUsually mildPatternPattern ParoxysmalParoxysmal ConstantConstantExac. by movement Exac. by movement YesYes VariableVariableAutonomicAutonomic FrequentFrequent VariableVariableLateralityLaterality UnilateralUnilateral Uni or bilatUni or bilatNystagmusNystagmus HorizontorotaryHorizontorotary AnyAnyFatigable/FixationFatigable/Fixation YesYes NoNoAuditory symptomsAuditory symptoms YesYes NoNoTMTM May be abnormalMay be abnormal NormalNormalCNS symptomsCNS symptoms AbsentAbsent PresentPresent

Vertigo-Ancillary TestsVertigo-Ancillary Tests

CT-if cerebellar mass, hemorrhage or CT-if cerebellar mass, hemorrhage or infarction suspectedinfarction suspected

Glucose and ECG in the “dizzy” patientGlucose and ECG in the “dizzy” patientCold caloric testingCold caloric testingAngiography for suspected VBIAngiography for suspected VBIMRIMRIElectronystagmography and audiologyElectronystagmography and audiology

Peripheral Vertigo-DifferentialPeripheral Vertigo-Differential

Labyrinthine DisordersLabyrinthine DisordersMost common cause of true vertigoMost common cause of true vertigoFive entitiesFive entities

Benign paroxysmal positional vertigo (BPPV)Benign paroxysmal positional vertigo (BPPV)LabyrinthitisLabyrinthitisMénière diseaseMénière diseaseVestibular neuronitisVestibular neuronitisAcoustic NeuromaAcoustic Neuroma

Benign Paroxysmal Positional Benign Paroxysmal Positional VertigoVertigo

Extremely commonExtremely common Otoconia displacementOtoconia displacement No hearing loss or tinnitusNo hearing loss or tinnitus Short-lived episodes brought on by rapid Short-lived episodes brought on by rapid

changes in head positionchanges in head position Usually a single position that elicits vertigoUsually a single position that elicits vertigo Horizontorotary nystagmus with crescendo-Horizontorotary nystagmus with crescendo-

decrescendo pattern after slight latency perioddecrescendo pattern after slight latency period Less pronounced with repeated stimuliLess pronounced with repeated stimuli Typically can be reproduced at bedside with Typically can be reproduced at bedside with

positioning maneuverspositioning maneuvers

Otoconia in BPPVOtoconia in BPPV

LabyrinthitisLabyrinthitisAssociated hearing loss and tinnitusAssociated hearing loss and tinnitus Involves the cochlear and vestibular Involves the cochlear and vestibular

systemssystemsAbrupt onsetAbrupt onsetUsually continuousUsually continuousFour types of LabyrinthitisFour types of Labyrinthitis

SerousSerousAcute suppurativeAcute suppurativeToxicToxicChronicChronic

LabyrinthitisLabyrinthitis SerousSerous

Adjacent inflammation due to ENT or meningeal Adjacent inflammation due to ENT or meningeal infectioninfection

Mild to severe vertigo with nausea and vomitingMild to severe vertigo with nausea and vomiting May have some degree of permanent impairmentMay have some degree of permanent impairment

Acute suppurative labyrinthitisAcute suppurative labyrinthitis Acute bacterial exudative infection in middle earAcute bacterial exudative infection in middle ear Secondary to otitis media or meningitisSecondary to otitis media or meningitis Severe hearing loss and vertigoSevere hearing loss and vertigo Treated with admission and IV antibioticsTreated with admission and IV antibiotics

LabyrinthitisLabyrinthitisToxicToxic

Due to toxic effects of medicationsDue to toxic effects of medicationsStill relatively commonStill relatively commonMild tinnitus and high frequency hearing lossMild tinnitus and high frequency hearing lossVertigo in acute phaseVertigo in acute phaseAtaxia in the chronic phaseAtaxia in the chronic phaseCommon etiologiesCommon etiologies

-Aminoglycosides-Aminoglycosides -Vancomycin-Vancomycin-Erythromycin-Erythromycin -Barbiturates-Barbiturates-Phenytoin-Phenytoin -Furosemide-Furosemide-Quinidine-Quinidine -Salicylates-Salicylates-Alcohol-Alcohol

LabyrinthitisLabyrinthitisChronicChronic

Localized inflammatory process of the inner Localized inflammatory process of the inner ear due to fistula formation from middle to ear due to fistula formation from middle to inner earinner ear

Most occur in horizontal semicircular canalMost occur in horizontal semicircular canal

Etiology is due to destruction by a Etiology is due to destruction by a cholesteatomacholesteatoma

Vestibular NeuronitisVestibular NeuronitisSuspected viral etiologySuspected viral etiology

Sudden onset vertigo that increases in Sudden onset vertigo that increases in intensity over several hours and gradually intensity over several hours and gradually subsides over several dayssubsides over several days

Mild vertigo may last for several weeksMild vertigo may last for several weeks

May have auditory symptomsMay have auditory symptoms

Highest incidence in 3Highest incidence in 3rdrd and 5 and 5thth decades decades

Vestibular GanglionitisVestibular Ganglionitis Usually virally mediated-most often VZVUsually virally mediated-most often VZV

Affects vestibular ganglion, but also may affect Affects vestibular ganglion, but also may affect multiple ganglionsmultiple ganglions

May be mistaken as BPPV or Ménière diseaseMay be mistaken as BPPV or Ménière disease

Ramsay Hunt SyndromeRamsay Hunt Syndrome-Deafness-Deafness -Vertigo-Vertigo

-Facial Nerve Palsy-Facial Nerve Palsy -EAC Vesicles-EAC Vesicles

Ménière DiseaseMénière Disease

First described in 1861First described in 1861Triad of vertigo, tinnitus and hearing lossTriad of vertigo, tinnitus and hearing lossDue to cochlea-hydropsDue to cochlea-hydrops

Unknown etiologyUnknown etiologyPossibly autoimmunePossibly autoimmune

Abrupt, episodic, recurrent episodes with Abrupt, episodic, recurrent episodes with severe rotational vertigosevere rotational vertigo

Usually last for several hoursUsually last for several hours

Ménière DiseaseMénière Disease

Often patients have eaten a salty meal Often patients have eaten a salty meal prior to attacksprior to attacks

May occur in clusters and have long May occur in clusters and have long episode-free remissionsepisode-free remissions

Usually low pitched tinnitusUsually low pitched tinnitusSymptoms subside quickly after attackSymptoms subside quickly after attackNo CNS symptoms or positional vertigo No CNS symptoms or positional vertigo

are presentare present

Acoustic NeuromaAcoustic Neuroma

Peripheral vertigo that ultimately develops Peripheral vertigo that ultimately develops central manifestationscentral manifestations

Tumor of the Schwann cells around the 8Tumor of the Schwann cells around the 8 thth CN CN Vertigo with hearing loss and tinnitusVertigo with hearing loss and tinnitus With tumor enlargement, it encroaches on the With tumor enlargement, it encroaches on the

cerebellopontine angle causing neurologic signscerebellopontine angle causing neurologic signs Earliest sign is decreased corneal reflexEarliest sign is decreased corneal reflex Later truncal ataxiaLater truncal ataxia Most occur in women during 3Most occur in women during 3rdrd and 6 and 6thth decades decades

Central Vertigo-DifferentialCentral Vertigo-DifferentialCentral VertigoCentral Vertigo

Vertebrobasilar InsufficiencyVertebrobasilar Insufficiency Atheromatous plaqueAtheromatous plaque Subclavian Steal Syndrome Subclavian Steal Syndrome Drop AttackDrop Attack Wallenberg SyndromeWallenberg Syndrome

Cerebellar HemorrhageCerebellar Hemorrhage Multiple SclerosisMultiple Sclerosis

Head TraumaHead Trauma Neck InjuryNeck Injury Temporal lobe seizureTemporal lobe seizure Vertebral basilar Vertebral basilar

migrainemigraine Metabolic Metabolic

abnormalitiesabnormalities HypoglycemiaHypoglycemia HypothyroidismHypothyroidism

Vertebrobasilar InsufficiencyVertebrobasilar Insufficiency Important causes of central vertigoImportant causes of central vertigo

Related to decreased perfusion of Related to decreased perfusion of vestibular nuclei in brain stemvestibular nuclei in brain stem

Vertigo may be a prominent symptom with Vertigo may be a prominent symptom with ischemia in basilar artery territoriesischemia in basilar artery territories

Unusual for vertigo to be only symptom of Unusual for vertigo to be only symptom of ischemiaischemia

Vertebrobasilar InsufficiencyVertebrobasilar Insufficiency Most commonly will also have:Most commonly will also have:

-Dysarthria-Dysarthria -Ataxia-Ataxia -Facial -Facial numbnessnumbness

-Hemiparesis-Hemiparesis -Diplopia-Diplopia -Headache-Headache

Tinnitus and hearing loss unlikelyTinnitus and hearing loss unlikely

Vertical nystagmus is characteristic of a Vertical nystagmus is characteristic of a (superior colliculus) brain stem lesion(superior colliculus) brain stem lesion

Up to 30% of TIA’s are VBI with pontine Up to 30% of TIA’s are VBI with pontine symptoms and a focal neurologic lesionsymptoms and a focal neurologic lesion

Drop attackDrop attack

Abruptly falls without warning, but does Abruptly falls without warning, but does not loose consciousnessnot loose consciousness

Believed to be caused by transient Believed to be caused by transient quadraparesis due to ischemia at the quadraparesis due to ischemia at the pyramidal decussationpyramidal decussation

Subclavian Steal SyndromeSubclavian Steal Syndrome

Rare, but treatableRare, but treatable

Arm exercise on side of stenotic Arm exercise on side of stenotic subclavian artery usually causes subclavian artery usually causes symptoms of intermittent claudicationsymptoms of intermittent claudication

Blood is shunted away from brainstem into Blood is shunted away from brainstem into ipsilateral vertebral arteryipsilateral vertebral artery

Classic history occurs only rarelyClassic history occurs only rarely

Wallenberg SyndromeWallenberg Syndrome

Occlusion of PICAOcclusion of PICA

Relatively common cause of central vertigoRelatively common cause of central vertigo

Associated Symptoms:Associated Symptoms:-nausea-nausea -vomiting-vomiting -nystagmus-nystagmus-ataxia -ataxia -Horner syndrome -Horner syndrome -palate, pharynx and laryngeal paresis-palate, pharynx and laryngeal paresis-loss of pain and temperature on ipsilateral -loss of pain and temperature on ipsilateral face and contralateral body face and contralateral body

Cerebellar HemorrhageCerebellar Hemorrhage Neurosurgical emergencyNeurosurgical emergency

Suspected in any patient with sudden onset Suspected in any patient with sudden onset headache, vertigo, vomiting and ataxiaheadache, vertigo, vomiting and ataxia

May have gaze preferenceMay have gaze preference

Motor-sensory exam usually normalMotor-sensory exam usually normal

Gait disturbance often not recognized because Gait disturbance often not recognized because patient appears too ill to movepatient appears too ill to move

Multiple SclerosisMultiple Sclerosis Vertigo is presenting symptom in 7-10%Vertigo is presenting symptom in 7-10% Thirty percent develop vertigo in the course of Thirty percent develop vertigo in the course of

the diseasethe disease May have any type of nystagmusMay have any type of nystagmus Internuclear ophthalmoplegia is virtually Internuclear ophthalmoplegia is virtually

pathognomonicpathognomonic Onset during 2Onset during 2ndnd to 4 to 4thth decade decade Rare after 5Rare after 5thth decade decade Usually will have had previous neurological Usually will have had previous neurological

symptomssymptoms

Head and Neck TraumaHead and Neck Trauma

Due to damage to the inner ear and central Due to damage to the inner ear and central vestibular nuclei, most often labyrinthine concussionvestibular nuclei, most often labyrinthine concussion

Temporal skull fracture may damage the labyrinth or Temporal skull fracture may damage the labyrinth or eighth cranial nerveeighth cranial nerve

Vertigo may occur 7-10 days after whiplashVertigo may occur 7-10 days after whiplash Persistent episodic flares suggest perilymphatic Persistent episodic flares suggest perilymphatic

fistulafistula Fistula may provide direct route to CNS infectionFistula may provide direct route to CNS infection

Vertebral Basilar MigraineVertebral Basilar Migraine

Syndrome of vertigo, dysarthria, ataxia, visual Syndrome of vertigo, dysarthria, ataxia, visual changes, paresthesias followed by headachechanges, paresthesias followed by headache

Distinguishing features of basilar artery migraineDistinguishing features of basilar artery migraine-Symptoms precede headache-Symptoms precede headache

-History of previous attacks-History of previous attacks

-Family history of migraine-Family history of migraine

-No residual neurologic signs-No residual neurologic signs

Symptoms coincide with angiographic evidence Symptoms coincide with angiographic evidence of intracranial vasoconstrictionof intracranial vasoconstriction

Metabolic AbnormalitiesMetabolic Abnormalities

HypoglycemiaHypoglycemia Suspected in any patient with diabetes with associated Suspected in any patient with diabetes with associated

headache, tachycardia or anxietyheadache, tachycardia or anxiety

HypothyroidismHypothyroidism Clinical picture of vertigo, unsteadiness, falling, truncal Clinical picture of vertigo, unsteadiness, falling, truncal

ataxia and generalized clumsinessataxia and generalized clumsiness

ManagementManagement

Based on differentiating central from peripheral Based on differentiating central from peripheral causescauses

VBI should be considered in any elderly patient with VBI should be considered in any elderly patient with new-onset vertigo without an obvious etiologynew-onset vertigo without an obvious etiology

Neurological or ENT consult for central vertigoNeurological or ENT consult for central vertigo Suppurative labrynthitis-admit and IV antibioticsSuppurative labrynthitis-admit and IV antibiotics Toxic labrynthitis-stop offending agent if possibleToxic labrynthitis-stop offending agent if possible

ManagementManagement

Severe Ménière disease may require chemical Severe Ménière disease may require chemical ablation with gentamicinablation with gentamicin

Attempt Epley maneuver for BPPVAttempt Epley maneuver for BPPV Mainstay of peripheral vertigo management are Mainstay of peripheral vertigo management are

antihistamines that possess anticholinergic antihistamines that possess anticholinergic propertiesproperties

-Meclizine-Meclizine -Diphenhydramine-Diphenhydramine

-Promethazine-Promethazine -Droperidol-Droperidol

-Scopolamine-Scopolamine

Epley ManeuverEpley Maneuver

Epley ManeuverEpley Maneuver

University of BaltimoreUniversity of Baltimore107 patients107 patientsDiagnosed with BPPVDiagnosed with BPPVRight ear affected 54%Right ear affected 54%Posterior semicircular canal in 105 patientsPosterior semicircular canal in 105 patientsTreated with 1.23 treatmentsTreated with 1.23 treatmentsSuccessful in 93.4%Successful in 93.4%

Laryngoscope. 1999 Laryngoscope. 1999 Jun;109(6):900-3Jun;109(6):900-3

SummarySummary

Ensure you understand what the patient means Ensure you understand what the patient means by “dizzy”by “dizzy”

Try to differentiate central from peripheralTry to differentiate central from peripheral Often there is significant overlapOften there is significant overlap

Not every patient needs a head CTNot every patient needs a head CT Central causes are usually insidious and more Central causes are usually insidious and more

severe while peripheral causes are mostly severe while peripheral causes are mostly abrupt and benignabrupt and benign

Most can be discharged with antihistaminesMost can be discharged with antihistamines

QuestionsQuestions

1. Nystagmus due to peripheral causes has 1. Nystagmus due to peripheral causes has all all of the following features except:of the following features except:

a. Diminishes with fixationa. Diminishes with fixation

b. Unidirectional fast componentb. Unidirectional fast component

c. Can be horizontorotary or c. Can be horizontorotary or verticalvertical

d. Nystagmus increases with gaze d. Nystagmus increases with gaze in in direction of fast component direction of fast component

e. Can be accentuated by head e. Can be accentuated by head movement movement

Nystagmus due to peripheral causes has all Nystagmus due to peripheral causes has all of the following features except:of the following features except:

c. Can be horizontorotary or c. Can be horizontorotary or verticalvertical

Peripheral nystagmus is typically Peripheral nystagmus is typically horozonto-rotary, not pure horizontal or horozonto-rotary, not pure horizontal or rotary and is definitely not vertical.rotary and is definitely not vertical.

2. 2. Nystagmus due to central causes has all Nystagmus due to central causes has all of the following features except:of the following features except:

a. Does not change with gaze fixation a. Does not change with gaze fixation

b. Can be unidirectional or bidirectionalb. Can be unidirectional or bidirectional

c. Can be horizontal, rotary or verticalc. Can be horizontal, rotary or vertical

d. Nystagmus increases with gaze in d. Nystagmus increases with gaze in direction of fast componentdirection of fast component

e. Can be dramatically accentuated by head e. Can be dramatically accentuated by head movementmovement

Nystagmus due to central causes has all of Nystagmus due to central causes has all of the following features except:the following features except:

e. Can be dramatically accentuated e. Can be dramatically accentuated by head movement by head movement

Vertigo and nystagmus produced by Vertigo and nystagmus produced by central causes does not significantly central causes does not significantly worsen with head movementworsen with head movement

3. All of the following will have hearing loss 3. All of the following will have hearing loss and tinnitus associated with the vertigo and tinnitus associated with the vertigo except:except:

a.a. Vestibular neuronitisVestibular neuronitis

b.b. Acute labrynthitisAcute labrynthitis

c.c. BPPVBPPV

d.d. Acoustic neuromaAcoustic neuroma

e.e. Ménière DiseaseMénière Disease

All of the following will have hearing loss and All of the following will have hearing loss and tinnitus associated with the vertigo except:tinnitus associated with the vertigo except:

c.c. BPPV will not have associated hearing BPPV will not have associated hearing loss or tinnitusloss or tinnitus

All of the other responses will have All of the other responses will have hearing loss and tinnitus to varying hearing loss and tinnitus to varying degreesdegrees

4. T or F The Dix-Halpike maneuver is useful 4. T or F The Dix-Halpike maneuver is useful in the in the treatmenttreatment of BPPV? of BPPV?

FalseFalse

The Dix-Halpike is used to precipitate the The Dix-Halpike is used to precipitate the nystagmus if the nystagmus and vertigo nystagmus if the nystagmus and vertigo have resolved so a correct diagnosis can have resolved so a correct diagnosis can be made.be made.

The Epley maneuver is used to relocate The Epley maneuver is used to relocate the otoliths and therefore treat the BPPV. the otoliths and therefore treat the BPPV.

5. All of the following have been implicated in 5. All of the following have been implicated in causing vertigo except:causing vertigo except:

a. Loop diuretics e. Fluoroquinolones a. Loop diuretics e. Fluoroquinolones

b. Anticonvulsants f. All of the aboveb. Anticonvulsants f. All of the above

c. Aminoglycosidesc. Aminoglycosides

d. NSAIDSd. NSAIDS

F All of the aboveF All of the above

Many everyday medications can cause vertigo Many everyday medications can cause vertigo which is easily reversible if recognized.which is easily reversible if recognized.

Vertigo and dizziness

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