VERTIGO VERTIGO A guide to diagnosis of otologic A guide to diagnosis of otologic causes of dizziness causes of dizziness Dr Nadina Thwaites Dr Nadina Thwaites General Practitioner and MOSS ORL CMDHB General Practitioner and MOSS ORL CMDHB
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