Vertigo. Definition Important history questions Examination Common vertigo cases and management Summary

Transcription

1 Vertigo

2 Vertigo Definition Important history questions Examination Common vertigo cases and management Summary

3 Cases 1) 46 year old man presents two weeks after knocking his head with recurrent episodes of dizziness which lasts around 20 seconds. 2) 32 year old female presents with a week of dizziness episodes lasting 40 minutes, associated with hearing loss and tinnitus in same ear. 3) 24 year old with a recent URTI present with 2 days of constant severe dizziness and vomiting which has kept her mostly bed-bound.

4 Vertigo Dizziness

5 Vertigo Hallucination of movement refers to a false sensation that oneself or the surroundings are moving or spinning Causes of vertigo are often differentiated into central and peripheral Dizziness a general, non-specific term to indicate a sense of disorientation.

6 Vertigo Central eg, cerebrovascular disease, migraine, multiple sclerosis, Vertebrobasilar ischaemia, diplopia, acoustic neuroma, alcohol intoxication. Peripheral labyrinthitis, benign paroxysmal positional vertigo (BPPV), Ménière's disease, perilymph fistula, ototoxicity (eg, gentamicin), herpes zoster (Ramsay Hunt syndrome).

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8 Dizziness Vasovagal Cardiac Cervicogenic Dizziness Epilepsy: the likely diagnosis if vertigo is associated with loss of consciousness. Acoustic neuroma: may cause mild vertigo but associated with unilateral sensorineural deafness and tinnitus. Nasopharyngeal carcinoma. Vestibular migraine. Following head injury. Vertebrobasilar ischaemia. Eustachian tube dysfunction (causes mild vertigo). Chronic otitis media. Drugs: salicylates, quinine, aminoglycosides.

9 Important questions in the history What do you mean by dizziness? Tell me about 1st time you became dizzy. Viral illness or head trauma before 1 st episode? How often to do they occur How long do they last Alleviating factors -?visual fixation Exacerbating factors?head position?loud noises?headache Ear problems?hearing loss?tinnitis?aural fullness?discharge

10 Important questions in the history PMHx cardio, diabetes, eye problems, joints, ear surgery, DHx Abx (gentamicin), Antihypertensives, FHx Meniere, SHx driving, affecting work, stress, ICE.

11 Examination Ear exam - Tuning Forks, Free Fields, Fistula test. Nystagmus Cranial Nerves Balance tests Rombergs & Unterbergers. Dix- Hallpike Othrostatic BP ECG

12 Ix No investigations are likely to be performed in primary care. Secondary care investigations include: PTA (audiometry) for cochlear function. Possible neurological cause: CT or MRI. Vestibular function: electronystagmography, calorimetry and brain stem-evoked responses

13 Case 1 46 year old man presents two weeks after knocking his head with recurrent episodes of dizziness which lasts around 20 seconds.

14 BPPV Displaced crystals in posterior semi-circular cannal. Only occurs on head movement Nystagmus Lasting seconds 20-40s 20-40s latency Rotatory (geotropic) Fatigable

15 BPPV Diagnosis Dix Hallpike maneuver Management Epleys Brandt Daroff exercises Surgical posterior SCC occlusion cut SSC nerves

16 Case 2 32 year old female presents with a week of dizziness episodes lasting 40 minutes, associated with hearing loss and tinnitus in same ear.

17 Meniere's Disease Endolymphatic hydrops Tetrad of Symptoms Vertigo lasting minutes to hours hearing loss Tinnitus Aural fullness

18 Meniere's Disease Management Conservative Diet reduce salt and caffeine intake Optimize BP if hypertensive Vestibular rehab Cawthorne-Cooksey exercises Medical No longer than 7 day course of vestibular sedatives (prochlorperizine) Histamines (e.g betahistine 16mg TDS) Anti histamine (e.g cinnarizine)?thiazides Surgical Endolymphatic decompression Cortical mastoidectomy +/- shunts Cut vestibular nerve Permeatal gentamicin injections

19 Case 3 24 year old with a recent URTI present with 2 days of constant severe dizziness and vomiting which has kept her mostly bedbound.

20 Labyrinthitis / Vestibular Neuritis Inflammation of the labyrinth Sx viral prodrome (most commonly secondary to URTI) Vertigo lasts hours to days Nausea and vomiting Horizontal nystagmus (fast phase towards effected ear). Mx Bed rest Medical 7 day course of vestibular sedatives (prochlorperazine) Anti histamine (e.g cinnarizine) Vestibular rehab Cawthorne-Cooksey exercises Surgical Cut vestibular nerve Permeatal gentamicin injections

21 Summary True vertigo? Duration of vertigo? Seconds = BPPV Minutes to hours Meniere's Days = laryrinthitis