CITY & HACKNEY PATHFINDER CLINICAL COMMISSIONING GROUP. Vertigo. (1) Vertigo. (4) Provisional Diagnosis. (5) Investigations. lasting days or weeks

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1 Authors: Dr Lucy O'Rouke and Mr N Eynon-Lewis Review date: January 2017 Vertigo (1) Vertigo (2) History (3) Examination (4) Provisional Diagnosis (5) Investigations (6) Medical Cause (7) Psychiatric Cause (8) ENT Cause (9) Neurological Cause (10) >75 (11) BPPV (12) Repositioning (13) Acute vertigo manoeuvre lasting days or weeks (14) Episodic vertigo (15) Vertigo with Persistent hearing loss or associated otoalgia or otorrhoea (16) Persistent vertigo? Cause (17) Refer ENT

2 1. Vertigo Vertigo can be defined as an illusion or hallucination of movement The terms vertigo, dizziness and imbalance are used in different ways by different clinicians. We recommend that vertigo and dizziness are used synonymously and that imbalance is used to refer to non rotatory vertigo Balance is maintained by information from the vestibular apparatus (20%), vision (60%) and proprioception (20%) being processed by the brain In general, vertigo can described as rotatory, usually indicating a vestibular cause, or non rotatory, which is less indicative of the underlying pathology It is described as positional if it is brought on by a change in the patients head position There are many pathological processes that can give rise to vertigo 2. History The history is usually the most important part of the assessment of a patient with vertigo The patient should be asked: To describe the exact sensation that they are complaining of (is this actually vertigo?) If there is a rotatory element If the vertigo is constant or episodic If episodic, how long the episodes last (often a key question) When they occur What brings on the episodes About associated vegetative symptoms (eg nausea and vomiting) About associated otological symptoms such as hearing impairment About associated neurological symptoms Past medical history, drug history, social history 3. Examination This should include an otological, neurological and medical examination as appropriate A Hallpike test should be performed if the vertigo positional (see 11) 4. Provisional Diagnosis Remember that the history is often the key to diagnosis

3 5. Investigations Pure tone audiometry should be performed if there is associated hearing impairment MRI brain should be requested if a central cause needs to be excluded. For example, if there are associated neurological symptoms or signs or associated headache. If unilateral sensorineural hearing loss is found then an MRI or IAMS is required to exclude acoustic neuroma Vestibular tests are requested by ENT or Neurology specialists 6. Medical Cause There may be overlap between medical, otological and neurological conditions. For example, cerebrovascular disease and diabetes can give rise to neurological and vestibular pathology. Other metabolic, endocrine and autoimmune conditions should be noted and the possibility of a drug side effect should be considered 7. Psychiatric Cause Psychiatric illness should be distinguished from vertigo. The patient may have a clear history of anxiety or agoraphobia. 8. ENT Cause Most patients with persistent vertigo are referred to ENT Clinics 9. Neurological Cause Ask about other neurological symptoms and remember that migraine is a cause of vertigo and that vertiginous episodes are not always associated with headache in these patients Typically, episodes occur every few weeks or months and last for hours. Very few patients will have neurological signs but they should not be missed. Test for nystagmus and then head impulse test (loss of vestibulo-ocular reflex or Doll s eye movement, in association with rapid sideways head movement performed by the examiner with the patient fixating directly on the examiner). Loss of fixation indicates unilateral impairment of vestibular function and a peripheral rather than central origin. Test the patients stance and gait. TIA or stroke are rarely causes of vertigo and are usually associated with other brainstem features e.g. diploplia, cerebellar signs, etc. (see also section 13)

4 10. >75 Elderly patients often have multiple pathology Visual and proprioceptive abnormalities can lead to de-compensation from previous vestibular failure The Elderly are often taking several medications Chronic vertigo should not be treated with a vestibular sedative such as prochlorperazine (stemetil) as this will impair compensation. Vestibular sedatives should only be used for the treatment of acute vertigo 11. BPPV Benign paroxysmal positional vertigo (BPPV) is one of the most common causes of dizziness It is thought to arise from the presence of dense particles, most likely to be otoconial debris, in the posterior semi-circular canal (although the other canals are rarely involved) It is characterised by severe, brief (seconds) episodes of rotatory vertigo provoked by change in head position Typically occurs looking up and to the side, for example when getting something down from a shelf or when turning in bed or getting up in the morning BPPV is idiopathic in many cases About 15% of patients have a history of relatively minor head injury The remainder probably represent a residual effect of a variety of vestibular pathologies such as vestibular neuronitis, ear surgery and inner ear ischaemia Hallpikes positional test (illustration 1) provokes rotatory vertigo and horizontal torsional nystagmus and is diagnostic of BPPV With the patient sitting, the neck is extended and turned 45 degrees to one side The patient is then placed supine rapidly, so that the head hangs over the edge of the couch, 30 degrees below the horizontal Nystagmus appears with a latency of a few seconds and lasts less than 3 seconds, fatiguing rapidly The patient is then sat up and they usually then develop further vertigo and nystagmus although of reduced severity The procedure is repeated and each time it is done the symptoms become less severe as it habituates For the test to be positive all of the above features need to be demonstrated. If the nystagmus is not characteristic or does not fatigue or habituate then it is assumed that there is a central cause for the vertigo and the patient will require and MRI of brain 12. Repositioning manoeuvre Epley manoeuvre: This is a re-positioning manoeuvre that aims to move the canal debris into the utricle which is a part of the inner ear adjacent to the canal It is said to lead to a resolution of symptoms in 80% of patients Home re-positioning techniques can also be helpful in some patients

5 Cont. Surgery in the form of canal occlusion can be considered in the few patients with intractable symptoms 13. Acute vertigo lasting days or weeks Acute vestibular failure: Acute vestibular failure presents with acute rotatory vertigo with associated nausea and vomiting. This can be an extremely unpleasant experience for the patient who is often initially confined to bed Consider vestibular neuronitis which is the most common cause of acute vestibular failure Labyrinthisis refers to inflammation of the labyrinth, consisting of inner ear vestibular apparatus and the cochlear removed and should only really be diagnosed if there is associated hearing impairment More commonly vertigo occurs without hearing loss and there is some evidence that Herpes Simplex Vestibular Nerve ganglion infection is the cause of this condition Unlike the majority od patients who present with vertigo, they will have nystagmus Initial treatment is supportive with medication to suppress vestibular activity such as prochlorperazine which may be given orally, sublingually, IM or suppository The vertigo gradually improves as the brain compensates for the disparity of vestibular input from the two sides. By 6 weeks the symptoms have usually improved significantly Some patients, however, do not compensate well from acute vestibular failure and go on to develop chronic vertigo. It is uncertain why this is but psychological factors may be important in some patients Acute vestibular failure can also be caused by head injury with or without temporal bone fracture, can be drug induced (e.g. aminoglycosides) and can be a complication of ear surgery Acute vestibular neuronitis is relatively common. Acute cerebellar stroke is rare although may present with isolated vertigo. In elderly patients with a high risk of vascular disease this should be considered. The majority will have a normal head thrust test (see 9) 14. Episodic vertigo Paroxysmal episodes of rotatory vertigo associated with hearing loss and tinnitus lasting less then 24 hours are typical of endolymphatic hydrops Meniere's disease is the term used to describe primary endolymphatic hydrops. It is the most commonly over diagnosed cause of vertigo Meniere's disease is thought to arise from an abnormal homeostasis of inner ear fluid It can only be definitively diagnosed by histopathological examination of the temporal bone Typically symptoms begin between 20 and 40 years of age Rarely children may present with Meniere s-like symptoms due to secondary endolymphatic hydrops associated with congenital malformations of the inner ear

6 Cont. Fluctuation hearing loss may progress over time, affecting both ears and resulting in irreversible hearing loss usually affecting the lower frequencies more severely This may also be accompanied by a general sense of imbalance between acute episodes The clinical course varies among individuals It is unilateral in most cases but may rarely affect both ears It is a diagnosis of exclusion, since other pathologies such as a acoustic neuroma and ostosyphilis may present as endolymphatic hydrops (secondary endolymphatic hydrops) Most patients can be managed conservatively. This usually includes betahistine 8 or 16mg and a low salt diet. Diuretics can also be used. Intra-tympanic gentamicin has become an established technique when conservative management is not successful Labyrinthectomy and vestibular nerve section are occasionally indicated Other causes of episodic vertigo include BPPV (11), labyrinthine fistula (caused by cholesteatoma), cervical vertigo (an ill defined condition associated with cervical spine osteoarthritis), migraine (9), autoimmune disease of the temporal bone (15) and episodes of decompensation from previous vestibular failure (13) 15. Vertigo with persistent hearing loss or associated otoalgia or otorrhoea There are several otological causes of vertigo including; Chronic Suppurative Otitis Media Cholesteatoma with labyrinthine fistula Perilymph fistula Chronic inflammatory conditions of the temporal bone such as syphilis Autoimmune disease of the temporal bone Temporal bone trauma Cerebellopontine angle lesions such as acoustic neuroma 16. Chronic Vertigo It is worth knowing that a definitive diagnosis is often not made even after vestibular investigations Psychological causes are very important in chronic vertigo and are thought to hinder rehabilitation after vestibular failure Failure to compensate adequately may also be related to impairment of other sensory inputs, the use of vestibular sedatives eg prochlorperzaine and systemic disease. Patients recovering from vestibular failure may develop vertigo in situations of increased visual stimulation such as in crowded situations or near a busy road and this is thought to be related to an over reliance on visual input for maintaining balance leading to visual stimulation. This is known as

7 Cont. visual vertigo and can sometimes be clearly elicited from the history. It is often associated with anxiety. Patients with chronic vertigo can benefit greatly from vestibular rehabilitation as it maximises the natural ability of the nervous system to compensate for vestibular failure 17. Refer ENT Refer to ENT Surgeon Refer id vertigo is persistent or associated with middle ear pathology Depending on the assessment, the patient may be referred for imaging or vestibular tests Referral can be made to the ELIC Community Clinic or to The Homerton by direct referral or choose and book Enquiries can be made to ENT ( ), Neurology ( ) and Care of the Elderly ( ) The Falls clinic is run by Dr Dasgupta at The Homerton. You can send a fax headed Falls Clinic to

8 Hall Pike Positional Test Hall pike 1 The patients head is rotated 45 degrees and the patient lent over the edge of the couch (Left) Hall pike 2 The patients head is extended 30 degrees and observed for nystagmus (Right)

9 Epley Manoeuvre Epley 1 The first step is the same as the Hallpike test (Above) Epley 3 The patient is then rotated through a further 90 degrees (Below) Epley 2 The second part of the manoeuvre involves turning the patients head through 90 degrees (Above) Epley 4 The patient is then sat up and puts chin on their chest (below)