VERTIGO. Tuesday 20 th February 2018 Dr Rukhsana Hussain. Disclaimers apply:

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1 VERTIGO Tuesday 20 th February 2018 Dr Rukhsana Hussain

2 WHAT IS VERTIGO? 4 Vertigo is defined as an illusory sensation of motion of either the self or the surroundings in the absence of true motion. Explaining vertigo/dizziness to patients: The balance system relies on 3 different senses. Using your eyes you can see where you are and where you are going. Using the sensors in your body you can feel where you are and how you are moving. And the balance organ in your inner ear senses whenever your head moves. Your brain acts like a computer, combining signals from these 3 senses to give you a stable picture of the world and to control your head, body and eye movements. If any part of this balance system is giving out unusual or faulty information then you may feel dizzy, disorientated or unsteady.

3 CAUSES OF VERTIGO 1 Vertigo with auditory symptoms Vertigo without auditory symptoms Vertigo with intracranial signs Ménière s disease Vestibular neuronitis Cerebello-pontine angle tumour Labyrinthitis Benign Paroxysmal Positional Vertigo (BPPV) Cerebrovascular disease - TIA/CVA Labyrinthine trauma Acute vestibular dysfunction Vertebrobasilar insufficiency and thromboembolism (lateral medullary syndrome, subclavian steal syndrome, basilar migraine) Acoustic neuroma Acute cochleo-vestibular dysfunction Cholesteatoma Syphilis (rare) Medication induced e.g. Aminoglycosides such as gentamicin Cervical spondylosis Following flexion-extension injury (whiplash) Brain tumour e.g, empendyoma Migraine Multiple Sclerosis Aura of epileptic attack esp. Temporal lobe epilepsy Drugs e.g. Phenytoin and Barbiturates. Syringobulbia

4 The most common causes of vertigo in the Primary Care setting (over 90% of cases) are: BPPV Acute Vestibular Neuronitis and Ménière s disease

5 IMPORTANT POINTS IN THE HISTORY 1 Determining whether the patient has peripheral or central vertigo is important in establishing a specific diagnosis. Points in the history to help with this are: Timing and duration of vertigo BPPV: lasts seconds, Ménière s disease: lasts hours, Labyrinthitis, post-head trauma, vestibular neuronitis: last weeks. Psychogenic: may last years. Speed of onset of vertigo Provoking or exacerbating factors e.g, flying or trauma Associated symptoms such as: Pain, Nausea and Vomiting: vestibular (peripheral)cause, Hearing loss, Neurological symptoms such as dysarthria and visual disturbance in a central lesion.

6 CENTRAL VERTIGO... Usually develops gradually except in an acute central vertigo which is probably vascular in origin e.g. CVA There are usually additional neurological signs to the vertigo Auditory features tend to be uncommon Causes severe imbalance Nystagmus is purely vertical, horizontal or torsional and is not inhibited by fixating eyes on an object Latency following a provocative diagnostic maneouvre is shorter (up to 5 seconds)

7 PERIPHERAL VERTIGO... Hearing loss and tinnitus are more common than in central vertigo Generally has a more sudden onset (except acute CVA) Is highly associated with rotatory illusions (esp. nausea and vomiting) Nystagmus is combined horizontal and rotational and lessens with fixed gaze There is mild to moderate imbalance Non-auditory neurological symptoms are rare Latency following a provocative diagnostic maneouvre is longer (up to 20 seconds)

8 TIMING OF SYMPTOMS Pathology Duration of episode Associated auditory symptoms BPPV Seconds No Peripheral Vestibular neuronitis Days No Peripheral Ménière s disease Hours Yes Peripheral Peripheral or Central origin Perilymphatic fistula Seconds Yes Peripheral TIA Seconds/hours No Central Vertiginous migraine Hours No Central Labyrinthitis Days Yes Peripheral Stroke Days No Central Acoustic Neuroma Months Yes Peripheral Cerebellar tumour Months No Central Multiple Sclerosis Months No Central

9 EXAMINATION/INVESTIGATION Examination of ear drums (Otoscopy): look for vesicles Ramsay-Hunt syndrome. Also look for the possibility of a cholesteatoma. Tuning fork tests for hearing loss. Cranial Nerve examination check for palsies, sensorineural hearing loss and nystagmus. Hennebert s sign: pressure on tragus and external auditory meatus on affected side causes vertigo or nystagmus indicates the presence of a perilymphatic fistula. Gait tests: Rombergs sign not particulary useful in diagnosis of vertigo Heel to toe walking test. Dix-Hallpike maneouvre most useful test in a patient with vertigo.

10 Dix-Hallpike test and Epley Maneouvre Video Clip. The Dix-Hallpike test helps to diagnose BPPV and the Epley Maneouvre is used to treat it. Audiometry: helps establish the diagnosis of Ménière s disease. Check BP/Bloods to exclude other causes of dizziness if appropriate. CT/MRI brain may be appropriate if CNS causes are suspected from the history and examination.

11 TREATMENT Should be aimed at the cause of the vertigo ideally. Options: Medical Management, Vestibular rehabilitation exercises. Main priority for most cases is effective symptom control. Acute vertigo: treatments include Cinnarizine 15-30mg tds or Prochlorperazine 5-10mg tds Prevention of recurrent attacks: Restrict salt and fluid intake, restrict excess alcohol and coffee Smoking cessation Betahistine 16mg tds regularly for Ménière s disease Cinnarizine or Prochlorperazine for frequent attacks. Longterm vestibular sedatives such as cinnarizine and prochlorperazine should be avoided as they dampen compensatory mechanisms and prolong symptoms in the recovery phase.

12 Epley Maneouvre: aims to reposition otoliths back into the utricles from the posterior semicircular canals. Success rate: 80 % cured in just one treatment. Contraindications include: Severe carotid artery stenosis Unstable heart disease Severe neck disease e.g. Cervical spondylosis with myelopathy GPs can refer to ENT if they are unfamiliar with the maneouvre.

13 REFERRAL CRITERIA FROM PRIMARY CARE Red flag symptoms in a patient with vertigo requiring prompt referral Unilateral tinnitus and/or hearing loss/dysacusis Unilateral otorrhoea Neurological symptoms and signs Nystagmus has central features Spontaneous nystagmus persists after 48 hours Positional vertigo/nystagmus which does not have all the features of posterior semicircular canal BPPV Significant vertigo/imbalance persist after a month Positive fistula sign (Hennebert s sign) Pressure on tragus reproduces symptoms suggests perilymphatic fistula

14 BENIGN PAROXYSMAL POSITIONAL VERTIGO 3 BPPV is thought to be caused by loose calcium carbonate debris (otoconia or otoliths) in the semi-circular canals of the inner ear. When the head moves, otoconia move in these canals and cause motion in the fluid (endolymph) triggering vertigo symptoms. The posterior semi-circular canal is the most commonly affected (in around % of people with BPPV). The maneouvre to treat BPPV differs according to which canal is affected. Precipitating factors include head injury, a prolonged recumbent position (e.g during a visit to the dentist), ear surgery or following an inner ear problem such as labyrinthitis or vestibular neuronitis. It may also be associated with sleep position.

15 Vertigo symptoms are brought on by specific head movements and positions of the head relative to gravity. The movements may be very subtle. Symptoms typically last less than a minute. Nausea and vomiting may occur. Examination is likely to be normal at rest in the sitting position. Diagnosis can be confirmed by the Dix-Hallpike maneouvre. If Dix-Hallpike maneouvre is negative, repeat it after one week.

16 DIX-HALLPIKE MANEOUVRE Advise the person that they may experience transient vertigo during the procedure. Ask the person to keep their eyes open throughout the manoeuvre and to look straight ahead. Ask the person to sit upright on the couch with their head turned 45 degrees to one side. From this position, lie the person down rapidly (over 2 seconds), supporting their head and neck, until their head is extended degrees over the end of the couch with the chin pointing slightly upwards and the test ear downwards. Support the head to maintain this position for at least 30 seconds.

17 Observe their eyes closely for up to 30 seconds for the development of nystagmus. If nystagmus is present, maintain the position for its duration (maximum 2 minutes if persistent) and note its duration, type, direction, and latency. Record duration, severity, and latency of any vertigo. Support the head in position and slowly sit the person up. Repeat with the head rotated 45 degrees to the other side. CONTRAINDICATIONS to the maneouvre include severe neck/back problems, severe carotid artery stenosis and significant cardiac problems such as carotid sinus syncope. Dix-Hallpike test and Epley Maneouvre Video Clip

18 If BPPV is confirmed patients can be advised that most people recover over several weeks without any treatment but symptoms can last longer and can recur. Advise patients regarding safety: Driving avoid driving when dizzy or if driving may trigger vertigo. The DVLA states that people with a 'liability to sudden and unprovoked or unprecipitated episodes of disabling dizziness' should stop driving and inform the DVLA. Experts suggest that in general BPPV is not spontaneous or unprovoked and most people with this condition continue to drive. Work Inform employer if vertigo may pose a risk at work e.g. If they operate heavy machinery Home Discuss risk of falls and measures to reduce this.

19 Management options include watchful waiting and a particle repositioning maneouvre. The Epley maneouvre is the most common repositioning maneouvre. Symptoms may improve shortly after treatment but full recovery can take days to weeks. Contraindications for the procedure are the same as for the Dix-Hallpike test.

20 EPLEY MANEOUVRE Advise the person that they will experience transient vertigo during the manoeuvre. Stand at the side or behind the person to guide head movements. Maintain each head position for at least 30 seconds. If vertigo continues, wait until it has subsided. Ideally, movements should be rapid, within 1 second, but this is often not possible, particularly in older people. Expert opinion suggests that the procedure can be effective if movements are carried out slowly. Start with the person sitting upright with their head turned 45 degrees to the affected side, then lie them back (with their head still turned 45 degrees) until the head is dependent 30 degrees over the edge of the couch (as if performing the Dix-Hallpike manoeuvre). Wait for at least 30 seconds. Then:

21 With the face upwards, but still tilted backwards by 30 degrees, rotate the head through 90 degrees to the opposite side. Hold the head in this position for about 20 seconds and ask the person to roll onto the same side as they are facing. Rotate the person's head so that they are facing obliquely downward with their nose 45 degrees below the horizontal. Sit the person up sideways while the head remains rotated and tilted to the side. Rotate the head to the central position and move the chin downwards by 45 degrees. There is usually no need to advise the person of any positional restrictions after the procedure has been performed.

22 Advise the patient to return for follow up in 4 weeks if symptoms have not resolved, in case the BPPV diagnosis is incorrect Resources for patients can be downloaded from the following links: BPPV Patient Information Leaflet BPPV brief factsheet for patients Self treatment exercises leaflet for BPPV Dix-Hallpike and Epley Maneouvre video clip

23 VESTIBULAR NEURONITIS/NEURITIS 3 Vestibular neuronitis is characterised by acute, isolated, spontaneous and prolonged vertigo of peripheral origin. The terms vestibular neuronitis and labyrinthitis have been used interchangeably, but experts now recommend specific terminology. Vestibular neuronitis is thought to be due to inflammation of the vestibular nerve and may occur after a viral infection. Hearing loss is NOT a feature. BPPV can develop following vestibular neuronitis in 10 % of people. There are no associated neurological symptoms or signs. Labyrinthitis is a different diagnosis that involves inflammation of the labyrinth. Hearing loss is a feature.

24 Initial severe symptoms usually last 2-3 days. People with vestibular neuronitis gradually recover over a period of weeks through a process of central nervous system compensation. Most recover after 6 weeks but a minority may have symptoms for much longer. Recurrence is rare and if it occurs alternative diagnoses need to be considered such as BPPV and migrainous vertigo. Symptoms can be managed by medication such as prochlorperazine and cinnarizine but they should be used for the shortest duration possible (a few days) as prolonged use may delay central nervous system compensatory mechanisms.

25 Advise patients to attend for review if severe symptoms not settled after a week or in the event of deterioration of symptoms. In this instance a review of the diagnosis would be required and consideration of an urgent referral to a secondary care specialist. Patient Information Leaflet Vestibular Neuronitis and Labyrinthitis

26 MÉNIÈRE S DISEASE 3 Ménière s disease is a syndrome characterised by episodes of vertigo, fluctuating hearing loss, and tinnitus. It is associated with a feeling of fullness in the affected ear. In most people the cause is unknown. Suggested risk factors include: autoimmunity (usually present with bilateral symptoms), genetic susceptibility, metabolic disturbances involving the fluid of the inner ear, vascular factors (there is an association between migraine and Ménière s disease), viral infection and head trauma. Symptoms and hearing loss can initially fluctuate, resolving completely between episodes. Later in the course of the disease, hearing loss progresses and tinnitus becomes persistent. The frequency of vertigo episodes often decreases. After 5-15 years vertigo is no longer experienced when the condition burns out but hearing loss, fullness in ear and a general sense of imbalance can persist despite treatment.

27 Acute attacks of Ménière s disease may be preceded by a change in tinnitus, increased hearing loss or a sensation of aural fullness shortly before the onset of vertigo. Symptoms typically present for at least 20 minutes but can last for hours (usually no more than 24 hours) and can occur in clusters over a few weeks although months or years of remission can also occur. Can involve mainly aural symptoms, vertigo or both.

28 A definite diagnosis requires all of the following criteria: Vertigo at least two spontaneous episodes lasting 20 minutes to 12 hours. Fluctuating hearing, tinnitus, and/or perception of aural fullness in the affected ear. Hearing loss confirmed by audiometry to be sensorineural, low-to-mid frequency, and defining the affected ear on one or more occasions before, during, or after an episode of vertigo. Not better accounted for by an alternative vestibular diagnosis. A probable diagnosis of Ménière s disease requires all of the above criteria (including dizziness in addition to vertigo), except for audiometric documentation of hearing loss. Refer to ENT to confirm the diagnosis.

29 Treatment of acute episodes of Ménière s disease can be with a short course (7-14 days) of Prochlorperazine or an antihistamine such as Cinnarizine, Cyclizine or Promethazine. Consider prescribing Betahistine to reduce the frequency and severity of hearing loss, tinnitus and vertigo, Secondary care interventions that may be considered if Betahistine does not work include: Vestibular rehabilitation Diuretics Intratympanic gentamicin or corticosteroids External pressure devices Endolymphatic shunts or sac surgery Labyrinthectomy or vestibular nerve section

30 MÉNIÈRE S DISEASE Resources and sources of information and support for patients with Ménière s disease: Patient information leaflet Ménière s disease Balance retraining vestibular rehabilitation exercise guide Controlling your symptoms booklet- a self help guide for patients with dizziness Vestibular rehabilitation exercises - shorter factsheet The Meniere's Society The British Tinnitus Association Action on Hearing Loss

31 SUMMARY The most common causes of vertigo in the Primary Care setting are BPPV, Vestibular Neuronitis and Ménière s disease. Distinguishing between central and peripheral causes of vertigo can help to establish a specific diagnosis. The history is crucial to making a diagnosis and points in the history to differentiate between peripheral and central causes include: Timing and Duration of vertigo Speed of onset of symptoms Provoking or exacerbating factors Associated symptoms including pain, nausea and vomiting, hearing loss and neurological symptoms

32 The Dix-Hallpike maneouvre can be performed to confirm BPPV and the Epley maneouvre can treat it. The Epley maneouvre has a high success rate. Vestibular sedatives such as prochlorperazine are not recommended for prolonged use as they delay the central nervous system compensatory mechanisms and so may prolong patient symptoms. Vertigo symptoms can be disabling and frightening for patients, It is essential that clinicians provide patients with adequate information and resources for support with regards to their condition. Significant vertigo/imbalance persisting longer than 1 month should prompt consideration of a referral to secondary care for further investigation.

33 REFERENCES 1.GP Notebook 2. Patient UK 3. NICE Clinical Knowledge Summaries 4. The Meniere's Society