Download Vertigo Care Pathway

Vertigo Care Pathway
Tower Hamlets Adult Care Pathway: For use in Primary Care
January 2012
Vertigo Care Pathway for Tower Hamlets
Background: Vertigo is a form of dizziness with an illusion or hallucination of movement. The broader term dizziness includes unsteadiness, lightheadedness, motion intolerance, imbalance, floating, or a tilting sensation.
Balance is maintained by information from the vestibular apparatus (15%), vision (70%) and proprioception (15%) being processed by the brain. Vertigo is
caused by peripheral causes in 80% of cases. Central causes are more common in elderly.
A full-time GP may expect to encounter 10-20 cases of vertigo each year.
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History:
•
Is there a rotatory element? Constant or episodic?
•
Duration of episode : seconds, minutes, hours and days
•
Otological symptoms ( e.g. hearing impairment, tinnitus, otorrhoea)
•
Associated symptoms (e.g., nausea or vomiting)
•
Neurological symptoms (including diplopia, dysarthria, dysphagia, focal weakness, autonomic symptoms, headache)
•
Triggers for vertigo (change of head position, menstrual cycle)
•
Past medical history, Drug history , Social history
Examination:
Otological examination: for signs of infection or inflammation
Hallpike test should be performed if vertigo is positional (see below for details)
Tuning fork test for hearing to ascertain whether hearing loss is conductive or sensorineural (SNHL)
Neurological examination: neck movements, eye movements and nystagmus, stance and gait (Romberg’s test, heel to toe walking), cerebellar signs,
cranial nerves and PNS as required
Systemic examination: Vital signs including supine and standing blood pressure if syncope is suspected, cardiovascular and respiratory system assessment
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Red Flags: headache, neurological symptoms and signs, irregular pulse (consider cardiac arrhythmia), history of cervical spine or head trauma.
Refer to neurology if central cause is suspected: e.g. CVA, Tumour, Multiple sclerosis (MS). Such cases will almost invariable have more symptoms than
just vertigo and will usually have neurological signs.
Elderly (>75) – Patients often have multiple pathologies. 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 vestibular sedative such as prochlorperazine as this
impairs compensation. This group may need assessment in the Falls Clinic if they fit the criteria (see local guidelines for referral criteria)
Is there any associated Deafness with the Vertigo?
Yes
No
Meniere’s:
Acute Labyrinthitis:
Vestibular neuronitis:
Benign Paroxysmal
Unexplained episodic
Lasting hours with tinnitus Acute onset of vertigo lasting days Acute onset lasting days or
Positional Vertigo
vertigo
AND deafness.
or weeks WITH deafness.
weeks WITHOUT hearing loss.
(BPPV):
Typically first symptoms
Due to inflammation of the
Vertigo in certain head
occur between ages 20-40 labyrinth which includes the
Thought to be caused by viral
positions, lasting seconds
years.
cochlea and the semicircular
infection of the vestibular nerve
only. 15% may have history
canals.
of relatively minor head
trauma.
Clinical features include
Acute episode from bacterial or
Abrupt onset of severe
Observing nystagmus
Migraine with or
vertigo (<24hours),
viral infections associated with
debilitating vertigo with
during a provoked
without aura is the
hearing loss (reversible
hearing loss, nausea and vomiting. unsteadiness and nausea and
manoeuvre confirms
most common cause
sensorineural),
Can be associated with bacterial
vomiting.
BPPV in typical history.
of otherwise
Tinnitus (fluctuating).
processes such as otitis media or
unexplained episodic
Aura of fullness or
meningitis.
Should NOT have hearing loss,
Hallpike’s Positional Test
vertigo lasting hours:
pressure in the ear or side
multi-directional non-fatiguing
– provoke vertigo with
- it may or may not be
of the head
Useful to establish if conductive or nystagmus (suggesting central
geotropic (towards the
associated with
sensory nerve hearing loss. If
cause), high fever, or mastoid
ground) torsional
headache
Abnormal homeostasis of
tuning fork test is not conclusive
tenderness
nystagmus which
- look for a family
inner ear fluid. Also known then needs an audiogram.
habituates on repeated
history and
as primary endolymphatic
Common in 4th and 5th decades.
tests (see below).
phonophobia or
hydrops.
Affects men and women equally.
photophobia.
Over diagnosed in General
Preceded often by an URTI.
Other causes:
Practice.
Labyrinthine fistula,
cervical vertigo
(cervical spine OA
related), Autoimmune
inner ear disease.
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Refer to ENT for diagnosis.
Treatment for acute
episodes consists of:
Antihistamines e.g.
cinnarizine
Phenothiazines e.g.
prochlorperazine (not for
longer than 7 days).
Betahistine hydrochloride
can also be helpful
(vasodilatation to inner
ear)
Reduction in dietary salt,
caffeine, alcohol and
tobacco is advised.
Meniere’s is a diagnosis of
exclusion, since other
pathologies such as
acoustic neuroma and
otosyphilis may cause
same symptoms.
(secondary endolymphatic
hydrops)
If patient presents with sudden
onset hearing loss (SNHL), refer
to ENT as an emergency and start
on high dose steroids such as
Prednisolone 40mg. Steroids can
be considered up to 2 weeks after
sudden onset SNHL.
Phenothiazines e.g.
prochlorperazine – to manage
acute symptoms of vertigo (not
for longer than 7 days).
Antibiotics may be required if
suspected bacterial cause. If
middle ear effusion may need
tympanotomy.
Bacterial infection is indicated by a
painful discharging ear with signs
of middle ear infection or chronic
suppurative otitis media (CSOM).
Antihistamines e.g. cinnarizine
Phenothiazines e.g.
prochlorperazine – should not be
given for more than 7 days as
patient loses capacity for central
vestibular compensation
affecting long-term recovery.
Symptoms usually recover within
6 weeks.
Consider referral to ENT If
symptoms persist beyond 4-6
weeks.
Vestibular rehabilitation therapy
For chronic vertigo.
Gaze stabilization exercise
Balance and gait training
(This will be through Audiology
department – Direct Referral
process is being explored)
Canalith Repositioning
manoeuvre – Epley’s
Manoeuvre (see below):
- used for BPPV
- approximately 80% of
patients can have
symptom resolution with
one or more sessions.
Refer to ENT if
uncertain of the
diagnosis.
Vestibular rehabilitation
exercises: Home
exercises include BrandtDaroff exercises (see
below).
Consider referral to ENT if
symptoms persist beyond
4-6 weeks
Vestibular rehabilitation therapy
for chronic vertigo. (This will be
through Audiology Department direct referral process is being
explored).
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Hallpike’s positional test
Provokes dizziness and a typical geotropic upbeat torsional nystagmus is diagnostic of BPPV:
With the patient sitting, the head is turned 45 degrees to one side.
The patient is then placed supine rapidly; so that the head hangs over the edge of the bed (it is perfectly acceptable to lie the patient flat without
extending their neck particularly if there are concerns about the neck). Keep in this position for at least 30 seconds.
If no nystagmus occurs, they are then returned to the upright position and observed for another 30 seconds for nystagmus.
The manoeuvre is repeated with the head turned to the other side.
Nystagmus usually appears with a latency of a few seconds and lasts less than 30 seconds.
It has a typical trajectory, beating torsionally, with the upper poles of the eyes beating towards the ground.
After it stops and the patient sits up, the nystagmus will recur but in the opposite direction.
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Further Reading/Resources
1.http://eng.mapofmedicine.com/evidence/map/dizziness2.html
2. Turner B, Eynon-Lewis N. Systematic approach needed to establish cause of vertigo. Practitioner 2010;254(1732): 19-23
3. www.vestibular.org – The vestibular disorder association provides support and advice for patients and healthcare professionals.
4. Epley’s manoeuvre: http://emedicine.medscape.com/article/791414-treatment , http://www.youtube.com/watch?v=NQr7MKJBAJY&feature=related
5. Brandt-Daroff exercises, patient leaflet: http://www.croftonandsharlston.co.uk/Leaflets/Brandt-Daroff.pdf
6. http://www.dizziness-and-balance.com/disorders/bppv/bppv.html
7. Patient information leaflets: http://www.patient.co.uk/health/Labyrinthitis-and-Vestibular-Neuritis.htm , also available on Mentor within EMIS and
also: http://www.patient.co.uk/health/Benign-Paroxysmal-Positional-Vertigo.htm, again within Mentor on EMIS
Local Referral pathway:
1.
Department of ENT, Barts and The London NHS Trust - appointments booked via Choose & Book system. Urgent Cases discussed with on-call
ENT.
2. Department of Neurology, Barts and The London NHS Trust – appointments booked via Choose & Book system. Urgent Cases discussed with
on-call medical consultant.
3. Falls Management Team, Services for Older people and Rehabilitation, Bancroft Unit Mile End Hospital Fax: 0207 377 7844
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This care pathway is not a full evidence based guideline and is aimed as a care pathway to guide referral decisions by Tower Hamlets
GPs.
Acknowledgements
Written by: Dr Ali Ahmed-Shuaib ([email protected]) with advice from Dr Victoria Tzortiziou Brown
([email protected]), Dr Nicholas Eynon-Lewis ([email protected]) and
Dr Kambiz Boomla ([email protected])
Clinical Effectiveness Group | Centre for Primary Care and Public Health | Blizard Institute
Barts and The London School of Medicine and Dentistry | Yvonne Carter Building
58 Turner Street | London E1 2AB | Phone: 020 7882 2553 | Fax: 020 7882 2552
email: [email protected] | www.icms.qmul.ac.uk/chs/ceg/
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