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Vertigo
Paul Chatrath
Consultant ENT/Head & Neck Surgeon
Charing Cross Hospital (Imperial Healthcare NHS Trust)
Honorary Senior Lecturer
Anglia Ruskin University, Chelmsford
Visiting Professor of Rhinology
Canterbury Christ Church University, Kent
6th September 2016
Objectives


Dizziness / vertigo in
general
ENT causes for
vertigo



Meniere’s
BPPV
Labyrinthitis


Other ENT causes of
dizziness
‘red flags’
Case - Dizziness



Please see this 40
year old female
suffering with short
lived episodes of
vertigo
Occurring almost daily
Occurs whenever
moves head in any
direction
Clinical approach

Vertigo vs dizziness

Vertigo
Rotatory
 Suggests a peripheral vestibular or cerebellar
problem


Dizziness / lightheadedness

Non-specific


‘whoozy’ ‘ lightheaded’ ‘unsteady’ ‘drunken’
Suggests non-vestibular pathology
Types of Dizziness
Rotation (Spinning)
Unsteadiness (Imbalance)
Light headedness (faint feeling)
If the patient has ever lost consciousness: it is not ENT!
Vertigo - causes
Vestibular

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


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

Viral labyrinthitis
BPPV
Meniere’s disease
Acute Otitis Media
Trauma
Cholesteatoma
Drug induced
Postsurgical
Central




Migraine
Vertebrobasilar ischaemia
MS
Tumours

Cerebellopontine angle



Acoustic neuroma
Brainstem
CVA
Psychogenic
Non-specific dizziness:
Causes

Cardiovascular





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Arrhythmias
Reduced cardiac output
Carotid artery stenosis
Arteriosclerosis
Hypotension (postural)
Peripheral neuropathy





Proprioception



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Arthritis (cervical and other)




DM
Hypothyroidism
Hypercholesterolaemia
Anaemia


B1, B6, B12
Genetic - Refsum’s disease
Toxins


Leprosy, TB, syphilis
Vitamin deficiencies

Metabolic

DM
Renal or hepatic failure
Alcohol
Vasculitis
Infections
Lead, metronizadole
Psychogenic
Vertigo:
Duration is key

Brief (<1min)



- specific head movement
- any head movement
Hours



BPPV
Psychogenic
BPPV
Psychogenic
Meniere’s
Migraine
Days (>24hrs)

Viral labyrinthitis
Meniere’s
Migraine
- classic triad
- classic headache
Nystagmus

Movement of the eyes:




Rhythmic
Oscillating
Synchronous
Involuntary

Two phases



Slow phase
(pathological)
Fast phase (corrective)
Direction described in
terms of fast phase
Nystagmus
Normal labyrinths
Abnormal Right Labyrinth
R
L
Eyes central
L
X
Slow drift to right
Rapid corrective flick to left
= Left nystagmus
Vertigo:
Compensation




Vestibular
phenomenon
Steady
accommodation to
the effects of vertigo
Gradual resolution of
symptoms over time
Typically occurs 6-12
weeks after acute
insult

Mechanisms

Habituation



Reduced output good
side
Increased output
affected side
Sensory substitution

Increased reliance on
eyes and
musculoskeletal system
Vertigo:
Compensation

Impaired
compensation due to:



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Poor visual acuity
Musculoskeletal
problems
Reduced peripheral
sensory input
Ongoing vestibular
pathology
Medication (prolonged
stemetil)

Rehabilitation:

General fitness


Physical programs



Vision, walking stick
Cawthorne-Cooksey
Psychological support
Specific exercises

Eg. Brandt-Daroff
exercises for BPPV
Vertigo:
Vestibular v Central
Vestibular
Central
Type of dizziness
Vertigo
Vertigo / Dizzy
Effect of head movement
Worse
Equivocal
Tinnitus/hearing loss
May be present
Absent
Compensation
Occurs
Does not occur
Nystagmus
Horizontal
+ unilateral
+ away from
affected ear
Horizontal or vertical
+ bilateral
Vestibular rehabilitation:
Cawthorne - Cooksey

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Head movements
Balance tasks
Coordination of eyes with head
Total body movements
Eyes open & closed
Noisy environments
Causes early exacerbation of vertigo
Caution:
Prochlorperazine




Powerful vestibular sedative
Suppresses acute vertiginous symptoms
BUT
Also suppresses natural compensatory
response
LT use:‘non-specific dizziness’persists
Psychogenic

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Type of dizziness: any (nonspecific or vertigo)
Frequency: constant
Duration: Typically brief <1min
Trigger: Stress, anxiety, crowds
Associated features: palpitations, sweating,
tremor
Examination: Normal
Labyrinthitis

History

Vertigo




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>24hrs
Vomiting
Constitutional symptoms
Usually following URTI

Treatment


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Examination

Nystagmus


Fast phase away from
affected ear
Pyrexia

Bed rest
Vestibular sedatives
Fluids
Cawthorne-Cooksey
vestibular
rehabilitation exercises
Rule of threes - 3
days: v bad, 3 weeks,
a lot better, 3 months
resolved
Meniere’s Disease

Key features:

Vertigo


Tinnitus/hearing loss

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Before/during/after vertigo
Other symptoms

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Hours
Pressure feeling
Nausea
Natural history
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One episode
Episodic
Increasing frequency

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Salt restriction
Diuretics - thiazides
Vasodilators

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Betahistine, cinnarizine
Evidence – no RCTs

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Cinnarizine > placebo
Diuretics = placebo
Serc of marginal
benefit
Salt restriction of
marginal benefit
Intratympanic therapy:
Steroids or Gentamicin
BPPV:
Benign Paroxysmal Positional Vertigo


Calcific debris in
semicircular canals
Vertigo


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Brief (<1min)
On head turn in a
particular direction
Typically self-limiting
Primary
Secondary




Trauma (HI)
Prolonged bed rest
Otological condition (up
to 70%)
Posterior SCC


In plane on
lying in bed
Hallpike’s test

Nystagmus on
lying back to
one side
BPPV - Epley
Epley, 1992
BPPV - Brandt & Daroff
Brandt & Daroff, 1980
Migraine

Clinical features

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Lifestyle change

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Family history
Motion intolerance
Vertigo occurs with classical headache either before or after
ENT/vestibular examination usually NAD
Exercise, diet, avoidance of stimulants
Medication:

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Abortive therapy eg. Sumatriptan
Prophylactic therapy eg. B blockers
Other ENT conditions causing
dizziness

Ear:




Nose/Sinus

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Malignant OE
Otitis media
Cholesteatoma
Sinusitis
Thyroid disturbance
Dizziness/Vertigo:
Indications for Urgent Referral
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Vertigo

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
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Intense
Disabling
Unremitting
Nystagmus
Sudden SNHL

Features to suggest
malignant pathology

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Elderly with
granulation in ear
canal
VIIn palsy
Post-traumatic
TM perforation +
vertigo
Conclusion

Must define the
dizziness / vertigo



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Rotatory or not
Frequency
Triggers
History is the most
important factor

Duration

Vertigo



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
BPPV (cervical / psychogenic)
Meniere’s (Migraine)
Labyrinthitis (Drug / multifactorial)
ENT causes for vertigo
When to refer urgently
Case



Please see this 40
year old female
suffering with short
lived episodes of
vertigo
Occurring almost daily
Occurs whenever
moves head in any
direction
Vertigo
Paul Chatrath
Consultant ENT/Head & Neck Surgeon
Charing Cross Hospital (Imperial Healthcare NHS Trust)
Honorary Senior Lecturer
Anglia Ruskin University, Chelmsford
Visiting Professor of Rhinology
Canterbury Christ Church University, Kent
[email protected]
6th September 2016