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Vertigo Clearing confusion for patients and doctors Dr SK Ng Specialist in Otorhinolaryngology Division of ENT NT East cluster The Chinese University of Hong Kong Dizziness and vertigo are common Dizziness and Vertigo Ear dysfunction Vascular insufficiency Neurological dysfunction Psychological problems Radiological and Laboratory Tests: Rarely helpful Systematic Approach Arrive at diagnosis Recognize potentially dangerous condition Specialist attention Diagnostic Approach History Physical examination Investigations The First Question: What does the patient mean by dizziness? Giddiness vs Vertigo Giddiness Most common form: non-specific light-headedness Vague and Subjective Never actual fall or veer Nonspecific light-headedness Psychogenic Hyperventilation Hypoglycemia Anemia Near-syncope Light-headedness Generalised weakness Faintness Rise from lying or sitting Typically worse in the morning When supine: No symptoms Causes: 1. Autonomic dysfunction DM Drugs: anti-HT, anti-arrhythmic 2. Cardiovascular disease Dysequilibrium Feeling of unsteadiness No actual illusion of movement No sensation of faintness Cause Dysequilibrium of ageing multi-sensory deficits vestibular sedatives not useful vestibular rehabilitation program a walking stick Refer for neurological evaluation Dysequilibrium + poor gait Vertigo Hallucination of movement Typically but not necessarily rotatory Lesion in the vestibular system The Second Question Is it Benign Paroxysmal Positional Vertigo? (BPPV) BPPV Common Very characteristic Highly treatable Benign Paroxysmal Positional Vertigo (BPPV) Rotatory vertigo last for seconds Positional: looking up rapidly rolling over in bed Nausea, no vomiting No tinnitus/ hearing loss Diagnosis confirmed by Dix Hallpike maneuver Pathophysiology Benign Paroxysmal Positional Vertigo (BPPV) Drugs: USELESS Treatment of choice: Epley maneuver 30 Seconds each step 90% chance of success What if the maneuver fails? Try again! If still fails, Refer to ENT The Third Question Is the vertigo central in origin? Central Vertigo Uncommon Potentially fatal Refer Central Vertigo Associate neurological symptoms Risk factors for CVA Severe imbalance Vertical nystagmus Peripheral Vertigo Peripheral Vestibular Disorders Meniere’s disease Vestibular neuronitis Meniere’s disease rotatory vertigo lasting for hours Classic triad hearing loss tinnitus to 60 years of age nausea and vomiting Meniere’s disease Pathogenesis: over-accumulation of fluid within the inner ear Meniere’s disease Normal Meniere’s disease Treatment: Vestibular sedatives Prophylactic treatment: ? Ablative surgery Vestibular neuronitis Rotatory vertigo last for days Nausea and vomiting No otological symptoms Commonly follow a flu Vestibular neuronitis Natural course: Vertigo followed by a period of unsteadiness Treatment Vestibular sedatives Vestibular rehabilitation Rarer Peripheral Disorders Acute suppurative labyrinthitis Perilymph fistula Acute suppurative labyrinthitis Bacterial infection of inner ear Severe vertigo + hearing loss + ear discharge Refer ENT Perilymph fistula Violation of barrier between middle and inner ear Vertigo onset after trauma Refer ENT To Sum Up …. Approach to Dizziness 1. Vertigo vs Giddiness 2. ? BPPV 3. ?Central vertigo 4. Peripheral vertigo: duration of attack associated otological symtoms Duration of Vertiginous Attacks Seconds: BPPV Minutes: vertebrobasilar insufficiency/ TIA Hours: Meniere’s disease, migraine Days: vestibular neuronitis acute labyrinthitis cerebellar stroke Constant: neurological disorder incomplete recovery of vestibular failure psychogenic Physical examination Dix Hallpike Maneuver Confirm BPPV Treatment of Peripheral Vertigo 1. BPPV Epley maneuver 2. Acute sustained vertigo Vestibular sedatives e.g. stemetil, stugeron Treatment of Peripheral Vertigo 3. Chronic unsteadiness Vestibular rehabilitation Refer if • Uncertain diagnosis •Perilymph fistula • Central vertigo •“BPPV” failed Epley • Suppurative labyrinthitis
