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Vertigo Simplified
Gary Kroukamp
Kingsbury Hospital
Tygerberg Hospital
At the end of this talk…
• Define vertigo
• Diagnose - just by the history
• Refer
• Investigate
• Manage
Definitions
Dizziness/lightheadedness: A distorted sense of
one’s spatial relationship
Vertigo: Hallucination of rotatory motion
Unsteadiness: Difficulty with gait/Tendency to fall
to one side
Blackouts: Loss of consciousness
Giddiness – Who the hell knows?
Anatomy and Physiology
Input
Output
Cortical awareness
Visual adaptation
Vision
Central integration
Proprioception
Vestibular labyrinth
Musculosceletal
Autonomic nervous
system
Anatomy and Physiology
Anatomy and Physiology
History
1.
2.
3.
4.
5.
6.
7.
Describing character of symptoms
Onset – Sudden or Gradual
Frequency
Duration
Severity
Aggravating factors (activity, darkness)
Associated symptoms (N+V, Tinnitus,
Hearing loss)
8. Medical history (CVS, Psych, CNS)
9. Trauma
10. Medications/Alcohol
History
Peripheral
Central
Syncopal
Psychogenic
Vertigo
Dizziness
Blackout
‘Out of body’
Episodic
Continuous
Episodic
Variable
N+V
Other CNS
Simptoms
+- CVS
history
Anxiety
Visual
fixation
Visual fixation
Examination
1. General
2. Vital signs
3. ENT -Middle ear disease, hearing(audiogram)
4. Neurologic -Cranial nerves, Cerebellum,
Nystagmus
5. Cardiovascular -postural hypotension, pulse,
carotid bruits, Cardiac murmurs
6. Manoeuvers -Hallpike
Special Investigations
1. FBC (Infection, leukemia)
2. VDRL, Bloodglucose, Thryroid functions
3. ECG (Arythmias, previous MI)
4. Electronystagmography, Videonystagmography
5. MRI
Causes
Otological (Peripheral)
vs
Non-otological (Central)
Otological causes
1. External ear (Foreign body, impacted wax)
2. Middle ear disease
3. Trauma -Temporal bone fracture)
4.
5.
6.
7.
Menière’s disease
BPPV
Labyrinthitis
Vestibular neuronitis (Viral)
8. Other -Syphilis, Ototoxic drugs, Acoustic
neuroma
Characteristics of Inner Ear
Disorders
• Dysequilibrium, not fainting
• Definite attacks/episodes
• “True vertigo”
• Severe
• Often with N & V
• Other Inner Ear symptoms
Clinical Scenario 1
• Mrs JW
• 59 years old
• 3 week h/o dizziness
• Some nausea, no vomiting
• Wakes her up at night
• Worse on rolling over to the left
• Worse on reaching up to high shelf
BPPV
Episodic Vertigo on position change
Pathology: Otoliths in semicircular canals
Diagnosis: Dix-Hallpike manoeuvre with rotational
nystagmus
Treatment: Repositioning manoeuvres, Epley
Clinical Scenario 2
• Mr SP
• 43 yo
• Dizzy “attacks” for 3 years
• 4 to 5 per year
• Last 2 to 3 hours
• N&V
• Has to lie down
• Tinnitus and muffled hearing left ear
Menière’s disease
Endolymphatic hydrops
1. Young to middle age
2. Episodic attacks
3. Cardinal features -Vertigo, Tinnitus, Hearing
loss, Fullness
4. Management
- Reassurance and Vestibular sedatives
- Reduction of Caffeine, smoking, salt, 3L
water
- Medical -Serc, mild diuretics
Menière’s disease
• Surgery now largely abandoned in favour of
• Middle ear installation of Gentamycin
• Middle ear installation of Steroids
Clinical scenario 3
• Mrs RvW
• 36 yo
• Sudden onset severe dizziness 2 days ago
• N&V
• Unable to stand/falls over
• Normal hearing
• Blurring of vision
• Left beating nystagmus
Vestibular Neuronitis
• Viral labyrinthitis
• Nonspecific viral illness followed 6/52 by a sudden onset
of vertigo, nausea + vomiting
• Initially severe- gradual resolution over 10 days
• Rx: Steroids
• Vestibular suppressants
Labyrinthitis
Infection of Vestibular labyrinth, associated with URTI
Rapid onset vertigo with nystagmus and hearing loss
First 24 hrs worse, normally resolve after 36 hrs
Clinical Scenario 4
• Mr AD
• 74 yo man
• Gradual onset hearing loss R ear – for years
• Also tinnitus R ear
• Vague poor balance
• 1 episode vertigo 4 years ago
• Hearing worse after this
Acoustic/Vestibular
Schwannoma
• Benign, slow-growing tumor in vestibular division of eighth
cranial nerve
• Not episodic vertigo
• MRI with gadolinium is reliable +cost-effective
• Rx: “Radiosurgery”Gamma knife/ Surgery
Characteristics of Central Causes
• Continuous
• Dysequilibrium more vague, not “True Vertigo”
• Less severe imbalance, can still function
Non-otological (Central)
1. Vascular -Vertebrobasilar insufficiency, TIA,
postural hypotension, Cardiac dysrythmias, Valvular lesions, Wallenberg
syndrome, Medullary infarction, Internal auditory artery obstruction, Vertebrobasilar migraine, Subclavian Steel
syndrome
2. Trauma -Head injury
3. Ageing -multifactorial
4. Infectious -Meningitis, Ramsay Hunt
Syndrome
Non-otological (Central)
5. Demyelinating diseases eg. MS
6. Epilepsy
7. Toxic -Alcohol, Anticonvulsants
8. Psychogenic –Hyperventilation,Anxiety
9. Tumour
10. Metabolic -thyroid, hypo- and hyperglycaemia,
Addison’s disease
11. Congenital -Familial episodic ataxia, Hydrocephalus, Arnold-Chiari malformation
Clinical Scenario 5
• Mrs TH
• 28 yo
• Poor balance and swaying 6 months
• After a cruise Durban to Cape Town
• Better with exercise
• Better with alcohol
Mal de Debarquement Syndrome
• After travel by ship
• Improvement with exercise/alcohol
• Psychogenic?/Anxiety
• Overly focused on balance correction
• Reassurance/exercise
Conclusion
• History!
• Clinical Picture
• Not everyone has Meniere’s
• Appropriate referral
• Management according to diagnosis