Vertigo The Dizzy Patient

Vertigo Latin origin: vertere , to spin the illusion that the environment is spinning distinct from “dizziness” light-headed faintness off-balanced feeling feeling of floating

Latin origin: vertere , to spin

the illusion that the environment is spinning

distinct from “dizziness”

light-headed faintness

off-balanced feeling

feeling of floating

Acute Vertigo Determine whether it represents a peripheral or a central problem peripheral (99:100) refers to the inner ear or vestibular nerve up to the root entry zone in the brain stem central (1:100) refers to the brain, usually associated with focal neurologic findings, may be from cerebellar infarct

Determine whether it represents a peripheral or a central problem

peripheral (99:100) refers to the inner ear or vestibular nerve up to the root entry zone in the brain stem

central (1:100) refers to the brain, usually associated with focal neurologic findings, may be from cerebellar infarct

Acute Vertigo clues from history and physical peripheral - look for signs of ear involvement: unilateral hearing loss, tinnitus, fullness, or pain central - most patients have vascular risk factors: age >60, HTN, smoking, known atherosclerotic cardiac or or peripheral vascular disease

peripheral - look for signs of ear involvement: unilateral hearing loss, tinnitus, fullness, or pain

central - most patients have vascular risk factors: age >60, HTN, smoking, known atherosclerotic cardiac or or peripheral vascular disease

Clues from History and Physical degree of imbalance peripheral - patients prefer to lie down, they can get up and walk if asked but tend to veer to one side central - patients with cerebellar lesions usually have such severe imbalance that they cannot stand up

peripheral - patients prefer to lie down, they can get up and walk if asked but tend to veer to one side

central - patients with cerebellar lesions usually have such severe imbalance that they cannot stand up

Clues from History and Physical nystagmus Most often found in patients with peripheral vestibular lesions peripheral - always beats in one direction; inhibited with fixation; usually disappears within a few days central - typically changes direction toward the direction of gaze; not inhibited with fixation; last > 1-2 days

Most often found in patients with peripheral vestibular lesions

peripheral - always beats in one direction; inhibited with fixation; usually disappears within a few days

central - typically changes direction toward the direction of gaze; not inhibited with fixation; last > 1-2 days

Clues from History and Physical double vision usually suggests central brainstem involvement, but may occur in peripheral inner-ear or vestibular nerve damage peripheral lesions siemicircular canal  nystagmus otolith organs  slight static eye displacement, use cover-uncover test

usually suggests central brainstem involvement, but may occur in peripheral inner-ear or vestibular nerve damage

peripheral lesions

siemicircular canal  nystagmus

otolith organs  slight static eye displacement, use cover-uncover test

Acute Vestibulopathy of unknown cause other diagnostic labels: vestibular neuritis vestibular neuronitis viral labyrinthitis viral neurolabyrinthitis vascular occlusion of inner ear

other diagnostic labels:

vestibular neuritis

vestibular neuronitis

viral labyrinthitis

viral neurolabyrinthitis

vascular occlusion of inner ear

Acute Vestibulopathy treatment hydration and promethazine vestibular rehabilitation begin with onset of symptoms make head movements that provoke vertigo, walk, bend, straighten up recovery occurs as the brain compensates for loss of function meclizine - for short term use only

hydration and promethazine

vestibular rehabilitation

begin with onset of symptoms

make head movements that provoke vertigo, walk, bend, straighten up

recovery occurs as the brain compensates for loss of function

meclizine - for short term use only

Benign Positional Vertigo vertigo produced by change in position the most common cause of vertigo after head trauma, or other damage to the ear, such as infections results from the free movement of dislodged utricle particulate debris - calcium carbonate crystals - in the semicircular canals

vertigo produced by change in position

the most common cause of vertigo after head trauma, or other damage to the ear, such as infections

results from the free movement of dislodged utricle particulate debris - calcium carbonate crystals - in the semicircular canals

Benign Positional Vertigo diagnostic testing Dix-Hallpike test positional testing using the head-hanging technique patients with benign positional vertigo will show a burst of nystagmus after a delay of 5 to 10 seconds, the nystagmus lasts about 30 seconds the test is never subtly positive

Dix-Hallpike test

positional testing using the head-hanging technique

patients with benign positional vertigo will show a burst of nystagmus after a delay of 5 to 10 seconds, the nystagmus lasts about 30 seconds

the test is never subtly positive

Benign Positional Vertigo treatment Epley maneuver the patient’s head is systematically rotated to move the loose particles out of the posterior semicircular canal back into the utricle ( see reference ) Otolaryngol Head Neck Surg 1992;107:399

Epley maneuver the patient’s head is systematically rotated to move the loose particles out of the posterior semicircular canal back into the utricle ( see reference )

Vertigo of Central Origin Diagnotic clues risk factors, focal neurologic findings Diagnostic tests MRI brain scan MRI angiography Treatment aspirin 325 mg a day

Diagnotic clues

risk factors, focal neurologic findings

Diagnostic tests

MRI brain scan

MRI angiography

Treatment

aspirin 325 mg a day

References Dizzy Patients: The Varieties of Vertigo Baloh RW, Baringer JR. Hosp Practice 1998;33(6):55-77. Dizziness, Hearing Loss, and Tinnitus Baloh RW. FA Davis, Philadelphia, 1998.

Dizzy Patients: The Varieties of Vertigo Baloh RW, Baringer JR. Hosp Practice 1998;33(6):55-77.

Dizziness, Hearing Loss, and Tinnitus Baloh RW. FA Davis, Philadelphia, 1998.