Theme of the Fortnight presentation from Dr Lucy Miller. For use of medical professionals - see full disclaimer at www.emcage.net

1. Vertigo
Lucy Webber

2. Vertigo = ‘Hallucination of movement’
Disturbance of vestibular system
CENTRALPERIPHERAL
CENTRAL NERVOUS
SYSTEM
OTOLOGICAL
CAUSES
Cerebellar haemorrhage/ischaemia
Vertebrobasilar insufficiency
Head & neck trauma
Multiple Sclerosis
Vertebrobasilar Migraine
Hypoglycaemia
Tumours
Migraine
Meningitis/encephalitis
Degenerative
BPPV
Ménières Disease
Acute labyrithitis
Otitis Media (Acute/Chronic
suppurative)
Acoustic Neuroma
Cholesteatoma
Foreign body/wax

3. Background
• Common presentation
• Typically rotational
• Illusion of tilting to one side/swaying
• Feeling of imbalance when standing/walking
• Diagnosis relies on accurate hx and examination
• Often described by pts as ‘dizziness’, ‘spinning’,
‘lightheadedness’, ‘unsteadiness’

4. History
• Onset and duration of first attack
• Associated symptoms:
• Exacerbating/relieving factors – effects of change in
posture, head/neck movements, darkness
• PMHx: Diabetes, CV disease, ear problems, trauma
• DHx
• SHx: ETOH intake, recreational drugs
OTOLOGICAL: Otalgia, otorrhoea, change in hearing, tinnitus
NON-OTOLOGICAL: Nausea & vomiting, fever, systemic upset, preceding viral
illness

5. Examination
• Full neurological exam incl. cerebellar exam (DANISH)
• Otoscopy, Rinnes/Weber’s Tests
• HINTS exam (YouTube video)
– Head Impulse, Nystagmus, Test of Skew
– Presence of 1 of 3 signs  sensitivity of 100%, specificity
of 96% for dx of stroke!

6. HINTS Exam
• Head Impulse
– Pt fixes eyes on examiner’s nose. Head quickly rotated. Normal side  eyes remain
fixated. Affected side  eyes make corrective saccade to fix on target
– Abnormal VOR reflex suggests peripheral pathology
• Nystagmus
– Vertical/bidirectional nystagmus = central pathology
• Test of Skew
– Cover/uncover test  pt focuses on examiner’s nose. Refixation of eyes/vertical
misalignment suggests central pathology

7. Approach to
Vertigo

8. Benign Paroxysmal Positional Vertigo
(BPPV)
• Commonest cause
• Debris in semicircular canals
Sx:
- Dizziness induced by sudden head movement
- Nausea
- Lasts 30-60 secs
Signs:
- Nystagmus towards affected side
Ix:
- Dix-Hallpike manoeuvre
Tx:
- Epley’s manoeuvre
- Vestibular exercises
- Reassurance

9. Ménière’s Disease
• Severe endolymphatic hydrops – abnormal
fluctuation in endolymph fluid =  inner ear
pressure
• Idiopathic

10. Acute Labyrinthitis
• Inner ear inflammation
• Vestibular neuronitis/neuritis –
affects balance only, no hearing loss
• Typical age of onset: 30-60yrs
• Causes: Viral, bacterial, head injury,
• drugs
• 95% of pts - single episode

11. Otitis Media
• Causes: Viral/bacterial infection, allergies  Inflamed mucous membranes  Eustachian
tube dysfunction
• Common bacterial infections: Strep. pneumoniae, H. influenzae, M. catarrhalis, Staph.
Aureus
Refer to ENT if:
 Failure of resolution
 Persistent discharge
 Recurrent episodes (≥3 in 6mths, ≥ 4 in 1
yr) - grommets
 Complications: VIIth nerve palsy,
mastoiditis

12. CVA
• Most common cause of central
vertigo
• Posterior Circulation Stroke
– Cranial nerve palsy & contralateral
motor/sensory deficit
– Bilateral motor/sensory deficit
– Conjugate eye movement disorder
– Cerebellar dysfunction
– Isolated homonymous hemianopia
• Admit
• MRI with DWI (CT has 16% sensitivity for
posterior fossa pathology)
• Bleed  Refer to Neurosurgeons
• Ischaemia  Aspirin 300mg for 2/52