this explains how to approach to a patient present with acute vertigo to emergency department. It mainly focus on management of benign positional paroxysmal vertigo, menieres disease, vestibular neuritis, acute labyrinthitis and brainstem stroke.

1. ACUTE VERTIGO
DR KTD PRIYADARSHANI
REGISTRAR IN EMERGENCY MEDICINE
NATIONAL HOSPITAL- KANDY

2. OUTLINE
1. INTRODUCTION & PATHOPHYSIOLOGY
2. CLASSIFICATION
3. ASSESSMENT
4. MANAGEMENT OPTIONS

3. INTRODUCTION
• VERTIGO- AN ILLUSION OF EITHER ONESELF OR THE ENVIRONMENT ROTATING WHEN THERE IS
NONE
• INCIDENCE 5-10%
• 40% IN PATIENTS OLDER THAN 40 YRS- FALLS DUE TO DIZZINESS 17.8%
• 25% IN PATIENTS OLDER THAN 65 YRS – FALLS DUE TO DIZZINESS 31%

4. PATHOPHYSIOLOGY

9. Vestibule ocular reflex

11. CLASSIFICATION
Vertigo
Single
central peripheral
vestibular
failure
labyrinthine
failure
Multiple
positional spontaneous
Chronic

12. ETIOLOGY
Peripheral Central
Benign paroxysmal positional vertigo Brainstem infarction- stroke, TIA
Meniere’s disease Cerebellar hemorrhage
Vestibular neuritis Acoustic neuroma
Acute labyrinthitis Cerebellopontine tumors
Otitis media
Cholesteatoma
Vestibular migraine

13. ASSESSMENT

14. HISTORY
• VAGUE TERM
• PRESYNCOPE, IMBALANCE, LIGHTHEADEDNESS
• POSITIONAL VS POSTURAL- ORTHOSTATIC HYPOTENSION, NEW MEDICATIONS
• PATTERN
• SINGLE EPISODE
• MULTIPLE EPISODES
• CHRONIC DIZZINESS

15. Peripheral Central
Onset Sudden Gradual- SOL
Sudden- stroke
Duration Usually <48 hr Persist >48 hr (except TIA)
Nausea & vomiting Severe Often mild
Auditory symptoms Aural fullness, tinnitus, hearing
loss
Usually absent except in acoustic
neuromas
Triggers Often exacerbate by head
movement
Little effect from head movement
Neurological
symptoms
None Usually present
(dysarthria, diplopia, dysphagia,
dysdiadochokinesia, dysmetria,
hemiparesis)
Past hx/ risk factors Previous hx of paroxysmal vertigo
Recent ear infection
AF, HT, HD, Prev stroke

16. EXAMINATION
• DIX HALLPIKE TEST- FOR BPPV
• HINTS
• INDICATION- PERSISTENT ONGOING VERTIGO + SPONTANEOUS OR GAZE EVOKED NYSTAGMUS
• USE- VESTIBULAR NEURITIS VS CEREBELLAR/ BRAINSTEM STROKE
• HINTS- MORE SENSITIVE AND SPECIFIC THAN EARLY MRI TO DETECT STROKES
• SENSITIVITY – 100%
• SPECIFICITY- 94%

17. HEAD IMPULSE TEST
• CHECK INTEGRITY OF VESTIBULE OCULAR REFLEX
• 20 DEGREE MOVEMENT- IN RANDOM FASHION
• ABNORMAL IN THE AFFECTED SIDE- NYSTAGMUS IN THE DIRECTION OF UNAFFECTED EAR + CATCH UP
SACCADE

18. NYSTAGMUS
• DIRECTION OF NYSTAGMUS- FAST PHASE
• NOTE SPONTANEOUS OR GAZE EVOKED NYSTAGMUS
• IN VESTIBULAR NEURITIS- AFFECTED EAR IS OPPOSITE THE
DIRECTION OF NYSTAGMUS

19. NYSTAGMUS
Peripheral vestibular nystagmus Central nystagmus
Effect of fixation Decreases with fixation Persists with fixation
Direction Torsional
Jerk nystagmus- beats away from
affected side
Any (vertical, horizontal, rotational)
Pendular, pure torsional , direction
changing nystagmus
Effect of gaze Nystagmus remains the same direction
regardless of direction of gaze
Velocity is greatest looking at quick side
(alexander’s law)
Nystagmus may change direction with
direction of gaze
Does not conform to alexander’s law
Fatigability Fatigues Does not fatigue

20. TEST OF SKEW
• EYE COVER TEST
• ANY VERTICAL OR DIAGONALLY UPWARD OR DOWNWARD MOVEMENT

21. HINTS- WORK UP
Acute peripheral vertigo Acute central vertigo
Head impulse test + ve Head impulse teat -ve
Peripheral nystagmus Central nystagmus
Skew deviation - ve Skew deviation + ve
HINTS PLUS
•BED SIDE TEST FOR NEW HEARING LOSS
•NEW HEARING LOSS- SUGGEST CENTRAL CAUSE
•AICA- ABNORMAL HEAD IMPULSE DUE TO INFARCTION OF LABYRINTH+ CEREBELLUM

22. INVESTIGATIONS
• LOOK FOR CENTRAL CAUSE
• CT/ MRI BRAIN
• EXCLUDE OTHER CAUSES OF DIZZINESS/ LOOK FOR RISK FACTORS
• ECG
• ECHO
• AUDIOLOGICAL TESTING

24. MANAGEMENT OPTIONS

25. BENIGN PAROXYSMAL POSITIONAL VERTIGO
• MOST COMMON CAUSE
• SPONTANEOUS
• POSITIONAL
• NYSTAGMUS- RELATIVE HYPERSTIMULATION
• COMMON- POSTERIOR CANAL

26. • ETIOLOGY
• IDIOPATHIC- 39%
• EAR DISEASES- 29%
• TRAUMA- 21%
• VERTEBRAL BASILAR INSUFFICIENCY- 9%
• OTITIS MEDIA- 9%

27. DIX-HALLPIKE TEST
• FOR DIAGNOSIS OF POSTERIOR CANAL BPPV
• VERTIGO PRECIPITATED BY POSITION
• NO SPONTANEOUS OR GAZE- EVOKED NYSTAGMUS
• PRETREATMENT WITH ANTI EMETIC SOS
• INSTRUCTIONS
• KEEP EYES OPEN
• NECK MOVEMENT ASSESSMENT

28. • DO FOR BOTH SIDES
• LOOK FOR NYSTAGMUS- UP BEATING TORSIONAL TOWARDS AFFECTED SIDE (GEOTROPHIC)
• LATENCY OF 15-30 SEC
• CRESCENDO – DECRESCENDO PATTERN VERTIGO
• ADAPTATION- FADE OFF DUE TO ADAPTATION
• REVERSAL
• FATIGABILITY

29. MANAGEMENT
• NO INVESTIGATIONS REQUIRED
• ELECTRONYSTAGMOGRAPHY
• INFRARED NYSTAGMOGRAPHY
• MANAGEMENT OPTIONS
1. WATCHFUL WAITING
2. VESTIBULAR SUPRESSANTS
3. VESTIBULAR REHABILITATION
4. CANALITH REPOSITIONING
5. SURGERY

30. VESTIBULAR REHABILITATION EXERCISES
• CAWTHORNE COOKSEY EXERCISES
• GAZE STABILIZATION EXERCISES
• BRANDT DAROFF EXERCISES

31. CANALITH REPOSITIONING PROCEDURES (CRP)
• EPLEY MANEUVER
• HOLD IN POSITION FOR THE LENGTH OF TIME PATIENT IS HAVING VERTIGO + 30 SEC
• REPEAT DHT AFTER 10 MIN
• NO SYMPTOM- DISCHARGE WITHOUT RESTRICTION
• STILL POSITIVE- REPEAT EPLEY → PERFORM AT HOME BD UNTIL SYMPTOM SETTLES & FOLLOW UP UNTIL
IMPROVES
• DO NOT PRESCRIBE VESTIBULAR SEDATIVES
• SEMONT LIBERATORY MANOEUVRE
• MULTI AXIAL POSITIONING DEVICES

33. • SURGICAL MANAGEMENT
• LABYRINTHECTOMY
• POSTERIOR CANAL OCCLUSION
• SINGULAR NEURECTOMY
• VESTIBULAR NERVE SECTION
• TRANS TYMPANIC AMINOGLYCOSIDE APPLICATION

34. HORIZONTAL CANAL BPPV
• RARE
• DHT- NEGATIVE ON BOTH SIDES OR PURELY HORIZONTAL
NYSTAGMUS
• SUPINE ROLL TEST
• GUFONI MANEUVER
• RESOLVE SPONTANEOUSLY MORE QUICKLY

35. ANTERIOR CANAL BPPV
• LEAST COMMON
• DHT- DOWNWARD VERTICAL NYSTAGMUS
• DEEP HEAD HANGING MANEUVER

36. PHARMACOTHERAPY
Category Drug Dose Advantages Disadvantages
Anticholinergics Scopolamine 0.5mg patch,
behind ear tds
Nause with vertigo Non availability
Antihistamines – H1 Diphenhydramine 25-50mg IM, IV, PO
4hrly
Nauses with vertigo Drowsiness
Antiemetics
Brainstem
dopamine receptor
block
Metoclopramide 10-20mg, IV, PO tds Nausea with vertigo Extrapyramidal
effects
Ondansetrone 4mg IV bd/tds Intractable vertigo
Promethasine 25mg IM, PO,PR tds Nausea with vertigo Extrapyramidal
effects

37. VESTIBULAR NEURITIS
• VIRAL
• PROLONGED, CONTINUOUS BOUT OF VERTIGO
• INTENSE FOR SEVERAL DAYS
• RESOLVES OVER DAYS, WEEKS OR MONTHS
• NO INVESTIGATION REQUIRED
Vestibular neuritis Acute labyrinthitis
No sensory hearing loss Sensorineural hearing loss
No tinnitus Tinnitus +
PTA

38. Category Drug Dose Advantage Disadvantage
Corticosteroids Methylprednisolo
ne
100mg/d tapered
by 20mg every
4th day
Vestibular
neuritis
Adverse effects
steroids
Antivirals Valacyclovir 1000mg tds – 7d Vestibular
neuritis
Efficacy unknown

39. LABYRINTHITIS
• COMPLICATION OF ACUTE OTITIS MEDIA
• LESS COMMON
• CONTINUOUS VERTIGO AND NYSTAGMUS FOR DAYS
• INVESTIGATION
• VIRAL- NONE
• BACTERIAL- MRI

40. MENIERE’S DISEASE
(IDIOPATHIC ENDOLYMPHATIC HYDROPS)
HISTORY
• SUDDEN ONSET, DURATION 20 MIN- 12 HRS
• USUALLY UNILATERAL, BUT CAN BE BILATERAL OVER TIME
• ASSOCIATED NAUSEA, VOMITING, DIAPHORESIS, TINNITUS, HEARING LOSS, EAR FULLNESS
• FREQUENCY SEVERAL/ WEEK- MONTHS
• WELL BETWEEN ATTACKS
• NO INVESTIGATION REQUIRED

41. • MANAGEMENT – SYMPTOMATIC
• SALT RESTRICTED DIET
• LABYRINTHINE SEDATIVES- ANTIHISTAMINE
• VASODILATORS- BETAHISTIDINE, TRIAMTERENE & HCT, CCB
• SYSTEMIC & INTRATYMPANIC INJECTIONS OF CORTICOSTEROIDS OR GENTAMICIN- CONTROL FREQUENCY
OF ATTACKS
• MENIETT DEVICE
Category Drug Dose Advantages
Vasodilators
Strong H3 and weak H1
antagonist
Betahistidine 48mg PO tds for 6-12
months
Meniere’s syndrome
Increase cochlera blood flow
& decrease peripheral
vestibular inputs

42. • SURGICAL MANAGEMENT
• ENDOLYMPHATIC SAC DECOMPRESSION
• SHUNT OPERATION
• SELECTIVE VESTIBULAR NERVE DESTRUCTION
• TOTAL LABYRINTHECTOMY

43. VESTIBULAR MIGRAINE
• SECOND MOST COMMON CENTRAL CAUSE OF VERTIGO
• MIGRAINE HEADACHE, AURA
• NO INVESTIGATION REQUIRED
• ANTI MIGRAINE RX
• REFER TO NEUROLOGIST
Diagnostic criteria
• Moderate to severe vertigo- 5min- 72hrs
• Past or recurrent hx of migraine
• 5 or more episodes of vertigo+ at least 50%
has- visual aura, photophobia or
phonophobia, typical migraine headaches
• Unilateral
• Pulsating
• mod to severe intensity
• aggravated by routine activity
• No other possible pathology

44. Anticonvulsants Topiramate 50-100mg/d Vestibular migraine
prophylaxis
Valproic acid 300-900 mg/day Vestibular migraine
prophylaxis
Beta blockers Metoprolol 100mg/day Vestibular migraine
prophylaxis
Calcium antagonists
Not responding to
anticholinergics or
antihistamine
Cinnarizine 25mg po bd/tds Peripheral vertigo,
vestibular migraine
Flunarizine 20mg bd Meniere’s syndrome
Nimodipine 30mg PO bd Peripheral vertigo,
vestibular migraine

45. CEREBELLAR/ BRAINSTEM STROKE
• DIPLOPIA, DYSARTHRIA, DYSPHAGIA, DYSPHONIA & DYSMETRIA
• WEAKNESS OR PARESTHESIA
• IF THE PATIENT IS UNABLE TO STAND UNAIDED- EXCLUDE CENTRAL CAUSE
• INVESTIGATIONS
• CT ANGIOGRAPHY- IF INTERVENTION PLANNED
• MRI- IF ACUTE INTERVENTION NOT PLANNED

46. • MANAGEMENT
• NEED ADMISSION
• STABILIZATION AND SUPPORTIVE CARE
• SECONDARY STROKE PREVENTION
• REHABILITATION

47. SUMMARY- PERIPHERAL CAUSES
Peripheral cause Key points Clinical course
BPPV
Most common
< 2 min episodes
Trigger by head movement
DHP- Vertical upward and rotatory nystagmus
Benign
Particle repositioning
maneuvers
Vestibular
Common
Continuous hours/days- constant vertigo
Nystagmus + use HINTS
Spontaneous recovery
over days/ weeks
Labyrinthitis
Less common
Ear pain, tinnitus and hearing loss onset days before vertigo A complication of OM
Serious if bacterial- rare
Meniere’s disease
Less common
Recurrent episodes of vertigo, hearing loss, tinnitus and ear
fullness
Slowly progressive, can
lead to profound hearing
loss

48. SUMMARY- CENTRAL CAUSES
Cause Key points Clinical course
Vestibular migraine
most common
Recurrent attacks with migraine + isolated vertigo
(>50%- with migraine)
As per migraine
Cerebellar/ brainstem
stroke
Less common
Other neurologic signs & symptoms
Headache
Nystagmus+ HINTS
Hearing loss +/-
Admit
Risk of edema &
hydrocephalus

49. REFERENCES
• DHINGRA ENT TEXTBOOK
• TINTINALI’S EMERGENCY MEDICINE- COMPREHENSIVE STUDY GUIDE – 9TH EDITION
• MEDSCAPE
• EM RAP- PODCASTS

50. QUESTIONS?

51. THANK YOU!