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An approach to vertigo with flowchart algorithm
- 1. An approach to Vertigo ASHOKARYAL MS (ENT)
- 2. Introduction Gowers “Any movement orsense of movement, either in an individual himself or in external rotation, that involves a defect, real or seeming, in the equilibrium of the body” Synopsis of Otolaryngology 5th ed. Need to differentiate with Presyncope and disequilibrium
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- 5. Peripheral (Common- 80-90%*) Labyrinth •BPPV * * • MD * • Peri-lymphatic fistula * • Cogan’s Syndrome *- autoimmune diz • Labyrinthitis- COM, post-surgical, inner ear neoplasm Vestibular/Vestibulocochlear Nerve • Vestibular neuritis (Labyrinthitis) • Acoustic Neuroma • Ramsay Hunt Syndrome • Vestibular paroxysmia * • Vestibulotoxic drugs- aminoglycoside (Streptomycin, gentamycin, kanamycin), diuretics, alchohol, tobacco, antimalarials, anticancer, analgesics (indomethacin, ibuprofen) * Most common cause of vertigo * Causes of episodic vertigo * American Medical Association
- 6. Central (Uncommon 10-20%*) Vascular •Stroke / TIA Non-vascular • Vestibular Migraines* • Multiple sclerosis (MS) * Most common cause of vertigo * Causes of episodic vertigo * American Medical Association
- 7. Peripheral • Unidirectional (Neverreverse the direction) • Fast component towards the normal ear • Horizontal with torsional • Never pure torsional or vertical Central • Bidirectional • Reverse the direction when patient looks in the direction of slow component • Purely vertical or torsional • No horizontal • Suppressed • Not suppressed • Unidirectional instability, walking preserved • Severe instability, patient often falls when walking • Absent • May be present • Often present • Diplopia, ataxia, dysarthria, dysphagia • Usually absent Nystagmus Effects of visual fixation Postural instability Deafness/ Tinnitus Neurological symptoms Characteristics
- 9. Diagnosis • Confirm whetherit is vertigo/presyncope/ dysequlibirium • Time Duration: episodic vs continuous • Triggering factors: Head position, Trauma, Cough, weight lift, bowel movement • Associated symptoms Hearing loss, tinnitus MD Headache, photophobia Migraine Eye pain, redness Cogan’s syndrome Neurological symptoms (Diplopia, dysarthria, dysphagia, weakness, numbness ) MS, Stroke Imbalance Vertigo Bil vestibular dysfunction MD Tilt illusion, drop attacks • PMH- atherosclerotic risk factors, Migraines, Head trauma (BPPV), Medications (Cisplatin, Aminoglycosides, Phenytoin) History
- 10. Examinations • Ear Examination----------------Otoscopy • Neurological examinations-------- Balance and gait • HINTS Exam • Dix-Hallpike maneuver • Blood tests does not provides any clue to diagnose vertigo • Audiometry, Electrocochleogram if MD is suspected • Brain Imaging (MRI/MRA) • Videonystagmography (VNG)
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- 15. Symptoms Description DurationSymptoms (Frequently associated) Mechanism Vertigo Illusion of motion while stationary Sec to weeks Nausea Disruption of vestibular pathway Presyncope Faintness, slowed consciousness leading to syncope Sec to min Warmth, visual changes Transient reduction of brain perfusion Dysequilibirium Difficulty in maintaining balance Sec to weeks Frequent falls without loss of consciousness Multiple sensory deficits
- 16. Vertigo BPPV Dix-Hallpike maneuver BPPV confirmed Uncommon forms of BPPV Vestibular Migraine vs MD Audiometry MD Vestibular migraine Vestibular Neuritis Symptomatic management Reassessin 1-2 wks No further workup unless recurs Central etiology Brain MRI +/- MRA Work-up as indicated Consider rare causes Recurrent episodes Triggered by head movement Duration: Sec-min Recurrent episodes Duration: Min-Hours Single, continuous episodes Duration: days or less Associated with viral symptoms Continuous vertigo and abnormal HINTS exam Abnormal Normal Episodic HL, tinnitus Low frequency HL in audiometry Normal audiogram No audiological symptoms Resolved Persistent Old age, risk factors for stroke with neurological sign and symptoms Diagnosis made Unremarkable Algorithm
- 17. References • Uptodate • Synopsisof Otolaryngology, 5th Edition, 1990 • Vertigo and Dizziness common complaints, 3rd edition, 2013
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