1. Identify the difference between vertigo, disequilibrium,, near-syncope, and Undifferentiated dizziness. 2. Identify helpful tests to distinguish peripheral from central vertigo. 3. Understand how to treat different kinds of vertigo

1. BY: Dr. Hassan Yousef
Consultant Family Medicine, PHCC.
Instructor of Family Medicine in Clinical Medicine, WCMC-Q
Core Faculty Member Family Medicine Training Program , Qatar
Dizziness in primary Care

2. Disclosure of Conflict of Interest
I Dr. Hassan Yousef
DO NOT have a financial
interest/arrangement or affiliation with
anyone in relation to this
program/presentation/organization that
could be perceived as a real or apparent
conflict of interest in the context of the
subject of this presentation.

3. 1. Identify the difference between vertigo, disequilibrium,, near-
syncope, and Undifferentiated dizziness.
2. Identify helpful tests to distinguish peripheral from central
vertigo.
3. Understand how to treat different kinds of vertigo.
Learning Objectives

4. You have 35 years old patient with history strongly suggest
BPPV and Negative Dix-Hallpike test, what is your best
next action?
A. Exclude BPPV.
B. Start betahistadine & follow up
C. Do supine head roll test.
D. Referral for Urgent C.T.
E. Do HINTS Examination
Warm up

5. What does a positive head impulse test imply?
A. The patient has BPPV
B. The patient has vertigo from a vestibular nerve process
C. The patient has a stroke
D. The patient has a brain tumor
E. The patient is intoxicated
Warm up

6. Practical approach to dizzy patient

7. What is your first question for any patient
complaining of dizziness

8. What do you mean by dizziness?
Off- Balance
Spinny
Fainty
Crazy
Disequilibrium Near syncope Lightheaded
ness
Undifferentiated
Vertigo Psychiatric

9. Helping tips
Disequilibrium UndifferentiatedNear syncope
Vertigo
- Neurological
- With walking
- With
standing
e.g. Postural
hypotension
- Medical causes
e.g. Anemia,
hyperthyroidism
,hypoglycemia,
fibromyalgia,
etc.
- Cerebral hypo
perfusion
- CVS causes
- Seated or
standing
- Transient
symptoms
- Blurring vision
or blackout
- Any position
- Big Three
Psychiatric
- Psychiatric or
stressor
history
- Non
physiological
course
- No
neurological
abnormalities

10. Vertigo
Vertigo is not a diagnosis, it is a symptom
from which you build a D.D

11. Peripheral causes
- Benign paroxysmal positional vertigo
- Vestibular neuritis
- Meniere disease
- Acoustic neuroma
- Perilymphatic fistula
- Herpes zoster oticus (Ramsay Hunt
syndrome)
- Recurrent vestibulopathy
- Semicircular canal dehiscence syndrome
- Aminoglycoside or cisplatin toxicity
- Otitis media
Central causes
- Vestibular migraine
- Brainstem ischemia
- Cerebellar infarction &
hemorrhage
- Multiple sclerosis
DD of vertigo

12. What type of vertigo worse with
movement?

13. How you will approach vertigo patient?

14. Big three
BPPV Vestibular
Neuritis
Stroke
Practical Approach to vertigo
Acute Vestibular
Syndrome (AVS)

15. T I T R A T E
Timing Triggering
Target
Examination
Am Fam Physician. 2017 Feb 1;95(3):154-162
Practical Approach to vertigo

16. History
• How can patient describe it?
• Onset (sudden or slow)
• Course (episodic or continuous)
• Duration (seconds, minutes or hours)
• Severity
• Provoking, aggravating factors
• Associated symptoms (CNS symptoms, hearing symptoms)
• Risk factors for Cardiovascular disease
• Past & Drug history.
Timing
Triggering
Am Fam Physician. 2017 Feb 1;95(3):154-162

17. What type of vertigo worse with
movement?

18. - Benign paroxysmal
positional Vertigo
- Vestibular neuritis
- Labyrinthitis
- Meniere disease
- Vestibular migraine
- Brainstem infarction
- Cerebellar infarction or
hemorrhage
Recurrent, brief (seconds)
Single episode, acute onset, lasts days
(more prolonged and severe episodes)
Recurrent, typically last hours but can be
briefer
History of Migraine
Single or recurrent, last several minutes
to hours
Timing

19. Triggering & Suggestive history
- Benign paroxysmal
positional Vertigo
- Vestibular neuritis
- Labyrinthitis
- Meniere disease
- Vestibular migraine
- Brainstem infarction
- Cerebellar infarction or
hemorrhage
- Perilymphatic fistula
Initiated by movement of head & neck
- Recent viral symptoms
- Labyrinthitis is same but associated
with unilat. hearing symptoms
Spontaneous, Unilateral tinnitus,
hearing loss, ear fullness
History of Migraine
Older patient, vascular risk factors, and
or cervical trauma, neurological
symptoms (Ds)
Coughing, sneezing, exertion, or loud
noises (Tullio phenomenon)

20. Target Examination
• Vital Signs :
BP (sitting & lying), pulse (A.F)
• CNS exam:
Cranial nerves, Sensory, Motor, reflexes,
Cerebellar signs, Romberg test.
• CVS exam: Auscultation for A.S
• Carotid bruit
• Ear exam: Otoscopy, Hearing assessment(Weber’s Test, Rinne Test
• Dix-Hallpike maneuver &/or Supine head roll test Vs HINTS exam

21. - Imbalance with open eye , then there may be a
problem with the cerebellum.
- Imbalance with closed eye, then the problem
may lie in the vestibular or proprioceptive
systems
Balance and Gait

22. - The otoscopic examination provides
evidence of otitis media, for vesicles
(i.e., herpes zoster oticus [Ramsay
Hunt syndrome]) or cholesteatoma.
- Unilateral sensorineural hearing loss
suggests a peripheral lesion (eg,
Meniere disease).
Ear Examination

23. How does nystagmus help in
differentiating central from peripheral
vertigo ?

24. None 2-30 sec
> 30 sec 5-30 sec
No Yes
Usually absent Usually present
No suppression
- Bidirectional
- Vertical or horizontal
suppression
- Unidirectional
- Horizontal or rotatory
Central PeripheralFeature
Latency1
Duration
Fatigability2
Vertigo
Fixation
Direction
1 Time between attaining head position and onset of symptoms.
2 Disappearance of symptoms with maintenance of offending position.
3 Lessening of symptoms with repeated trials.
Habituation3 No Yes

26. Sensitivity of 82% and a specificity of 71% in
posterior canal BPPV
Dix-Hallpike maneuver
Am J Otolaryngol. 2006;27:173-178.
Nystagmus from the Dix- Hallpike test in posterior
semicircular canal BPPV is upbeating & torsional.

27. Supine roll test
DIAGNOSIS OF LATERAL (HORIZONTAL) SEMICIRCULAR CANAL BPPV:
If the patient has a history compatible with BPPV and the Dix- Hallpike test
exhibits horizontal or no nystagmus, the clinician should perform, or refer to a
clinician who can perform, a supine roll test to assess for lateral semicircular
canal BPPV.
Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update)
Otolaryngology– Head and Neck Surgery 2017, Vol. 156(3S) S1– S47

28. Head Impulse
test
Nystagmus
Test of Skew
HINTS Examination
In stroke it is : INFARCT
Impulse Normal
Fast Phase Alternating
Refixation on Cover Test
Any positive one points
to stroke in AVS

29. Benign Examination : SEND HIM ON HOME
- Straight Eyes (normal eye alignment, esp. vertical)
- No Deafness (no moderate to severe hearing loss)
- Head Impulse Misses (unilaterally abnormal HIT)
- One-way Nystagmus (unidirectional, horizontal)
- Healthy Otic and Mastoid Examination (pearly; no pimples, pus,
perforation, or pain on palpation)

30. Investigations
- No routine investigations
But if indicated you can ask for
- CBC, TFT, KFT.
- C.T, MRI.
- ECG, Cardiac monitoring, carotid doppler .
- Audiometry

31. - Benign paroxysmal
positional Vertigo
- Vestibular neuritis
- Labyrinthitis
- Meniere disease
- Vestibular migraine
- Brainstem infarction
- Cerebellar infarction or
hemorrhage
Treatment
Repositioning Maneuvers
Medications & vestibular rehabilitation
Salt, caffeine, tobacco restriction
Diuretics
Surgical
As Migraine
A/E Referral

32. Treatment BPPV
Epley maneuver
- Clinicians should treat, or refer to a clinician who
can treat, patients with posterior canal BPPV.
Strong recommendation 1
- The success rate of the Epley maneuver is ~ 80% 2
1-Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update) Otolaryngology– Head and Neck Surgery 2017, Vol. 156(3S) S1– S47
2-emedicine.medscape.com/article/791414-treatment
When not to do it?

33. Treatment BPPV
At home maneuver

34. Treatment BPPV
Lempert Maneuver (Roll maneuver, Barbeque roll)
- ~ 75% effective in treating Lat. BPPV
1 2
3
4
5
6
7
8
9

35. Treatment of vestibular neuritis
- In 50% of patients, the underlying nerve damage may take two months to
Resolve
- Reassurance, explanation, and advice are essential, in combination with
symptomatic treatment for the first few days .
- Antiemetics and antinausea medications should be used for no more than three
days because of their effects in blocking central compensation
- Although systemic corticosteroids have been recommended as a treatment for
vestibular neuritis, there is insufficient evidence for their routine use.
- Antiviral medications are ineffective.
Am Fam Physician. 2017 Feb 1;95(3):154-162

36. Treatment of vestibular neuritis
Medication Dosage
Antiemetics
Metoclopramide
Prochlorperazine
5 to 10 mg orally every 6 hours, or 5 to 10 mg slowly IV every 6 hours
5 to 10 mg orally or IM every 6 to 8 hours
Antihistamines
Dimenhydrinate
Meclizine
Promethazine
50 mg orally every 6 hours
12.5 to 50 mg orally every 4 to 8 hours
25 mg every 6 hours orally, IM, or rectally every 4 to 12 hours
Benzodiazepines
Diazepam (Valium)
Lorazepam (Ativan)
2 to 10 mg orally or IV every 4 to 8 hours
1 to 2 mg orally every 4 hours
Am Fam Physician. 2017 Feb 1;95(3):154-162

37. Betahistadine in vertigo
- This observational study found that treatment of vestibular vertigo with
betahistine (dosed at 48 mg/day) appeared to be effective in reducing vertigo-
associated symptoms in a routine outpatient clinical setting.
- Betahistine was well tolerated when administered at 48 mg/day for 2 months,
and should be considered as a good therapy option by physicians treating
vertigo
- Low quality evidence suggests that in patients suffering from vertigo from
different causes there may be a positive effect of betahistine in terms of
reduction in vertigo symptoms.
•First published: 21 June 2016
•Editorial Group: Cochrane ENT Group
•DOI: 10.1002/14651858.CD010696.pub2
•PLOS ONE | https://doi.org/10.1371/journal.pone.0174114 March 30, 2017

38. Vestibular rehabilitation

39. - Classify
- TITRAETE
- Refer when indicated
- Perform Maneuvers
Summary

40. Am Fam Physician. 2017 Feb 1;95(3):154-162
T I T R A T E