The document discusses vertigo, highlighting its definition as a hallucination of movement and detailing various central and peripheral causes, including otological and neurological origins. It emphasizes the importance of history and examination in diagnosis and describes specific types of vertigo such as benign paroxysmal positional vertigo (BPPV) and Ménière’s disease, along with their symptoms, signs, and treatments. It further notes the significance of differentiating central causes of vertigo, particularly those related to the posterior circulation stroke.

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