Vertigo

Clearing confusion for patients and doctors

Dr SK Ng Specialist in Otorhinolaryngology Division of ENT NT East cluster The Chinese University of Hong Kong

Dizziness and vertigo are common

Dizziness and Vertigo Ear dysfunction Vascular insufficiency Neurological dysfunction Psychological problems

Radiological and Laboratory Tests: Rarely helpful

Systematic Approach Arrive at diagnosis Recognize potentially dangerous condition Specialist attention

Diagnostic Approach

History

Physical examination Investigations

The First Question

: What does the patient mean by dizziness?

Giddiness vs Vertigo

Giddiness Most common form: non-specific light-headedness Vague and Subjective Never actual fall or veer

Nonspecific light-headedness Psychogenic Hyperventilation Hypoglycemia Anemia

Near-syncope Light-headedness Generalised weakness Faintness Rise from lying or sitting

Typically worse in the morning When supine: No symptoms Causes: 1. Autonomic dysfunction DM Drugs: anti-HT, anti-arrhythmic 2. Cardiovascular disease

Dysequilibrium Feeling of unsteadiness No actual illusion of movement No sensation of faintness

Cause Dysequilibrium of ageing multi-sensory deficits vestibular sedatives not useful vestibular rehabilitation program a walking stick

Refer for neurological evaluation Dysequilibrium + poor gait

Vertigo Hallucination of movement Typically but not necessarily rotatory Lesion in the vestibular system

The Second Question

Is it Benign Paroxysmal Positional Vertigo?

(BPPV)

BPPV Common Very characteristic Highly treatable

Benign Paroxysmal Positional Vertigo (BPPV) Rotatory vertigo last for seconds Positional: looking up rapidly rolling over in bed Nausea, no vomiting No tinnitus/ hearing loss

Diagnosis confirmed by Dix Hallpike maneuver

Pathophysiology

Benign Paroxysmal Positional Vertigo (BPPV) Drugs: USELESS Treatment of choice: Epley maneuver

30 Seconds each step

90% chance of success What if the maneuver fails?

Try again!

If still fails, Refer to ENT

The Third Question

Is the vertigo central in origin?

Central Vertigo Uncommon Potentially fatal Refer

Central Vertigo Associate neurological symptoms Risk factors for CVA Severe imbalance Vertical nystagmus

Peripheral Vertigo

Peripheral Vestibular Disorders Meniere’s disease Vestibular neuronitis

Meniere’s disease Classic triad rotatory vertigo lasting for hours hearing loss to 60 years of age tinnitus nausea and vomiting

Meniere’s disease Pathogenesis: over-accumulation of fluid within the inner ear Meniere’s disease Normal

Meniere’s disease Treatment: Vestibular sedatives Prophylactic treatment: ?

Ablative surgery

Vestibular neuronitis Rotatory vertigo last for days Nausea and vomiting No otological symptoms Commonly follow a flu

Vestibular neuronitis Natural course: Vertigo followed by a period of unsteadiness

Treatment

Vestibular sedatives Vestibular rehabilitation

Rarer Peripheral Disorders Acute suppurative labyrinthitis Perilymph fistula

Acute suppurative labyrinthitis Bacterial infection of inner ear Severe vertigo + hearing loss + ear discharge Refer ENT

Perilymph fistula Violation of barrier between middle and inner ear Vertigo onset after trauma Refer ENT

To Sum Up ….

Approach to Dizziness 1. Vertigo vs Giddiness 2. ? BPPV 3. ?Central vertigo 4. Peripheral vertigo: duration of attack associated otological symtoms

Duration of Vertiginous Attacks Seconds: BPPV Minutes: Hours: vertebrobasilar insufficiency/ TIA Meniere’s disease , migraine

Days: vestibular neuronitis acute labyrinthitis cerebellar stroke Constant: neurological disorder incomplete recovery of vestibular failure psychogenic

Physical examination

Dix Hallpike Maneuver Confirm BPPV

Treatment of Peripheral Vertigo 1. BPPV Epley maneuver 2. Acute sustained vertigo Vestibular sedatives e.g. stemetil, stugeron

Treatment of Peripheral Vertigo 3. Chronic unsteadiness Vestibular rehabilitation

• Uncertain diagnosis • Central vertigo • Suppurative labyrinthitis Refer if •Perilymph fistula •“BPPV” failed Epley