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VERTIGOTuesday 20th February 2018
Dr Rukhsana Hussain
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WHAT IS VERTIGO?4
Vertigo is defined as an illusory sensation of motion of either the self or
the surroundings in the absence of true motion.
Explaining vertigo/dizziness to patients:
The balance system relies on 3 different senses. Using your eyes you
can see where you are and where you are going. Using the sensors in
your body you can feel where you are and how you are moving. And
the balance organ in your inner ear senses whenever your head
moves.
Your brain acts like a computer, combining signals from these 3
senses to give you a stable picture of the world and to control your
head, body and eye movements. If any part of this balance system is
giving out unusual or faulty information then you may feel dizzy,
disorientated or unsteady.
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CAUSES OF VERTIGO1
Vertigo with auditory
symptoms
Vertigo without auditory
symptoms
Vertigo with intracranial
signs
Ménière’s disease Vestibular neuronitis Cerebello-pontine angle tumour
Labyrinthitis Benign Paroxysmal
Positional Vertigo (BPPV)
Cerebrovascular disease -
TIA/CVA
Labyrinthine trauma Acute vestibular dysfunction Vertebrobasilar insufficiency
and thromboembolism (lateral
medullary syndrome,
subclavian steal syndrome,
basilar migraine)
Acoustic neuroma Medication induced e.g.
Aminoglycosides such as
gentamicin
Brain tumour e.g, empendyoma
Acute cochleo-vestibular
dysfunction
Cervical spondylosis Migraine
Cholesteatoma Following flexion-extension
injury (whiplash)
Multiple Sclerosis
Aura of epileptic attack esp.
Temporal lobe epilepsy
Syphilis (rare) Drugs e.g. Phenytoin and
Barbiturates.
Syringobulbia
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The most common causes of vertigo in the Primary Care setting (over 90%
of cases) are:
BPPV
Acute Vestibular Neuronitis and
Ménière’s disease
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IMPORTANT POINTS IN THE HISTORY1
Determining whether the patient has peripheral or central vertigo is
important in establishing a specific diagnosis.
Points in the history to help with this are:
➢ Timing and duration of vertigo BPPV: lasts seconds, Ménière’s
disease: lasts hours, Labyrinthitis, post-head trauma, vestibular
neuronitis: last weeks. Psychogenic: may last years.
➢ Speed of onset of vertigo
➢ Provoking or exacerbating factors e.g, flying or trauma
➢ Associated symptoms such as:
Pain,
Nausea and Vomiting: vestibular (peripheral)cause,
Hearing loss,
Neurological symptoms such as dysarthria and
visual disturbance in a central lesion.
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CENTRAL VERTIGO...
Usually develops gradually except in an acute central vertigo which is
probably vascular in origin e.g. CVA
There are usually additional neurological signs to the vertigo
Auditory features tend to be uncommon
Causes severe imbalance
Nystagmus is purely vertical, horizontal or torsional and is not
inhibited by fixating eyes on an object
Latency following a provocative diagnostic maneouvre is shorter (up to
5 seconds)
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PERIPHERAL VERTIGO...
Hearing loss and tinnitus are more common than in central vertigo
Generally has a more sudden onset (except acute CVA)
Is highly associated with rotatory illusions (esp. nausea and vomiting)
Nystagmus is combined horizontal and rotational and lessens with
fixed gaze
There is mild to moderate imbalance
Non-auditory neurological symptoms are rare
Latency following a provocative diagnostic maneouvre is longer (up to
20 seconds)
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TIMING OF SYMPTOMS
Pathology Duration of
episode
Associated
auditory
symptoms
Peripheral or Central
origin
BPPV Seconds No Peripheral
Vestibular neuronitis Days No Peripheral
Ménière’s disease Hours Yes Peripheral
Perilymphatic fistula Seconds Yes Peripheral
TIA Seconds/hours No Central
Vertiginous migraine Hours No Central
Labyrinthitis Days Yes Peripheral
Stroke Days No Central
Acoustic Neuroma Months Yes Peripheral
Cerebellar tumour Months No Central
Multiple Sclerosis Months No Central
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EXAMINATION/INVESTIGATION
Examination of ear drums (Otoscopy): look for vesicles – Ramsay-Hunt
syndrome. Also look for the possibility of a cholesteatoma.
Tuning fork tests for hearing loss.
Cranial Nerve examination – check for palsies, sensorineural hearing loss
and nystagmus.
Hennebert’s sign: pressure on tragus and external auditory meatus on
affected side causes vertigo or nystagmus – indicates the presence of a
perilymphatic fistula.
Gait tests: Rombergs sign – not particulary useful in diagnosis of vertigo
Heel to toe walking test.
Dix-Hallpike maneouvre – most useful test in a patient with vertigo.
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Dix-Hallpike test and Epley Maneouvre Video Clip.
The Dix-Hallpike test helps to diagnose BPPV and the Epley Maneouvre
is used to treat it.
Audiometry: helps establish the diagnosis of Ménière’s disease.
Check BP/Bloods to exclude other causes of dizziness if appropriate.
CT/MRI brain may be appropriate if CNS causes are suspected from the
history and examination.
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TREATMENT
Should be aimed at the cause of the vertigo ideally.
Options: Medical Management, Vestibular rehabilitation exercises.
Main priority for most cases is effective symptom control.
Acute vertigo: treatments include Cinnarizine 15-30mg tds or Prochlorperazine 5-10mg tds
Prevention of recurrent attacks:
Restrict salt and fluid intake, restrict excess alcohol and coffee
Smoking cessation
Betahistine 16mg tds regularly for Ménière’s disease
Cinnarizine or Prochlorperazine for frequent attacks.
Longterm vestibular sedatives such as cinnarizine and prochlorperazineshould be avoided as they dampen compensatory mechanisms and prolong symptoms in the recovery phase.
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Epley Maneouvre: aims to reposition otoliths back into the utricles from
the posterior semicircular canals. Success rate: 80 % cured in just one
treatment.
Contraindications include:
Severe carotid artery stenosis
Unstable heart disease
Severe neck disease e.g. Cervical spondylosis with myelopathy
GPs can refer to ENT if they are unfamiliar with the maneouvre.
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REFERRAL CRITERIA FROM PRIMARY CARE
Red flag symptoms in a patient with vertigo requiring prompt referral
Unilateral tinnitus and/or hearing loss/dysacusis
Unilateral otorrhoea
Neurological symptoms and signs
Nystagmus has central features
Spontaneous nystagmus persists after 48 hours
Positional vertigo/nystagmus which does not have all the features of
posterior semicircular canal BPPV
Significant vertigo/imbalance persist after a month
Positive fistula sign (Hennebert’s sign) – Pressure on tragus reproduces
symptoms – suggests perilymphatic fistula
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BENIGN PAROXYSMAL POSITIONAL
VERTIGO3
BPPV is thought to be caused by loose calcium carbonate debris (otoconia
or otoliths) in the semi-circular canals of the inner ear. When the head
moves , otoconia move in these canals and cause motion in the fluid
(endolymph) triggering vertigo symptoms.
The posterior semi-circular canal is the most commonly affected (in
around 85-95 % of people with BPPV).
The maneouvre to treat BPPV differs according to which canal is affected.
Precipitating factors include head injury, a prolonged recumbent position
(e.g during a visit to the dentist), ear surgery or following an inner ear
problem such as labyrinthitis or vestibular neuronitis. It may also be
associated with sleep position.
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Vertigo symptoms are brought on by specific head movements and
positions of the head relative to gravity. The movements may be very
subtle.
Symptoms typically last less than a minute.
Nausea and vomiting may occur.
Examination is likely to be normal at rest in the sitting position.
Diagnosis can be confirmed by the Dix-Hallpike maneouvre.
If Dix-Hallpike maneouvre is negative, repeat it after one week.
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DIX-HALLPIKE MANEOUVRE
Advise the person that they may experience transient vertigo during
the procedure.
Ask the person to keep their eyes open throughout the manoeuvre and
to look straight ahead.
Ask the person to sit upright on the couch with their head turned
45 degrees to one side.
From this position, lie the person down rapidly (over 2 seconds),
supporting their head and neck, until their head is extended 20–
30 degrees over the end of the couch with the chin pointing slightly
upwards and the test ear downwards. Support the head to maintain
this position for at least 30 seconds.
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Observe their eyes closely for up to 30 seconds for the development of
nystagmus. If nystagmus is present, maintain the position for
its duration (maximum 2 minutes if persistent) and note its duration,
type, direction, and latency.
Record duration, severity, and latency of any vertigo.
Support the head in position and slowly sit the person up.
Repeat with the head rotated 45 degrees to the other side.
CONTRAINDICATIONS to the maneouvre include severe neck/back
problems, severe carotid artery stenosis and significant cardiac
problems such as carotid sinus syncope.
Dix-Hallpike test and Epley Maneouvre Video Clip
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If BPPV is confirmed patients can be advised that most people recover
over several weeks without any treatment but symptoms can last longer
and can recur.
Advise patients regarding safety:
Driving – avoid driving when dizzy or if driving may trigger vertigo.
The DVLA states that people with a 'liability to sudden and
unprovoked or unprecipitated episodes of disabling dizziness' should
stop driving and inform the DVLA. Experts suggest that in general
BPPV is not spontaneous or unprovoked and most people with this
condition continue to drive.
Work – Inform employer if vertigo may pose a risk at work e.g. If they
operate heavy machinery
Home – Discuss risk of falls and measures to reduce this.
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Management options include watchful waiting and a particle
repositioning maneouvre.
The Epley maneouvre is the most common repositioning maneouvre.
Symptoms may improve shortly after treatment but full recovery can take
days to weeks.
Contraindications for the procedure are the same as for the Dix-Hallpike
test.
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EPLEY MANEOUVRE
Advise the person that they will experience transient vertigo during the
manoeuvre.
Stand at the side or behind the person to guide head movements.
Maintain each head position for at least 30 seconds. If vertigo continues,
wait until it has subsided.
Ideally, movements should be rapid, within 1 second, but this is
often not possible, particularly in older people. Expert opinion
suggests that the procedure can be effective if movements are carried
out slowly.
Start with the person sitting upright with their head turned 45 degrees to
the affected side, then lie them back (with their head still turned
45 degrees) until the head is dependent 30 degrees over the edge of the
couch (as if performing the Dix-Hallpike manoeuvre). Wait for at least
30 seconds. Then:
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With the face upwards, but still tilted backwards by 30 degrees, rotate
the head through 90 degrees to the opposite side.
Hold the head in this position for about 20 seconds and ask the person
to roll onto the same side as they are facing.
Rotate the person's head so that they are facing obliquely downward
with their nose 45 degrees below the horizontal.
Sit the person up sideways while the head remains rotated and tilted
to the side.
Rotate the head to the central position and move the chin downwards
by 45 degrees.
There is usually no need to advise the person of any positional restrictions
after the procedure has been performed.
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Advise the patient to return for follow up in 4 weeks if symptoms have not
resolved, in case the BPPV diagnosis is incorrect
Resources for patients can be downloaded from the following links:
BPPV Patient Information Leaflet
BPPV brief factsheet for patients
Self treatment exercises leaflet for BPPV
Dix-Hallpike and Epley Maneouvre video clip
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VESTIBULAR NEURONITIS/NEURITIS3
Vestibular neuronitis is characterised by acute, isolated, spontaneous and
prolonged vertigo of peripheral origin.
The terms vestibular neuronitis and labyrinthitis have been used
interchangeably, but experts now recommend specific terminology.
Vestibular neuronitis is thought to be due to inflammation of the
vestibular nerve and may occur after a viral infection. Hearing loss is
NOT a feature. BPPV can develop following vestibular neuronitis in 10 %
of people. There are no associated neurological symptoms or signs.
Labyrinthitis is a different diagnosis that involves inflammation of the
labyrinth. Hearing loss is a feature.
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Initial severe symptoms usually last 2-3 days.
People with vestibular neuronitis gradually recover over a period of weeks
through a process of central nervous system compensation.
Most recover after 6 weeks but a minority may have symptoms for much
longer.
Recurrence is rare and if it occurs alternative diagnoses need to be
considered such as BPPV and migrainous vertigo.
Symptoms can be managed by medication such as prochlorperazine and
cinnarizine but they should be used for the shortest duration possible (a
few days) as prolonged use may delay central nervous system
compensatory mechanisms.
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Advise patients to attend for review if severe symptoms not settled after a
week or in the event of deterioration of symptoms. In this instance a
review of the diagnosis would be required and consideration of an urgent
referral to a secondary care specialist.
Patient Information Leaflet Vestibular Neuronitis and Labyrinthitis
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MÉNIÈRE’S DISEASE3
Ménière’s disease is a syndrome characterised by episodes of vertigo,
fluctuating hearing loss, and tinnitus. It is associated with a feeling of
fullness in the affected ear.
In most people the cause is unknown.
Suggested risk factors include: autoimmunity (usually present with
bilateral symptoms), genetic susceptibility, metabolic disturbances
involving the fluid of the inner ear, vascular factors (there is an
association between migraine and Ménière’s disease), viral infection and
head trauma.
Symptoms and hearing loss can initially fluctuate, resolving completely
between episodes. Later in the course of the disease, hearing loss
progresses and tinnitus becomes persistent. The frequency of vertigo
episodes often decreases. After 5-15 years vertigo is no longer experienced
when the condition “burns out” but hearing loss, fullness in ear and a
general sense of imbalance can persist despite treatment.
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Acute attacks of Ménière’s disease may be preceded by a change in
tinnitus, increased hearing loss or a sensation of aural fullness shortly
before the onset of vertigo.
Symptoms typically present for at least 20 minutes but can last for hours
(usually no more than 24 hours) and can occur in clusters over a few
weeks although months or years of remission can also occur.
Can involve mainly aural symptoms, vertigo or both.
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A definite diagnosis requires all of the following criteria:
Vertigo — at least two spontaneous episodes lasting 20 minutes to 12
hours.
Fluctuating hearing, tinnitus, and/or perception of aural fullness
in the affected ear.
Hearing loss confirmed by audiometry to be sensorineural, low-to-mid
frequency, and defining the affected ear on one or more occasions
before, during, or after an episode of vertigo.
Not better accounted for by an alternative vestibular diagnosis.
A probable diagnosis of Ménière’s disease requires all of the above
criteria (including dizziness in addition to vertigo), except for audiometric
documentation of hearing loss.
Refer to ENT to confirm the diagnosis.
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Treatment of acute episodes of Ménière’s disease can be with a short
course (7-14 days) of Prochlorperazine or an antihistamine such as
Cinnarizine, Cyclizine or Promethazine.
Consider prescribing Betahistine to reduce the frequency and severity of
hearing loss, tinnitus and vertigo,
Secondary care interventions that may be considered if Betahistine does
not work include:
Vestibular rehabilitation
Diuretics
Intratympanic gentamicin or corticosteroids
External pressure devices
Endolymphatic shunts or sac surgery
Labyrinthectomy or vestibular nerve section
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MÉNIÈRE’S DISEASE
Resources and sources of information and support for patients with
Ménière’s disease:
Patient information leaflet Ménière’s disease
Balance retraining vestibular rehabilitation exercise guide
Controlling your symptoms booklet- a self help guide for patients with
dizziness
Vestibular rehabilitation exercises - shorter factsheet
The Meniere's Society
The British Tinnitus Association
Action on Hearing Loss
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SUMMARY
The most common causes of vertigo in the Primary Care setting are
BPPV, Vestibular Neuronitis and Ménière’s disease.
Distinguishing between central and peripheral causes of vertigo can help
to establish a specific diagnosis.
The history is crucial to making a diagnosis and points in the history to
differentiate between peripheral and central causes include:
Timing and Duration of vertigo
Speed of onset of symptoms
Provoking or exacerbating factors
Associated symptoms including pain, nausea and vomiting,
hearing loss and neurological symptoms
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The Dix-Hallpike maneouvre can be performed to confirm BPPV and the
Epley maneouvre can treat it. The Epley maneouvre has a high success
rate.
Vestibular sedatives such as prochlorperazine are not recommended for
prolonged use as they delay the central nervous system compensatory
mechanisms and so may prolong patient symptoms.
Vertigo symptoms can be disabling and frightening for patients, It is
essential that clinicians provide patients with adequate information and
resources for support with regards to their condition.
Significant vertigo/imbalance persisting longer than 1 month should
prompt consideration of a referral to secondary care for further
investigation.
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REFERENCES
1.GP Notebook
2. Patient UK
3. NICE Clinical Knowledge Summaries
4. The Meniere's Society