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Vertigo

 

Definition of vertigo

  • Vertigo is the false sensation that either oneself or the surroundings are moving or rotating.
  • This is distinct from other causes of dizziness or light-headedness such as postural hypotension, arrhythmias, epilepsy, tumours, anaemia, etc.

 

Causes of vertigo

  • Peripheral (i.e. ear) – vertigo is ROTATORY in nature
    • Benign Paroxysmal Positional Vertigo
      • BPPV: due to dislodged otoliths in semicircular canals
    • Meniere’s disease
    • Labyrinthitis/vestibular neuronitis
    • Cholesteatoma
    • Vestibular schwannoma
  • Central (i.e. brain)
    • Cerebrovascular events
    • Migraine
    • MS

 

History in vertigo

  • This can be extremely difficult! Initially let the patient talk and they will be very grateful for the opportunity as vertigo can be very debilitating indeed. Then ask about:
  • First episode
    • Before
      • Prodrome
      • What were they doing
      • Head position at time
      • Head movement
    • During
      • Neuro
        • Loss of consciousness/collapse; headaches; visual changes
        • Numbness; tingling; weakness
      • Cardiac
        • Chest pain; palpitations; shortness of breath
    • After
      • Resolution speed; post ictal features
  • General
    • Frequency and severity
    • Last episode
    • Precipitating features
    • Assoociated features
      • Hearing loss; tinnitus; otorrhoea; otalgia; trauma

 

Examination in vertigo

  • Gait
  • Ears (also see otoscopy)
  • Cranial nerves
    • Especially V, VII, VIII and eye movements
  • Cerebellar tests
    • Including nystagmus, past pointing, and ataxic gait
    • Fistula test, Romberg’s test, Unterberger’s test, Halmagyi Head thrust, Dix-Hallpike test (see links below)

 


Video explaining the Epley manoeuvre in vertigo

 

Investigation of vertigo

  • Pure tone audiogram (PTA)
  • Vestibular function tests
  • MRI

 

ENT differentials of vertigo (classic presenting symptoms)

  • BPPV
    • Positional, lasts for seconds but can feel unsteady for longer, classically turning over in bed, nauseated and vomiting, perhaps recent URTI/head trauma, Dix Hallpike positive
  • Vertibular neuronitis/labyrinthitis
    • Lasts for days, single severe attack, often wake up with it, unwell for a week with possible URTI, normal hearing and PTA
  • Menieres
    • Two or more episodes, aural fullness/tinnitus, fluctuating hearing loss (documented on PTA), other causes excluded
  • Cholesteatoma
    • Intermittent vertigo, hearing loss, discharging ear, keratin in attic
  • Acoustic neuroma
    • Unilateral hearing loss, cranial nerve palsies, vertigo
  • Rarer causes
    • Superior semicircular canal dehiscence, complicated AOM, trauma to temporal bone

 

Management of vertigo

  • For management see individual conditions.

 

Relevant vertigo videos:

 

Click here to download free teaching notes on vertigo: Vertigo

Perfect revision for medical students, finals, OSCEs and MRCP PACES