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
rotatory vertigo lasting for hours
Classic triad
hearing loss
tinnitus
to 60 years of age
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:
vertebrobasilar insufficiency/ TIA
Hours:
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
Refer if
• Uncertain diagnosis
•Perilymph fistula
• Central vertigo
•“BPPV” failed Epley
• Suppurative
labyrinthitis