vertigo - pennine gp learning

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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.

https://www.youtube.com/watch?v=59EIKztATiw&feature=related

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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

https://patient.info/health/dizziness/benign-paroxysmal-positional-vertigo

http://www.uhs.nhs.uk/Media/Controlleddocuments/Patientinformation/Earnoseandthroat/Benignparoxysmalpositionalvertigo-patientinformation.pdf

https://www.pennine-gp-training.co.uk/res/BPPV self rx PIL.pdf


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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

https://patient.info/health/dizziness/vestibular-neuritis-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

https://patient.info/health/tinnitus-leaflet/menieres-disease

http://www.menieres.org.uk/files/pdfs/balance-retraining-2012.pdf

http://www.menieres.org.uk/files/pdfs/controlling-your-symptoms.pdf

https://www.brainandspine.org.uk/sites/default/files/documents/BSF_Vestibular_rehabilitation_exercises.pdf

http://www.menieres.org.uk/

http://www.tinnitus.org.uk/

http://www.actiononhearingloss.org.uk/

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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

http://www.gpnotebook.co.uk/

http://www.patient.co.uk/

https://cks.nice.org.uk/

http://www.menieres.org.uk/

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