As the world Turns

Saleh Fares Aal-Ali

FRCP-R3

Objective to be
addressed:
Difference between dizziness and vertigo.

Difference between dizziness and vertigo.

Diagnostic approach to True vertigo.

Characteristics of peripheral vertigo.
Characteristics of central vertigo.
Treatment Considerations.

Patients refer to Dizziness

as:

Light headedness

Sense of strangeness
Faintness
Giddy
Imbalanced
out-of-it

Most dizzy patients can be placed

in to one of four categories:

1- True Vertigo (50%)

2-Pre-syncope:

Transient sensation that a faint in

about to occur.

May present as nausea ,weakness,

SOB or change in vision.
Transient.

3-Dysequilibrium:

A sensation of imbalance when

standing or walking.

No illusion.
No sense of faintness.

4-Vague
lightheadedness:

Holds the reminder of symptoms

of dizziness (which cant fit to
the other categories)
1.Psychiatric disorders,
2.Hyperventilation syndrome
3.Encephalopathies

What is Vertigo?

True vertigo:

Defined as an illusion or
hallucination of movement.

Both vertigo and dysequilibrium

imply a loss of balance, but vertigo
involves a sense of motion.

How do we maintain
equilibrium?

Visual input

equilibrium

Proprioceptiual

Vestibular input

input

labyrinths.

Anatomy: Semicircular
canals

Semicircular Canals
(SCC)

Cupula

Horizontal
Anterior
Posterior
End organ receptors

Endolymph

Anatomy: Utricle

Utricle

Connected to SCC
Contains
endolymph
Otoliths
(otoconia)

Calcium carbonate
Attached to hair
cells
Macule (end organ)

Vestibular system

Tells brain which way the head

moves without looking

SCC: angular acceleration

Utricle: linear acceleration

How can we clinically

evaluate the patient with
vertigo?

CN VIII

labyrinth

Cerebellum

(Vestibular portion)

Vertigo
Brainstem
Vestibular
nuclei

Vertigo

Central

peripheral

Key points in History:

Is true vertigo present?
Are there associated neurologic symptoms?
What is the pattern of onset ?
What is the duration of the symptoms?
Have there been auditory symptoms?

Are there other associated symptoms?

What medications is the patient taking?
What is the patients past medical history?
Any recent or remote head or neck injury?

Key points in the physical

examination:
Vital signs
Bruits
Ear exam
Eye exam
Positional testing
Neurological exam (including gait)

SPINNED

PERIPHERAL CENTRAL
Yes
Yes
Severe
Frequent

Slow, gradual
No
Ill defined
Infrequent

Nystagmus

Torsional/horizont
al

Vertical

Ear (hearing loss)

Can be present
Absent
Paroxysmal
Constant
Absent
Usually

Sudden (Onset)
Positional
Intensity
Nausea/Diaphores
is

Duration
CNS signs

Carvalho et al.

CTU , Oct, 2004

Case 1

Peripheral vertigo:
Approximation 85% of ED patients
with vertigo.
Due to dysfunction of one of vestibular organs.
Asymmetry of input
Sensation of rotation
Associated with nausea, pallor
and diaphoresis.

Differential Diagnosis

Benign paroxysmal positional

vertigo (BPPV) (50%)
Vestibular neuritis
Labyrinthitis (suppurative, serous,
toxic, chronic)
Menieres disease
FB in ear canal
A cute otitis media
Perilymphatic fistula.

BPPV

Benign Paroxysmal Positional

Vertigo
Age 60- 70 (F:M 2:1)
Head trauma

Characteristic story

Turn head
After a few seconds delay, vertigo
occurs
Resolves within 1 minute if you dont
move
If you turn your head back, vertigo
recurs in the opposite direction

BPPV

B = Benign

Not a brain
tumor
Can be
severe and
disabling

BPPV

P = Paroxysmal

Episodic, not persistent

Helpful feature in the differential
diagnosis

BPPV

P = Positional

Occurs with position of head

Turning over in bed
Looking up
Bending over

BPPV

V = Vertigo

An illusion of motion
The room is spinning
Other descriptions
Rocking
Tilting
Somersaulting
Descending in an elevator

Pathophysiology of BPPV

Otoliths become
detached from
hair cells in
utricle
Inappropriately
enter the
posterior
semicircular
canal
. Parnes LS, McClure JA. Laryngoscope 1992;102:988-92.

Physiology

Normal situation

As one turns head to the right

Endolymph moves SCC receptors
fire head turning right
Stop turning head endolymph
stops moving SCC receptors stop
firing head has stopped
moving

Pathophysiology of BPPV

BPPV

Stop turning head otoliths

keep moving drag endolymph
receptors continue to fire
inappropriately head is still
moving
Eyes head is NOT moving
Brain room must be spinning
in the opposite direction

Dix-Hallpike Maneuver
The diagnosis of BPPV is generally from the
history.
Can confirm the diagnosis of BPPV
First described by Dix and Hallpike in 1952.
Also called the Nylen-Brny,
Brny Brny,
Brny
Nylen, or Hallpike maneuver

Dix-Hallpike Maneuver
They include:
1- Nystagmus
2- Provocative head position
3- Brief latency to symptoms after
change in position
4- Short duration of attack
5- Fatigability of nystagmus on repeat testing
6-Reverse of nystagmus on returning to
upright position.

Lab studies

In a straightforward case, no
lab studies are needed!

Hemoglobin
Fingerstick glucose
Electrolytes if prolonged
vomiting

BHCG

ED Therapy:
1-The Epley Maneuver

First described in 19922

Bedside
Immediate relief

Epley reported an 80% success rate

after a single time and 100% success
rate after more than one session

30%

recurrence rate over a

30-month period.
2.
3.

Epley J. Otolaryngol Head Neck Surg 1992;107:399-404

Lynn S, et al. Otolaryngol Head Neck Surg 1995;113:712-20.

Epley Maneuver:

Randomized controlled trials

reported success rates ranging from
44% - 88%

Froehling et al.
Wolf et al.

Mayo clin proc

Clin otolaryngol

Asawarichianginda et al.

Jul 2000

feb 1999

ENT J

Sep 2000

Epley maneuver

Canalith repositioning maneuver

5 step head hanging maneuver
Moves otoliths out of the
posterior semicircular canal and
back into utricle where they
belong

Epley maneuver

1. Repeat
Hallpike

Previously
performed
diagnostic
Hallpike test tells
you the starting
position (right or
left)

Epley maneuver

2. Turn head 90
degrees in the
other direction

Epley maneuver

3. Patient rolls
onto shoulder,
rotates head and
looks down
towards floor

Epley maneuver

Epley maneuver

Repeating the Epley maneuver

Post procedure

Remain upright for 8-24 hours

The Epley Maneuver

Contraindications

Unstable heart disease

High grade carotid stenosis
Severe neck disease
Ongoing CNS disease (TIA/stroke)
Pregnancy beyond 24th week
gestation (relative)

Furman JM, Cass SP. N Engl J Med 1999;341:1590-96

Complications

Vomiting
Converting to horizontal canal
BPPV

ED therapy
2- Vestibular Suppressants:
Meclizine is the most commonly used
(H1 antagonist)
Can significanthy reduce symptoms.

Cohen et at. Arch Nenrol. Aug 1972(RCT)

Dimenhydrinate (Gravol) and diphenhydramine

(Benedryl) have also been used.
Their efficacy is likely mediated by their
anticholinergic activity.
They inhibit muscarinic acetylcholine
receptors involved in feedback from the
brainstem to the vestibular labyrinth.
If N/V
promethazine (phenergan) or
prochlorperazine (stemetil)
(extrapyramidal effect)

Benzodiazepines

generalized inhibition of neural

activity
In a review article:
Authors did not encourage the use
of vestibular suppressants:
suppress the intensity of
symptoms.

but do not reduce the

frequency of attacks.
Furman JM, Cass SP. N Engl J Med 1999;341:1590-96

The Vast majority of peripheral

vertigo can be managed
conservatively.
Surgery for intractable and
incapacitating symptoms.

Labyrinthitis and Vestibular

neuronitis

A cute unilateral loss of peripheral

vestibular function
Associated with vertigo, N/V, and
nystagmus
Worsened by head movement
Occurs in healthy young to middleaged adults
Often after respiratory infections
self-limiting

Perilymphatic fistula:

Due to a traumatic fistula at the

round or oval window.
After forceful cough, sneeze, scuba
diving or direct blow to the ear.
Recurrence of vertigo with pneumootoscopy (Henneberts sign)
Self-limiting

Menieres disease:

Characterized by triad of:

vertigo
tinnitus
hearing loss (sensorineural)
Chronic relapsing illness (? familial)
Due to a build-up of endolymphatic
pressure in the labyrinth.
Treatment: vestibular suppressants.

Menieres disease

When to D/C?
1- Peripheral vertigo.
2- Healthy

3- Help at home.
4- Symptoms controlled.
5- Able to ambulate.

F/U with PMD to arrange

further evaluation if patient
does not improve.

Case 2

Central vertigo
May include disorders with
significant potential
morbidity.
Warrants the initiation of
further work-up.

SPINNED

PERIPHERAL CENTRAL
Yes
Yes
Severe
Frequent

Slow, gradual
No
Ill defined
Infrequent

Nystagmus

Torsional/horizont
al

Vertical

Ear (hearing loss)

Can be present
Absent
Paroxysmal
Constant
Absent
Usually

Sudden (Onset)
Positional
Intensity
Nausea/Diaphores
is

Duration
CNS signs

Carvalho et al.

CTU , Oct, 2004

Differential Diagnosis:

Vertebral-basilar
circulation events:
1. Vestibular nuclei (TIA or
stroke)
2. Cerebellar infarction or
hemorrhage
3. Lateral medullary
infarction (Wallenbergs
syndrome)

4. Vertebral artery dissection

Migraine
Post concussive syndrome.
Tumors (acoustic reuromas)
Multiple sclerosis
Infection (encephalitis,
meningitis)

Neuroimaging in vertigo:

Headache(sudden onset or severe)

Hard neurological findings
No imaging for patients with no
risk factors and exam suggestive
of peripheral vertigo.

Twenty four patients with risk factors

with stroke with history of vertigo
(>48 hrs) and normal neurologic
exam (except nystagemus)
25%
had inferior cerebellar infarction.

Norrving et al. Acta Neurol Scand. Jan 1995

CT vs MRI:

MRI/MRA for vertebrobasilar

disease and cerebellar ischemia .
CT is more sensitive for
hemorrhage
negative CT is not always
reassuring.

Bad Excuses In Court:

1. "I thought the medications

would helpnot cause her to fall
and break her hip.

2. "I know it was vertical

nystagmus, but there were no
other neurological findings so I
assumed it was peripheral
vertigo."

3. "I thought it was obvious that

the patient shouldnt drive."

4. "The vertigo had subsided, so

I thought it was okay for him to
walk to the bathroom.

5. "The patient was too young to

worry about a stroke.

6. "I didnt know that the patient

had decreased hearing.

7. "The CT was normal, so I

thought it was safe to send the
patient home."

8. "The patient came from the

psychiatric hospital, so I
assumed that he was crazy."

The end