VERTIGO

IDENTIFICATION DATA
 ผูป้ ่ วยหญิงโสด อายุ 24 ปี
 ภูมลำ ี งใหม่
ิ เนา อ.เมือง จ.เชย
 ร ับจ้าง
CHIEF COMPLAIN
 เวียนศรี ษะบ ้านหมุน 15 นาที ก่อนมารพ.
PRESENT ILLNESS
 15 นาทีกอ ่ นมารพ. ขณะกำลังลุกขึน ้ จากทีน ่ อนมีอาการเวียน
ศรี ษะ ร่วมกับบ ้านหมุน บอกไม่ได ้ว่าภาพหมุนไปทางไหน ลืมตา
หรือหันศรี ษะแล ้วมีอาการมากขึน ้ อาการดีขน ึ้ เมือ
่ อยูก
่ บ
ั ที่ ไม่ม ี
อาการปวดศรี ษะ รู ้สก ึ คลืน ้ ไม่อาเจียน ไม่มอ
่ ไสแต่ ี าการหูออ ื้ หรือ
มีเสยี งในหู ผู ้ป่ วยนอนพักประมาณ 10 นาทีอาการไม่ดข ี น
ึ้ จึงมา
รพ.
 ให ้ประวัตวิ า่ เคยมีอาการแบบเดียวกันมาแล ้ว 3-4 ครัง้ เมือ ่ ปี ท ี่
แล ้ว ซอื้ ยามาทานแล ้วนอนพักอาการดีขน ึ้ เอง
 ิ รี ษะกระแทก, ไม่มป
ปฏิเสธประวัตศ ิ วดศรี ษะเรือ
ี ระวัตป ้ รัง
 ไม่เคยมีปัญหาในเรือ่ งการมองเห็น
 ปฏิเสธประวัตก ่ ในชว่ ง 3 เดือนทีผ
ิ ารเจ็บป่ วยอืน ่ า่ นมา
OTHER INFORMATIONS
 ปฏิเสธโรคประจำตัว
 ้
ปฏิเสธการใชยาประจำหรื อสารเสพติด
 ปฏิเสธการแพ ้ยา
 ปฏิเสธประวัตก
ิ ารทานสุราหรือสูบบุหรี่
PHYSICAL EXAMINATION
 V/S : BT 36.7 C, PR 80/min ,regular, BP 100/60
mmHg , RR 16/min,
 GA : A woman with good consciousness
 HEENT : not pale, no icteric sclera , cervical LN
can’t be palpated, thyroid gland not
enlargement, intact TM both ears
 Lung : clear , no adventitious sound
 Heart : PMI at 5th ICS ,MCL ,no heaving, no
thrill, regular rhythm ,normal S1,S1 ,no murmur
PHYSICAL EXAMINATION
 Abdomen : Soft, Normal contour, Active
bowel sound, no rebound tenderness, no
Hepatosplenomegaly
 Ext : no edema , no skin lesion
 LN : no lymphadenopathy
NEUROLOGIC EXAMINATION
 Alert, Orientation*III
 CN II : No RAPD, No visual field defect
 CN III, IV, VI : Pupils 3 mm RTLBE. Full EOM, Horizontal
nystagmus to right (can suppress by fixation)
 CN V : No jaw deviation, Corneal Reflex +ve,
 CN VII : No facial palsy
 CN VIII : Weber > No lateralization, Rinne > AC> BC Both sides,
Head Thrust -ve
 CN IX & X : uvula in midline. Gag reflex +ve
 CN XI : Normal Trapezius and Sternocleidomastoid motor power
both sides
 CN XII : No Tongue deviation
COCHLEAR NERVE EVALUATION
NEUROLOGICAL EXAMINATION
 No cerebellar sign
 No motor deficit
 No sensory impairment
 DTR 2 + all
 MMSE > 29/30
 No auditory agnosia
PROBLEM LISTS
 Acute onset of vertigo
VERTIGO
 Latin origin: vertere, to spin
 The illusion that the environment is spinning
 Distinct from “dizziness”
 light-headed faintness
 off-balanced feeling
 feeling of floating
ANATOMY AND PHYSIOLOGY
ANATOMY AND PHYSIOLOGY
ANATOMY AND PHYSIOLOGY
 The vestibular system consists of the two
otolithic organs, the utricle and the saccule (
which are located in the vestibule, or central
portion of the labyrinth), and the semicircula
r canals which run off of the vestibule.
 Semicircular Canals (Anterior, Posterior,
Horizontal or Lateral) > Angular
movements
 Utricle and Saccule > Linear
movements
ANATOMY AND PHYSIOLOGY
ANATOMY AND PHYSIOLOGY
TYPES OF VERTIGO
 Central vestibular causes (Brain stem or
cerebellum)
 Peripheral vestibular causes ( Labyrinth or
vestibular nerve)
CAUSES OF VERTIGO
 CENTRAL
PERIPHERAL
 Vestibular Neuritis
Cerebrovascular Disease
 Migraine
BPPV
 Multiple Sclerosis
Menier’s Disease
 Neurodegenerative
Vestibular ParoxysmiaDisorders
 Epilepsy
Perilymphatic Fistula
 Inherited
Other Disorders
Peripheral Disorders
 Familial Bilateral Vestibulopathy
Drugs
 Familial Hearing loss and Vertigo
Toxins
 Familial Ataxia
Acoustic Neuroma
Syndromes
CAUSES..
 Drugs
 Alcohol
 Aminoglycosides
 Anticonvulsants
 Antidepressants
 Antihypertensives
 Barbiturates
 Cocaine
HISTORY
 Timings
 Duration
 Provoking, aggravating factors
 Associated symptoms
 Risk factors for Cardiovascular disease
PHYSICAL EXAMINATION
 General Medical Examination
 General Neurological Examination
 Ocular motor function
 Facial strength and symmetry
 Observing palatal elevation, tongue protrusion,
and trapezius and sternocleidomastoid strength
 Coordination (Ataxia, the finger-nose-finger test,
the heel-knee-shin test, and rapid alternating mo
vements)
PHYSICAL EXAMINATION
 The Neurotological Examination
 Ocular Motor Function Testing
 Gaze Testing
 Smooth Pursuit
 Saccades
 Optokinetic Nystagmus and Fixation Suppression of the Vestibulo-o
cular Reflex
 Vestibular Nerve Examination
 Positional Testing
 Fistula Testing
 Gait Assessment
 Auditory Examination
OCULAR MOTOR FUNCTION TESTING
 Nystagmus is characterized by a slow and
fast phase component and is classified as sp
ontaneous, gaze-evoked, or positional.
The direction of nystagmus is described conv
entionally by the direction of the fast pha
se.
 Spontaneous nystagmus can have either a
peripheral or a central pattern.
OCULAR MOTOR FUNCTION TESTING
 Central lesions can mimic a “peripheral”
pattern of nystagmus but peripheral lesions c
annot cause “central” patterns of nystagmus.
 Saccadic intrusions
 Square wave jerks - normal intersaccadic delay
 Saccadic oscillations - do not have the
intersaccadic interval
 Ocular Flutter - Horizontal
 Opsoclonus – Vertical or Torsional
NYSTAGMUS
 Nystagmus of Central Origin
 May be purely vertical
 May be purely horizontal
 May be horizonto-rotary
 May change direction with gaze
 Not diminished by fixation
NYSTAGMUS
 Nystagmus of Peripheral Origin
 Horizontal and torsional
 Diminished by fixation
 May fatigue (if elicited by head movement)
 Does not change direction with gaze change
 Diminishes with fixation
Clues to Distinguish Between Peripheral and Central Vertigo
Clues Peripheral vertigo Central vertigo
Findings on Dix-Hallpike Latency of symptoms and None
maneuver nystagmus 2 to 40 seconds

Severity of vertigo Severe Mild

Duration of nystagmus Usually< 1 minute Usually>1 minute

Fatigability Yes No
Other findings
Postural instability Able to walk; Falls while walking; severe
unidirectional instability instability
Hearing loss or tinnitus Can be present Usually absent

Other neurologic Absent Usually present

Symptoms
SMOOTH PURSUIT AND SACCADES
 Abnormalities of smooth pursuit occur as the result
of disorders throughout the central nervous syst
em and with use of tranquilizing medicines or a
lcohol and with fatigue.
 Saccades are generated by the burst neurons of
the pons (horizontal movements) and the midbrain
(vertical movements).
 Lesions or degeneration of these regions leads to
slowing of saccades
 Ocular dysmetria (Overshooting saccades) -
indicates a lesion of the cerebellum.
VESTIBULAR NERVE EXAMINATION
POSITION TESTING
 Dix-Hallpike test
 Positional testing using the head-hanging
technique
 patients with benign positional vertigo will show
a burst of nystagmus after a delay of 5 to 10 sec
onds, the nystagmus lasts about 30 seconds
 The test is never subtly positive
DIX-HALLPIKE TEST
PATHOLOGY AND PHYSICAL EXAMINATION
CHARACTERISTICS OF PERIPHERAL VERTIGO
CHARACTERISTICS OF CENTRAL VERTIGO
“RED FLAGS” OF ACUTE VERTIGO
 Any central neurological symptoms or signs
 New type of headache (especially occipital)
 Acute deafness
 Vertical nystagmus
COMMON PRESENTATIONS OF VERTIGO
 Acute Severe Vertigo
 Focal neurological symptoms, particularly those
that can be related to the posterior circulation, sug
gests an ischemic stroke
 If a peripheral vestibular pattern of nystagmus is
identified, a positive result on head thrust testi
ng localizes the lesion to the vestibular nerve
 Young patient > Vestibular neuritis
 Older patient > Acute ischemia of the vestibula
r nerve or vestibular labyrinth cannot be excluded
COMMON PRESENTATIONS OF VERTIGO
 Acute Severe Vertigo
 If hearing loss accompanies the episode, Labyrinthitis
is the most likely diagnosis
 When hearing loss and facial weakness accompany
acute-onset vertigo, the examiner should closely inspec
t the outer ear for vesicles characteristic of Herpes zos
ter (Ramsay Hunt syndrome)
 Migraine can mimic vestibular neuritis, although the di
agnosis of migraine - associated vertigo hinges on recur
rent episodes and lack of progressive auditory symptom
s
COMMON PRESENTATIONS OF VERTIGO
 Recurrent Attacks of Vertigo
 Meniere's disease is the likely cause in patients
with recurrent vertigo lasting longer than 20 minu
tes and associated with unilateral auditory sympt
oms
 Transient ischemic attacks (TIAs) should be
suspected in patients who experience brief episod
es (minutes in duration) of vertigo, particularly w
hen vascular risk factors are present and other ne
urological symptoms are reported
COMMON PRESENTATIONS OF VERTIGO
 Recurrent Attacks of Vertigo
 The migraine equivalent, benign recurrent
vertigo, is characterized by a history of similar s
ymptoms, normal findings on physical examinatio
n, family or personal history of migraine headach
es, and typical triggers.
COMMON PRESENTATIONS OF VERTIGO
 Recurrent Positional Vertigo
 In the patient complaining of recurrent episode
s of vertigo triggered by certain head movement
s, the likely diagnosis is BPPV
 The history strongly suggests the diagnosis of
BPPV when the positional vertigo is brief (duratio
n less than 1 minute), has typical triggers, and is
unaccompanied by other neurological symptoms
COMMON PRESENTATIONS OF VERTIGO
 Recurrent Positional Vertigo
 Central positional nystagmus occurs as the result
of disorders affecting the posterior fossa inclu
ding tumors, cerebellar degeneration, Chiar
i malformation, and MS
 Following loss of one vertebral artery, vertigo
or significant dizziness after head turns to the dir
ection opposite the intact artery may develop, be
cause the bony structures of the spinal column ca
n pinch off the remaining vertebral artery
COMMON PRESENTATIONS OF VERTIGO
 Recurrent Positional Vertigo
 Patients with migraine as the cause typically
report a longer duration of symptoms once the p
ositional vertigo is triggered, and the nystagmus
may be of a central or peripheral type
DIAGNOSIS
 History
 Physical Exam
 Neurologic Exam
 No Laboratory Investigation
 Brain Imaging
GENERAL TREATMENT PRINCIPLES
 Medication for Acute Vertigo that lasts for few
hours to several days
 Medications have various combinations of
acetylecholine, dopamineand histamine receptor an
tagonism.
 Benzodiazepines enhance GABA action ( GABA is
inhibitory neurotransmitter in vestibular system)
STRENGTH OF RECOMMENDATION
The canalith repositioning procedure (Epley maneuver) is reco
mmended in patients with benign paroxysmal positional vertigo
.A
The modified Epley maneuver also is effective in patients with b

enign paroxysmal positional vertigo. B

Vestibular suppressant medication is recommended for sympto

m relief in patients with acute vestibular neuronitis. C

Vestibular exercises are recommended for more rapid and com

plete vestibular compensation in patients with acute vestibular

neuronitis. B
 A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence,
usual practice, opinion, or case series.
STRENGTH OF RECOMMENDATION
Treatment with a low-salt diet and diuretics is recommended
for patients with Ménière's disease and vertigo. B
Effective treatments for vertiginous migraine include migrain

e prophylaxis (e.g., tricyclic antidepressants, beta blockers, c

alcium channel blockers), migraine-abortive medications (e.g
., sumatriptan), and vestibular rehabilitation exercises. B
Selective serotonin reuptake inhibitors can relieve vertigo in

patients with anxiety disorders. Because of side effects, slow

titration is recommended. B
 A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evi
dence, usual practice, opinion, or case series. See page 1046 for more information.
MEDICATIONS
 Meclizine* (Antivert) 12.5 to 50 mg orally
every 4 to 8 hour
 Dimenhydrinate* (Dramamine) 25 to 100
mg orally, IM, or IV every 4 to 8 hours
 Diazepam (Valium) 2 to 10 mg orally or IV
every 4 to 8 hours
 Lorazepam (Ativan) 0.5 to 2 mg orally, IM,
or IV every 4 to 8 hours
MEDICATIONS
 Metoclopramide (Reglan) 5 to 10 mg orally
every 6 hours; 5 to 10 mg by slow IV every 6
hours
 Prochlorperazine (Compazine) 5 to 10 mg
orally or IM every 6 to 8 hours 25 mg; rectall
y every 12 hours; 5 to 10 mg by slow IV over
2 minutes
 Promethazine (Phenergan) 12.5 to 25 mg
orally, IM, or rectally every 4 to 12 hours
VESTIBULAR REHABILITATION EXERCISES
 These exercises train the brain to use
alternative visual and proprioceptive clues to
maintain balance and gait
 Improve postural control during the first
month after acute unilateral vestibular lesion
s resulting from vestibular neuronitis
TREATMENT OF BPPV
 Medications
 Head Rotation Maneuvers : Epley Maneuver
 Contraindication: Severe carotid stenosis,
unstable heart disease, severe neck disease
 Success rate: 80 % after one treatment,
100% with repeated treatments.
 Recurrence rates: 15% /year, 20% at 20
months, and 37% at 60 months.
TREATMENT OF BPPV
 Epley maneuver
 The patient’s head is systematically rotated to
move the loose particles out of the posterior se
micircular canal back into the utricle
TREATMENT OF BPPV
TREATMENT OF VESTIBULA NEURONITIS
 Symptom relief using vestibular suppressant
medications, followed by vestibular exercises
.
 Vestibular compensations occurs mor
e rapidly and more completely if the patient
begins twice-daily vestibular rehabilitation ex
ercises soon after symptom control with med
ications.
TREATMENT OF MENIER’S DISEASE
 Low salt diet ( < 1-2 gm/day)
 Diuretics
 Surgery in rare cases - ablation of vestibular
hair cells)
TREATMENT OF VASCULAR ISCHEMIA
 TIA /Stroke: BP control, Cholesterol Lowering
, smoking cessation, inhibition of platelet fun
ction, anticoagulation
 Vestibular suppressant medications plus
minimal head maneuver on first day, then ini
tiate rehabilitation
 Vestibular stents for symptomatic critical
vertebral artery stenosis
THE END