Vertigo: Difference between revisions

(Created page with "WORKUP Basic 1) Glu check 2) Full neuro (including nystagmus, cerebellar, EOM) 3) TM exam 4) CT/MRI age >55 (some studies) Central 4) CT/MRI 5) B pulses/BP (subclavian...")
 
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WORKUP
Basic
1) Glu check
2) Full neuro (including nystagmus, cerebellar, EOM)
3) TM exam
4) CT/MRI age >55 (some studies)
Central
4) CT/MRI
5) B pulses/BP (subclavian steal)
6) Bruits
DIAGNOSIS
Peripheral
-sudden onset
-severe intensity
-seconds-hours or intermittent for days
-unidirectional/bilateral horizontal/rotary nystagmus
(fatigable, suppressed by fixation)
-positional (often one specific)
-no focal neuro
-poss auditory findings (incld tinnitus)
Central
-gradual onset
-mild intensity
-weeks-months (continuous)
-horizontal or vertical nystagmus
(nonfatigable, not suppressed by fixation)
-not positional; or associated with mult positions
-usually focal neuro
-no auditory findings
DIAGNOSTIC ALGORITHM
I. Systemic*
1) DM
2) Hypothyroidism
II. Peripheral
1) Non-auditory
A) BPV
-pos Hallpike
B) Vestibular neuronitis
-neg Hallpike
-severe x hrs, then lessons dys
-mild may persist x wk-mos
-occ assoc w/ past infect/toxin
2) Auditory (hearing loss)
A) TMs Cl
i) Meniere's dz
-clusters
-sx-free intervals
ii) Acoustic neuroma^^
-progresses to central sx
iii) Toxic (drug) labyrinthitis*
-aminoglycosides
-anticonvulsants
-alcohols
-quinine/quinidine
-minocycline
iv) Serous labyrinthitis
-h/o antecedent ENT infection
-nontoxic/minimal fever
B) TM abnl
i) Foreign body in ear canal
ii) Acute suppurative labyrinthitis*
-acute OM
-febrile/toxic
iii) Perilymphatic fistula (chronic labyrinth)^^
-?abnl TM
-chronic hx
III. Central*
1) Cerebellar hemorrhage
-toxic appearing
-severe vertigo, HA, n/v, ataxia
-cerebellar findings
-poss ipsilateral 6th
2) Vertebrobasilar artery insufficiency (VBI)
-elderly
-h/o cardiac/vasc dz
-HA; poss dysarthria/numbness
-h/o neck hyperextension
3) PICA occlusion (Wallenberg)
-ipsilateral Horners
-ipsilateral face pain/temp dec
-contralateral paralysis pharynx
4) Subclavian steal sy
-unequal UE pulse/BP
-scyncopal attacks during exercise
-arm fatigue
5) Vertebrobasilar migraine
6) MS
-bilat internuclear opthalmo^
-20-40 year olds
7) Temporal lobe epilepsy
-memory impairment/trancelike state
8) Trauma
A) Head
i) Postconcussive sy
ii) Temporal bone fx
B) Neck trauma (c-spin/lig/whiplash)
9) Infection
A) Encephalitis
B) Meningitis
C) Brain abcess
<nowiki>*Must R/O</nowiki>
^Bilat internuclear opthalmo (MLF) = abduction of bilat eyes okay w/ acomidation but not medial gaze
^^ENT follow-up
Admit if unable to walk (all)
SYMPTOMATIC TREATMENT
1) Diazepam (PO/IV)
2) Meclizine
3) Benadryl
4) Promethazine
BPV TESTING*
Hallpike (test): quickly from sitting to supine, head to one side, brought 30deg off stretcher; + = nystag/reproduced symptoms
Eply (treatment): Head at 45deg rotation, 30deg hyperextension; 30 sec motions-->RUQ,LUQ,LLQ,sitting w/slight flexion (for pos Hallpike on right)
Brandt-Daroff (home treatment)
<nowiki>*caution if concern for VBI</nowiki>
2/26/06 DONALDSON (adapted from Rosen)
WORKUP
WORKUP


Revision as of 23:09, 28 March 2011

WORKUP

Basic

1) Glu check

2) Full neuro (including nystagmus, cerebellar, EOM)

3) TM exam

4) CT/MRI age >55 (some studies)

Central

4) CT/MRI

5) B pulses/BP (subclavian steal)

6) Bruits

DIAGNOSIS

Peripheral

-sudden onset

-severe intensity

-seconds-hours or intermittent for days

-unidirectional/bilateral horizontal/rotary nystagmus

(fatigable, suppressed by fixation)

-positional (often one specific)

-no focal neuro

-poss auditory findings (incld tinnitus)

Central

-gradual onset

-mild intensity

-weeks-months (continuous)

-horizontal or vertical nystagmus

(nonfatigable, not suppressed by fixation)

-not positional; or associated with mult positions

-usually focal neuro

-no auditory findings

DIAGNOSTIC ALGORITHM

I. Systemic*

1) DM

2) Hypothyroidism

II. Peripheral

1) Non-auditory

A) BPV

-pos Hallpike

B) Vestibular neuronitis

-neg Hallpike

-severe x hrs, then lessons dys

-mild may persist x wk-mos

-occ assoc w/ past infect/toxin

2) Auditory (hearing loss)

A) TMs Cl

i) Meniere's dz

-clusters

-sx-free intervals

ii) Acoustic neuroma^^

-progresses to central sx

iii) Toxic (drug) labyrinthitis*

-aminoglycosides

-anticonvulsants

-alcohols

-quinine/quinidine

-minocycline

iv) Serous labyrinthitis

-h/o antecedent ENT infection

-nontoxic/minimal fever

B) TM abnl

i) Foreign body in ear canal

ii) Acute suppurative labyrinthitis*

-acute OM

-febrile/toxic

iii) Perilymphatic fistula (chronic labyrinth)^^

-?abnl TM

-chronic hx

III. Central*

1) Cerebellar hemorrhage

-toxic appearing

-severe vertigo, HA, n/v, ataxia

-cerebellar findings

-poss ipsilateral 6th

2) Vertebrobasilar artery insufficiency (VBI)

-elderly

-h/o cardiac/vasc dz

-HA; poss dysarthria/numbness

-h/o neck hyperextension

3) PICA occlusion (Wallenberg)

-ipsilateral Horners

-ipsilateral face pain/temp dec

-contralateral paralysis pharynx

4) Subclavian steal sy

-unequal UE pulse/BP

-scyncopal attacks during exercise

-arm fatigue

5) Vertebrobasilar migraine

6) MS

-bilat internuclear opthalmo^

-20-40 year olds

7) Temporal lobe epilepsy

-memory impairment/trancelike state

8) Trauma

A) Head

i) Postconcussive sy

ii) Temporal bone fx

B) Neck trauma (c-spin/lig/whiplash)

9) Infection

A) Encephalitis

B) Meningitis

C) Brain abcess

*Must R/O

^Bilat internuclear opthalmo (MLF) = abduction of bilat eyes okay w/ acomidation but not medial gaze

^^ENT follow-up

Admit if unable to walk (all)

SYMPTOMATIC TREATMENT

1) Diazepam (PO/IV)

2) Meclizine

3) Benadryl

4) Promethazine

BPV TESTING*

Hallpike (test): quickly from sitting to supine, head to one side, brought 30deg off stretcher; + = nystag/reproduced symptoms

Eply (treatment): Head at 45deg rotation, 30deg hyperextension; 30 sec motions-->RUQ,LUQ,LLQ,sitting w/slight flexion (for pos Hallpike on right)

Brandt-Daroff (home treatment)

*caution if concern for VBI

2/26/06 DONALDSON (adapted from Rosen)


WORKUP

Basic

1) Glu check

2) Full neuro (including nystagmus, cerebellar, EOM)

3) TM exam

4) CT/MRI age >55 (some studies)


Central

4) CT/MRI

5) B pulses/BP (subclavian steal)

6) Bruits


DIAGNOSIS


Peripheral

-sudden onset

-severe intensity

-seconds-hours or intermittent for days

-unidirectional/bilateral horizontal/rotary nystagmus

(fatigable, suppressed by fixation)

-positional (often one specific)

-no focal neuro

-poss auditory findings (incld tinnitus)


Central

-gradual onset

-mild intensity

-weeks-months (continuous)

-horizontal or vertical nystagmus

(nonfatigable, not suppressed by fixation)

-not positional; or associated with mult positions

-usually focal neuro

-no auditory findings


DIAGNOSTIC ALGORITHM

I. Systemic* 

    1) DM

    2) Hypothyroidism

II. Peripheral 

    1) Non-auditory

         A) BPV

              -pos Hallpike

         B) Vestibular neuronitis

              -neg Hallpike

              -severe x hrs, then lessons dys

              -mild may persist x wk-mos

              -occ assoc w/ past infect/toxin

    2) Auditory (hearing loss)

         A) TMs Cl

              i) Meniere's dz

                   -clusters

                   -sx-free intervals

              ii) Acoustic neuroma^^

                   -progresses to central sx

              iii) Toxic (drug) labyrinthitis*

                   -aminoglycosides

                   -anticonvulsants

                   -alcohols

                   -quinine/quinidine

                   -minocycline

              iv) Serous labyrinthitis

                   -h/o antecedent ENT infection

                   -nontoxic/minimal fever

         B) TM abnl

              i) Foreign body in ear canal

              ii) Acute suppurative labyrinthitis*

                   -acute OM

                   -febrile/toxic

              iii) Perilymphatic fistula (chronic labyrinth)^^

                   -?abnl TM

                   -chronic hx

III. Central* 

    1) Cerebellar hemorrhage

         -toxic appearing

         -severe vertigo, HA, n/v, ataxia

         -cerebellar findings

         -poss ipsilateral 6th

    2) Vertebrobasilar artery insufficiency (VBI)

         -elderly

         -h/o cardiac/vasc dz

         -HA; poss dysarthria/numbness

         -h/o neck hyperextension

    3) PICA occlusion (Wallenberg)

         -ipsilateral Horners

         -ipsilateral face pain/temp dec

         -contralateral paralysis pharynx

    4) Subclavian steal sy

         -unequal UE pulse/BP

         -scyncopal attacks during exercise

         -arm fatigue

    5) Vertebrobasilar migraine

    6) MS

         -bilat internuclear opthalmo^

         -20-40 year olds

    7) Temporal lobe epilepsy

         -memory impairment/trancelike state

    8) Trauma

         A) Head

              i) Postconcussive sy

              ii) Temporal bone fx

         B) Neck trauma (c-spin/lig/whiplash)

    9) Infection

         A) Encephalitis

         B) Meningitis

         C) Brain abcess


  • Must R/O

^Bilat internuclear opthalmo (MLF) = abduction of bilat eyes okay w/ acomidation but not medial gaze

^^ENT follow-up


Admit if unable to walk (all)


SYMPTOMATIC TREATMENT

1) Diazepam (PO/IV)

2) Meclizine

3) Benadryl

4) Promethazine


BPV TESTING*

Hallpike (test): quickly from sitting to supine, head to one side, brought 30deg off stretcher; + = nystag/reproduced symptoms

Eply (treatment): Head at 45deg rotation, 30deg hyperextension; 30 sec motions-->RUQ,LUQ,LLQ,sitting w/slight flexion (for pos Hallpike on right)

Brandt-Daroff (home treatment)

  • caution if concern for VBI


2/26/06 DONALDSON (adapted from Rosen)

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