Vertigo

Workup

Basic

1. Glu check
2. Full neuro (including nystagmus, cerebellar, EOM)
3. TM exam
4. CT/MRI age >55 (some studies)

Central

1. Above +
   1. CT/MRI
   2. B pulses/BP (subclavian steal)
   3. Bruits

Diagnosis

Peripheral

1. sudden onset
2. severe intensity
3. seconds-hours or intermittent for days
4. unidirectional/bilateral horizontal/rotary nystagmus
   1. (fatigable, suppressed by fixation)
5. positional (often one specific)
6. no focal neuro (able to tandem walk)
   
7. poss auditory findings (incld tinnitus)
8. assoc with acute nausea and vomiting

Central

1. gradual onset
2. mild intensity
3. weeks-months (continuous)
4. horizontal or vertical nystagmus
   1. (nonfatigable, not suppressed by fixation)
5. not positional; or associated with mult positions
6. usually focal neuro
7. no auditory findings

Diagnostic Algorithm

1. Systemic^
   1. DM
   2. Hypothyroidism
2. Peripheral
   1. Non-auditory
      1. BPV
         1. pos Hallpike
      2. Vestibular neuronitis
      3. neg Hallpike
      4. severe x hrs, then lessons dys
      5. mild may persist x wk-mos
      6. occ assoc w/ past infect/toxin
   2. Auditory (hearing loss)
      1. TMs Cl
         1. Meniere's dz
            1. clusters
            2. sx-free intervals
         2. Acoustic neuroma^^
            1. progresses to central sx
         3. Toxic (drug) labyrinthitis*
            1. aminoglycosides
            2. anticonvulsants
            3. alcohols
            4. quinine/quinidine
            5. minocycline
         4. Serous labyrinthitis
            1. h/o antecedent ENT infection
            2. nontoxic/minimal fever
      2. TM abnl
         1. Foreign body in ear canal
         2. Acute suppurative labyrinthitis^
            1. acute OM
            2. febrile/toxic
         3. Perilymphatic fistula (chronic labyrinth)^^
            1. ?abnl TM
            2. chronic hx
3. Central^
   1. Cerebellar hemorrhage
      1. toxic appearing
      2. severe vertigo, HA, n/v, ataxia
      3. cerebellar findings
      4. poss ipsilateral 6th
   2. Vertebrobasilar artery insufficiency (VBI)
      1. elderly
      2. h/o cardiac/vasc dz
      3. HA; poss dysarthria/numbness
      4. h/o neck hyperextension
   3. PICA occlusion (Wallenberg)
      1. ipsilateral Horners
      2. ipsilateral face pain/temp dec
      3. contralateral paralysis pharynx
   4. Subclavian steal sy
      1. unequal UE pulse/BP
      2. scyncopal attacks during exercise
      3. arm fatigue
   5. Vertebrobasilar migraine
   6. MS
      1. bilat internuclear opthalmo^
      2. 20-40 year olds
   7. Temporal lobe epilepsy
      1. memory impairment/trancelike state
   8. Trauma
      1. Head
         1. Postconcussive sy
         2. Temporal bone fx
      2. Neck trauma (c-spin/lig/whiplash)
   9. Infection
      1. Encephalitis
      2. Meningitis
   10. Brain abcess

^Must R/O

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

^^ENT follow-up

Disposition

Admit if unable to walk (all)

Treatment

Symptomatic

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

Source

2/26/06 DONALDSON (adapted from Rosen)