Vertigo: Difference between revisions

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==Workup==
== Background ==
===Basic===
# Glu check
# Full neuro (including nystagmus, cerebellar, EOM)
# TM exam
# CT/MRI age >55 (some studies)


===Central===
*Perception of movement (rotational or otherwise) where no movement exists
# Above +
*Pathophysiology
## CT/MRI
**Mismatch or asymmetric activity of visual, vestibular, and/or proprioceptive systems
## B pulses/BP (subclavian steal)
*Must distinguish peripheral from central cause
## Bruits
**Peripheral: 8th CN, vestibular apparatus
**Central: Brainstem, cerebellum


==Diagnosis==
== Clinical Features==
=== Peripheral  ===


#sudden onset
{| width="400" border="1" cellpadding="1" cellspacing="1"
#severe intensity
|-
#seconds-hours or intermittent for days
|
#unidirectional/bilateral horizontal/rotary nystagmus
| Peripheral
##(fatigable, suppressed by fixation)
| Central
#positional (often one specific)
|-
#no focal neuro (able to tandem walk)<br>
| Onset
#poss auditory findings (incld tinnitus)
| Sudden
#assoc with acute nausea and vomiting
| Sudden or slow
|-
| Severity
| Intense spinning
| Ill defined, less intense
|-
| Pattern
| Paroxysmal, intermittent
| Constant
|-
| Aggravated by position/movement
| Yes
| Variable
|-
| Nausea/diaphoresis
| Frequent
| Variable
|-
| Nystagmus
| Rotatory-vertical, horizontal
| Vertical
|-
| Fatigue of symptoms/signs
| Yes
| No
|-
| Hearing loss/tinnitus
| May occur
| Does not occur
|-
| Abnormal tympanic membrane
| May occur
| Does not occur
|-
| CNS symptoms/signs
| Absent
| Usually present
|}


===Central===
== DDX ==
#gradual onset
#Vestibular/otologic
#mild intensity
##Benign paroxysmal positional vertigo
#weeks-months (continuous)
##Traumatic: following head injury
#horizontal or vertical nystagmus
##Infection: labyrinthitis, vestibular neuronitis, Ramsay Hunt syndrome
##(nonfatigable, not suppressed by fixation)
#Syndrome
#not positional; or associated with mult positions
##Meniere syndrome
#usually focal neuro
##Neoplastic
#no auditory findings
##Vascular
##Otosclerosis
##Paget disease
##Toxic or drug-induced: aminoglycosides
#Neurologic
##Vertebrobasilar insufficiency
##Lateral Wallenberg syndrome
##Anterior inferior cerebellar artery syndrome
##Neoplastic: cerebellopontine angle tumors
##Cerebellar disorders: hemorrhage, degeneration
##Basal ganglion diseases
##Multiple sclerosis
##Infections: neurosyphilis, tuberculosis
##Epilepsy
##Migraine
##Cerebrovascular disease
#General
##Hematologic: anemia, polycythemia, hyperviscosity syndrome
##Toxic: alcohol
##Chronic renal failure
##Metabolic
###Thyroid disease
###Hypoglycemia
==Work-up==
#Glucose check
#Full neuro exam
#TM exam
#?CT/MRI


=== Diagnostic Algorithm ===
== Diagnostic Algorithm ==
== Disposition ==
*Admit if unable to walk


#Systemic^
== Treatment ==
##DM
#Epley maneuver (see [[BPPV]])
##Hypothyroidism
#Anticholinergics
#Peripheral
##Scopolamine transdermal patch 0.5mg (behind ear) QID
##Non-auditory
#Antihistamines
###BPPV  
##Diphenhydramine (benadryl) 25-50mg IM, IV, or PO q4hr
####pos Dix-Hallpike
##Dimenhydrinate (dramamine) 50-100mg IM, IV, or PO q4hr
###Vestibular neuronitis(pos Head Impulse test)<br>
##Meclizine (antivert) 25mg PO QID
###neg Hallpike
#Antidopaminergics
###severe x hrs, then lessons dys
##Metoclopramide 10-20 IV or PO TID
###mild may persist x wk-mos
#Benzodiazepines
###occ assoc w/ past infect/toxin
##Diazepam 2-5mg PO QID
##Auditory (hearing loss)  
##Clonazepam 0.5mg PO BID
###TMs Cl
####Meniere's dz
#####clusters
#####sx-free intervals
####Acoustic neuroma^^
#####progresses to central sx
####Toxic (drug) labyrinthitis*
#####aminoglycosides
#####anticonvulsants
#####alcohols
#####quinine/quinidine
#####minocycline
####Serous labyrinthitis
#####h/o antecedent ENT infection
#####nontoxic/minimal fever
###TM abnl
####Foreign body in ear canal
####Acute suppurative labyrinthitis^
#####acute OM
#####febrile/toxic
####Perilymphatic fistula (chronic labyrinth)^^
#####?abnl TM
#####chronic hx
#Central^
##Cerebellar hemorrhage
###toxic appearing
###severe vertigo, HA, n/v, ataxia
###cerebellar findings
###poss ipsilateral 6th
##Vertebrobasilar artery insufficiency (VBI)  
###elderly
###h/o cardiac/vasc dz
###HA; poss dysarthria/numbness
###h/o neck hyperextension
##PICA occlusion (Wallenberg)
###ipsilateral Horners
###ipsilateral face pain/temp dec
###contralateral paralysis pharynx
##Subclavian steal sy
###unequal UE pulse/BP
###scyncopal attacks during exercise
###arm fatigue
##Vertebrobasilar migraine
##MS
###bilat internuclear opthalmo^
###20-40 year olds
##Temporal lobe epilepsy
###memory impairment/trancelike state
##Trauma
###Head
####Postconcussive sy
####Temporal bone fx
###Neck trauma (c-spin/lig/whiplash)
##Infection
###Encephalitis
###Meningitis
##Brain abcess


^Must R/O
==Algorithm==
[[File:Vertigo_and_Dizziness.jpg]]


Bilat internuclear opthalmo (MLF) = abduction of bilat eyes okay w/ acomidation but not medial gaze
== Source ==
 
*Tintinalli
^^ENT follow-up
 
==Disposition==
Admit if unable to walk (all)
 
==Treatment==
===Symptomatic===
# Diazepam (PO/IV)
# Meclizine
# Benadryl
# 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)


[[Category:Neuro]]
[[Category:Neuro]]

Revision as of 05:14, 4 October 2011

Background

  • Perception of movement (rotational or otherwise) where no movement exists
  • Pathophysiology
    • Mismatch or asymmetric activity of visual, vestibular, and/or proprioceptive systems
  • Must distinguish peripheral from central cause
    • Peripheral: 8th CN, vestibular apparatus
    • Central: Brainstem, cerebellum

Clinical Features

Peripheral Central
Onset Sudden Sudden or slow
Severity Intense spinning Ill defined, less intense
Pattern Paroxysmal, intermittent Constant
Aggravated by position/movement Yes Variable
Nausea/diaphoresis Frequent Variable
Nystagmus Rotatory-vertical, horizontal Vertical
Fatigue of symptoms/signs Yes No
Hearing loss/tinnitus May occur Does not occur
Abnormal tympanic membrane May occur Does not occur
CNS symptoms/signs Absent Usually present

DDX

  1. Vestibular/otologic
    1. Benign paroxysmal positional vertigo
    2. Traumatic: following head injury
    3. Infection: labyrinthitis, vestibular neuronitis, Ramsay Hunt syndrome
  2. Syndrome
    1. Meniere syndrome
    2. Neoplastic
    3. Vascular
    4. Otosclerosis
    5. Paget disease
    6. Toxic or drug-induced: aminoglycosides
  3. Neurologic
    1. Vertebrobasilar insufficiency
    2. Lateral Wallenberg syndrome
    3. Anterior inferior cerebellar artery syndrome
    4. Neoplastic: cerebellopontine angle tumors
    5. Cerebellar disorders: hemorrhage, degeneration
    6. Basal ganglion diseases
    7. Multiple sclerosis
    8. Infections: neurosyphilis, tuberculosis
    9. Epilepsy
    10. Migraine
    11. Cerebrovascular disease
  4. General
    1. Hematologic: anemia, polycythemia, hyperviscosity syndrome
    2. Toxic: alcohol
    3. Chronic renal failure
    4. Metabolic
      1. Thyroid disease
      2. Hypoglycemia

Work-up

  1. Glucose check
  2. Full neuro exam
  3. TM exam
  4. ?CT/MRI

Diagnostic Algorithm

Disposition

  • Admit if unable to walk

Treatment

  1. Epley maneuver (see BPPV)
  2. Anticholinergics
    1. Scopolamine transdermal patch 0.5mg (behind ear) QID
  3. Antihistamines
    1. Diphenhydramine (benadryl) 25-50mg IM, IV, or PO q4hr
    2. Dimenhydrinate (dramamine) 50-100mg IM, IV, or PO q4hr
    3. Meclizine (antivert) 25mg PO QID
  4. Antidopaminergics
    1. Metoclopramide 10-20 IV or PO TID
  5. Benzodiazepines
    1. Diazepam 2-5mg PO QID
    2. Clonazepam 0.5mg PO BID

Algorithm

Vertigo and Dizziness.jpg

Source

  • Tintinalli
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