Vertigo
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)