VERTIGO by yurtgc548

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									VERTIGO
Outline

•   Definition
•   Common Causes
•   Physical examination findings
•   Investigations
•   Principles of treatment
•   Summary
DEFINITION
Definition of Vertigo

• Subjective sensation of
  movement, usually rotatory
• Illusion of movement around the
  patient
• Often accompanied by pallor,
  sweating and vomiting
• Objective sign - nystagmus
IMPORTANT HISTORY
Important History

• Timing: episodic, persistent?
• Aural symptoms
  •   Deafness
  •   Tinnitus
  •   Earache
  •   Discharge
Important History

• Neurological symptoms
 •   Loss of consciousness
 •   Weakness
 •   Numbness
 •   Dysarthria
 •   Diplopia
 •   Fitting
History guided
differential diagnosis
• Episodic
• Constant
• Solitary
Episodic vertigo
With aural symptoms   Without aural
                      symptoms
• Meniere’s disease   • Benign paroxysmal
                        positional vertigo
• Migraine            • Migraine
                      • Transient ischemic
                        attacks
                      • Cardiac
                        arrhythmias
Constant vertigo
With aural         Without aural
symptoms           symptoms
• Chronic otitis   • Multiple
  media with         sclerosis
  labryinthine     • Posterior fossa
  fistula            tumor
• Ototoxicity      • Cardiovascular
• Acoustic           disease
  neuroma          • Alcoholism
Solitary Vertigo
With aural symptoms      Without aural
                         symptoms
• Head injury            • Vasovagal faint
• Labyrinthine fistula   • Vestibular
• Viral infection e.g.     neuronitis
  mumps, herpes          • Trauma
  zoster
• Vascular occlusion
Differential diagnosis
according to organ
affected
• Vestibular end-organs and vestibular
  nerve
• Brainstem and cerebellum
• Cerebello-pontine angle
• Eyes
• Others

Disorders of the labyrinth, vestibular
nerve and vesticular nuclei accounts
for most of the cases!!!!
Vestibular end-organs
and vestibular nerve
•   Meniere’s disease
•   Acute labyrinthitis
•   Benign positional vertigo
•   Motion sickness
•   Trauma
•   Ototoxicity
•   Ramsay Hunt syndrome
Brainstem and
cerebellum
• Multiple sclerosis
• Infarction/TIA
• Hemorrhage
Others

• Cerebellopontine angle
 • Vestibular schwannoma
• Alcohol intoxication
• Ophthalmoplegia with diplopia
What is NOT vertigo?

• Lightheadedness
  • Anemia – palpitation, SOB?
  • Orthostatic hypotension
• Loss of consciousness
  • Suggests epilepsy more than vertigo
• Anxiety
  • Associated palpitations, termore,
    sweating?
PHYSICAL
EXAMINATION
Important Points

•   Nystagmus
•   Hearing
•   Specific positional tests
•   Neurological examination
•   Cardiovascular examination
NYSTAGMUS

• Multidirectional
  • diffuse cerebellar disease
• Unilateral
  • Ipsilateral cerebellar disease
    • Multiple sclerosis
    • Posterior circulation TIA
  • Contralateral cerebellar disease
    • Meniere’s disease
    • Labyrinthitis
HEARING

• Assessed with Rinne’s and Weber’s
  tests
• Sensorineural hearing loss
  • Meniere’s disease
  • Acoustic neuroma
  • Drug-induced ototoxicity
• Hearing loss + facial nerve palsy
  • Tumor effects at the cerebellopontine
    angle??!
Neurological
examination
• Visual field - Homonymous
  hemianopia
  • Posterior circulation infarcts
  • Brainstem lesions
• Fundoscopy - Pale optic disc
  • Optic atrophy possibly due to
    multiple sclerosis
• Cerebellar signs
  •   Scanned speech
  •   Intention tremor
  •   Dysdiadochokinesia
  •   Dysarthria
  •   Nystagmus
  •   Wide based gait
  •   Inability to walk heel-to-toe
INVESTIGATIONS
Principles

• Most causes of vertigo can be
  diagnosed on history and
  clinical examination
• Investigations should be
  selective if clinically indicated
General Investigations

• Full blood count (FBC)
  • Increase in white cell count – infection
  • Increase in Hb level – predisposes to
    CVA
• Erythrocyte sedimentation rate
  (ESR)
  • Increase in cerebrovascular accident
    (CVA), malignancy, infection
Specific Investigations

• 24 hours ECG
  • Arrhythmia
• Audiometry
  • Assessment and classification of
    hearing loss
• Carotid Dopplers
  • Evaluation of the vessel and
    screen forcthe presence of plaque
Specific Investigations

• CT head
 • Stroke, cerebellar hemorrhage,
   evaluation of severe head injuries
• MRI
 • Acoustic neuroma and other
   cerebellopontine angle tumors
 • Demyelination with multiple
   sclerosis
Cardiovascular
examination
• Pulse assessment
 • Irregularities – Atrial fibrillation?
• Blood pressure
 • BOTH lying and standing
 • Screened for postural hypotension
• Murmurs and bruits
 • Potential sites for emboli – heart
   valves and carotid vessels
MANAGEMENT OF
VERTIGO
Principles

• Treatment directed against
  underlying etiology
• For mild and non-persistent
  cases
  • Expectant management -
    Reassurance and advise bed rest
SUMMARY
SUMMARY

• VERTIGO – an illusion of
  movement, often rotatory, of the
  patient or his surroundings
• Important History
  • Timing
  • Aural symptoms
  • Neurological symptoms
SUMMARY

• Physical examination
 •   Nystagmus
 •   Hearing test
 •   Neurological examination
 •   Cardiovascular examination
SUMMARY

• Common etiology
 • Vestibular end-organs and nerves
   • Meniere’s disease
   • Acute labyrinthitis
   • Benign positional vertigo
 • Brainstem and cerebellum lesions
SUMMARY

• Usually diagnosed by clinical
  history and physical
  examination
• Treatment directed against
  underlying pathology
THE END

								
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