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VERTIGO. AYESHA SHAIKH PGY2 EMORY FAMILY MEDICINE 09.17.2008. CASE. 31,female doctor, otherwise healthy, post partum week 5. First episode, sudden feeling of room spinning, while entering patient data in computer, during Family Medicine Clinic… One fine day last year same time! .

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VERTIGO

AYESHA SHAIKH

PGY2

EMORY FAMILY MEDICINE

09.17.2008


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CASE

  • 31,female doctor, otherwise healthy, post partum week 5.

  • First episode, sudden feeling of room spinning, while entering patient data in computer, during Family Medicine Clinic… One fine day last year same time!


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DIZZINESS

  • Vertigo

  • Lightheadedness

  • Pre syncope

  • Dys-equilibrium


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VERTIGO

  • FALSE SENSE OF MOTION, usually rotational.

  • 2 TYPES

    1- CENTERAL VESTIBULAR CAUSES

    (Brain stem or cerebellum)

    2- PERIPHERAL VESTIBULAR CAUSES

    ( Labyrinth or vestibular nerve)


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CENTRAL

Cerebellopontine angle tumor

Cerebrovascular disease

Migraine

Multiple sclerosis

PERIPHERAL

Acute labrynthitis

Vestibular neuritis

BPPV

Cholestotoma

Menier’s disease

Ostosclerosis

Perilymphatic fistula

CAUSES OF VERTIGO


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Causes..

  • Drugs

  • Alcohol

  • Aminoglycosides

  • Anticonvulsants

  • Antidepressants

  • Antihypertensives

  • Barbiturates

  • Cocaine

    ( Slowly progressive Unilateral/Bilateral)


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History

  • Timings

  • Duration

  • Provoking, aggreviating factors

  • Associated symptoms

  • Risk factors for Cardiovascular disease

    Q: When you have dizzy spells , do you feel lightheaded or do you see the world spin around you?

    Q: Duration of Vertigo and associated symptoms?

    ( differentiate peripheral vs central causes)


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Typical Duration of Symptoms for Different Causes of Vertigo

Duration of episode Suggested diagnosis

A few seconds Peripheral cause: unilateral loss of vestibular function; late stages of

acute vestibular neuronitis; late stages of Ménière's disease

Several seconds

to a few minutes Benign paroxysmal positional vertigo; perilymphatic fistula

Several minutes

to one hour Posterior transient ischemic attack; perilymphatic fistula

Hours Ménière's disease; perilymphatic fistula from trauma or surgery;

migraine; acoustic neuroma

Days Early acute vestibular neuronitis*; stroke; migraine; multiple sclerosis

Weeks Psychogenic (constant vertigo lasting weeks without improvement)

*-Vertigo with early acute vestibular neuritis can last as briefly as two days or as long as one week or more.

Information from references 3, 6, and 12.


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  • Provoking Factors for Different Causes of Vertigo

  • Provoking factor Suggested diagnosis

  • Changes in head position Acute labyrinthitis; benign positional paroxysmal vertigo; cerebellopontine angle tumor;

  • multiple sclerosis; perilymphatic fistula

  • Spontaneous episodes Acute vestibular neuronitis; cerebrovascular disease (stroke or transient ischemic attack);

  • (i.e., no consistent Ménière's disease; migraine; multiple sclerosis

  • provoking factors)

  • Recent upper respiratory

  • viral illness Acute vestibular neuronitis

  • Stress Psychiatric or psychological causes; migraine

  • Immunosuppression

  • (e.g., immunosuppressive Herpes zoster oticus

  • medications, advanced age

  • , stress)

  • Changes in ear pressure, Perilymphatic fistula

  • head trauma,

  • excessive straining, loud noises

  • Information from references 1, 3, 5, 12, and 13.


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Associated Symptoms for Different Causes of Vertigo

Symptom Suggested diagnosis

Aural fullness Acoustic neuroma; Ménière's disease

Ear or mastoid pain Acoustic neuroma; acute middle ear disease (e.g., otitis media, herpes zoster oticus)

Facial weakness Acoustic neuroma; herpes zoster oticus

Focal neurologic Cerebellopontine angle tumor; cerebrovascular disease;

findings) multiple sclerosis (especially findings not explained by single neurologic lesion

Headache Acoustic neuroma; migraine

Hearing loss Ménière's disease; perilymphatic fistula; acoustic neuroma; cholesteatoma;

otosclerosis; transient ischemic attack or stroke involving anterior inferior cerebellar

artery,herpes zoster oticus

Imbalance Acute vestibular neuronitis (usually moderate); cerebellopontine angle tumor

(usually severe)

Nystagmus Peripheral or central vertigo

Phonophobia, photophobia Migraine

Tinnitus Acute labyrinthitis; acoustic neuroma; Ménière's disease

Information from references 1, 6, and 12 through 14.


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Table 5

Causes of Vertigo Associated with Hearing Loss

Diagnosis Characteristics of hearing loss

Acoustic neuroma Progressive, unilateral, sensorineural

Cholesteatoma Progressive, unilateral, conductive

Herpes zoster oticus

(i.e., Ramsay Hun

syndrome) Subacute to acute onset, unilateral

Ménière's diseases Sensorineural, initially fluctuating, initially affecting lower frequencies;

later in course: progressive, affecting higher frequencies

Otosclerosis Progressive, conductive

Perilymphatic fistula Progressive, unilateral

Transient ischemic attack or

stroke involving anterior inferior cerebellar

artery or internal auditory artery Sudden onset, unilateral

Information from references 9, 12, and 13.


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Distinguishing Characteristics of Peripheral vs. Central Causes of Vertigo

Feature Peripheral vertigo Central vertigo

Nystagmus Combined horizontal and torsional; Purely vertical, horizontal, or torsional

inhibited by fixation of eyes onto object; ; not inhibited by fixation of eyes onto object;

fades after a few days; does not change may last weeks to months

direction with gaze to either side ; may change direction with gaze

Imbalance Mild to moderate; able to walk Severe; unable to stand still or walk

Nausea May be severe Varies

, vomiting

Hearing loss,

tinnitus Common Rare

Nonauditory Rare Common

neurologic

symptoms

Latency following

provocative

diagnostic Longer (up to 20 seconds) Shorter (up to 5 seconds)

maneuver)

Information from references 14 and 15.


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Physical Exam Causes of Vertigo

  • Special attention to head and neck

  • Cardiovascular and neurologic symptoms

  • Provocative diagnostic tests


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Physical Exam Causes of Vertigo

  • Vertical nystagmus is 80% sensitive for central lesions.

  • Horizontal nystagmus for peripheral lesions.

  • Rhomberg sign : sensitivity 19 % only for peripheral causes.

  • Dix-Hallpike maneuver PPV 83%, NPV 52 %.


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Clues to Distinguish Between Peripheral and Central Vertigo Causes of Vertigo

Clues Peripheral vertigo Central vertigo

Findings on Latency of symptoms None

Dix-Hallpike and nystagmus 2 to 40 seconds

maneuver

Severity of vertigo Severe Mild

Duration of nystagmus Usually< 1 minute Usually>1 minute

Fatigability* Yes No

Habituation† Yes No

Other findings

Postural instability Able to walk; Falls while walking;

unidirectional instability severe instability

Hearing loss

or tinnitus Can be present Usually absent

Other neurologic

Symptoms Absent Usually present

*-Response remits spontaneously as position is maintained.

†-Attenuation of response as position repeatedly is assumed.

Information from references 3 and 4.


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Diagnosis Causes of Vertigo

  • History

  • Physical Exam: Orthostatic vital signs, and Otoscopic examination,

  • Neurologic Exam: Dix-Hallpike Maneuver ( central vs Peripheral)

  • Complete Audiometric Testing for suspected Menier’s disease

    No LAB testing!

    Brain imaging : MRI with contrast for acute vertigo and Sensorineural hearing loss, MRA for vertebrobasilar circulation


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General Treatment Principles Causes of Vertigo

  • Medication for Acute Vertigo that lasts for few hours to several days

  • Medications have various combinations of acetylecholine, dopamineand histamine receptor antagonism.

  • Benzodiazepines enhance GABA action ( GABA is inhibitory neurotransmitter in vestibular system)


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  • Strength of Recommendation Causes of Vertigo

  • Key clinical recommendation

  • The canalith repositioning procedure (Epley maneuver) is recommended in patients with benign paroxysmal positional vertigo. A

  • The modified Epley maneuver also is effective in patients with benign paroxysmal positional vertigo.B

  • Vestibular suppressant medication is recommended for symptom relief in patients with acute vestibular neuronitis. C

  • Vestibular exercises are recommended for more rapid and complete vestibular compensation in patients with acute vestibular neuronitis. B

  • Treatment with a low-salt diet and diuretics is recommended for patients with Ménière's disease and vertigo.B

  • Effective treatments for vertiginous migraine include migraine prophylaxis (e.g., tricyclic antidepressants, beta blockers, calcium channel blockers), migraine-abortive medications (e.g., sumatriptan [Imitrex]), and vestibular rehabilitation exercises B

  • Selective serotonin reuptake inhibitors can relieve vertigo in patients with anxiety disorders. Because of side effects, slow titration is recommended.B

  • A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, opinion, or case series. See page 1046 for more information.


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Medications Causes of Vertigo

  • Meclizine* (Antivert) 12.5 to 50 mg orally every 4 to 8 hour

  • Dimenhydrinate* (Dramamine) 25 to 100 mg orally, IM, or IV every 4 to 8 hours

  • Diazepam (Valium) 2 to 10 mg orally or IV every 4 to 8 hours

  • Lorazepam (Ativan) 0.5 to 2 mg orally, IM, or IV every 4 to 8 hours

  • Metoclopramide (Reglan) 5 to 10 mg orally every 6 hours

    5 to 10 mg by slow IV every 6 hours

  • Prochlorperazine (Compazine) 5 to 10 mg orally or IM every 6 to 8 hours

    25 mg rectally every 12 hours

    5 to 10 mg by slow IV over 2 minutes

  • Promethazine (Phenergan) 12.5 to 25 mg orally, IM, or rectally every 4 to 12 hours


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Vestibular Rehabilitation Exercises Causes of Vertigo

  • These exercises train the brain to use alternative visual and proprioceptive clues to maintain balance and gait.

  • Improve postural control during the first month after acute unilateral vestibular lesions resulting from vestibular neuronitis.


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Treatment of Specific Disorders Causes of Vertigo

1- BPPV

(Usually posterior canal Calcium Debris)

  • MEDS..?

  • Head Rotation Maneuvers

    Eply Maneuver

    Contraindication: Severe carotid stenosis, unstable heart disease, severe neck disease

    Success rate: 80 % after one treatment, 100% with repeated treatments.

    Recurrence rates: 15% /year, 20% @ 20 months, and 37% @ 60 months.


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Treatment of specific Disorders Causes of Vertigo

2- Vestibular Neuronitis

( Acute Prolonged Vertigo)

  • Symptom relief using vestibular suppressant medications, followed by vestibular exercises.

  • Vestibular compensations occurs more rapidly and more completely if the patient begins twice-daily vestibular rehabilitation exercises soon after symptom control with medications.


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Treatment of specific disorders Causes of Vertigo

3-Menier’s Disease

(Distension of Endolymphatic compartment due to impaired endolymphatic filtration and excretion)

  • Low salt diet ( < 1-2 gm/day)

  • Diuretics ( combo HCTZ and Triamterene)

  • Surgery in rare cases - ablation of vestibular hair cells)


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4- Vascular Ischemia Causes of Vertigo

(Sudden onset of vertigo with additional symptoms eg

diplopia, ataxia, dysphagia, dysarthria)

  • TIA /Stroke: BP control, Cholesterol Lowering , smoking cessation, inhibition of platelet function, anticoagulation

  • Vestibualr suppressant medications plus minimal head maneuver on first day, then initiate rehabilitation

  • Vestibular stents for symptomatic critical vertebral artery stenosis.


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6-Migraine Headaches Causes of Vertigo

Treat Migraine!

Reduce or eliminate Aspartame, chocolate, caffeine and alcohol, Lifestyle changes, Vestibular rehabilitation exercises.

Meds: BDZ, TCA, BB, SSRI, CCB, Antiemetics.


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7- Psychiatric Disorders Causes of Vertigo

( Anxiety , Panic disorders more common than depression; Hyperventilation is the cause.)

  • Vesibular supressants and Benzodiazepines- transient to inadequate relief.

  • SSRI show better relief.

  • Cognitive behaviour therapy may be helpful.


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Physiologic Vertigo Causes of Vertigo

  • Motion sickness: incongruence in the sensory input from the vestibular, visual, and somatosensory systems.Visual system does not sense the movement.

  • Bring systems back in congruence! Eg watch horizon when on a boat.also scopolamine patch behind ear 4 hours before boating.


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Dix- Causes of VertigoHallpike Maneuver


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Epley Causes of Vertigo Maneuver


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Internet resources for patient education Causes of Vertigo

  • http://www.youtube.com/watch?v=hhinu_oU_hM

  • http://www.youtube.com/watch?v=NQr7MKJBAJY

  • http://www.youtube.com/watch?v=eOuzUi5ckrk


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THANKS ! Causes of Vertigo


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References Causes of Vertigo

  • Labuguen R. Initial Evaluation of Vertigo. American Family Physician. January 15, 2006.

  • Swartz R, Longwell P. Treatment of Vertigo. American Family Physician. March 15, 2005.


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