Vertigo ======= þ "The Five Ds" suggesting vertebrobasiliar insufficiency as cause of dizziness: - Dizzy - Diplopia - Dysrthria - Dysphagia - Dystaxia þ Time course for vertigo: - Seconds: BPPV - Minutes: TIA or VBI - Hours: Meniere's - Days: Labyrinthitis þ Dix-Hallpike maneuver - works only with anterior or posterior canal, not horizontal canal otolith. þ Horizontal Canal repositioning - start supine with head to the side that causes vertigo - turn head straight up (90 degrees left) - turn head to the left (90 degrees left) - turn entire body to the left (90 degrees left) - turn head to the left (90 degrees left) þ Vestibular neuronitis, - suspect may be like Bell's palsy only 8th cranial nerve - some recommend acyclovir or steroids but no real studies þ Ototoxicity - usually bilateral - loop diuretics or cytotoxic drugs (quinolones, NSAIDs, aminoglycosides) - oscillopsia: things seem to move as you're walking, have to stop to read signs. þ Central Vertigo: - usually embolic - can have an infarction limited to the internal auditory artery (just to the cochlea and semicircular canal) þ Scan if: - cerebellar - neck pain ? dissection þ Psychological Dizzyness - constant dizzyness - unusual illusory movements - perioral numbness - globus hystericus - palpitations - trembling - unusual fears þ Perilymphatic fistula - divers, those who've been hit in the ear - treatment conservative, rarely surgical closure of oval or round window - pneumatic otoscopy or pressure on tragus should provoke þ Otolith repositioning: - [Kohut RI. Postural vertigo. Quick relief from the postural vertigo component of vestibular diseases. Archives of Family Medicine. 5(3):172-3, 1996 Mar. Abstract: Patients who had disorders of the vestibular system with a component of benign postural vertigo as a symptom were studied, using an examination table suitable for the canalith (otolith) repositioning maneuver as described by Epply, followed by lack of recumbency for 48 hours. The patients regularly had resolution or decreased intensity of symptoms, as did those described by Epply. A repeated positioning maneuver may be needed in some of the patients. The application of a vibrator, as previously described has not been found to be essential. - maneuver is described as: 1. place in sitting position 2. place in vertigo-producing position (e.g., lying supine with head turned with right ear down) for 2 minutes 3. smoothly rotate patient to opposite ear down (e.g., lying prone with head turned with the left ear down) but rotate the nose to a 45 degree angle to the floor) for 2 minutes 4. move the patient to the sitting patient. Have the patient stay up at more than a 45 degree angle for 48 hours. Reportedly effective in 80% of cases. - Semont maneuver: + have patient sitting up, in middle of cot, with legs over the edge. Have the patient sit this way without moving the head for 3 minutes. + have the patient lie over to the right, with the right ear down on the cot, i.e., with the head tilted down laterally about 30 degrees; rotate the head to the left with the nose pointing up at a 45 degree angle. + if this provokes vertigo, especially with nystagmus, latency, and fatiguing, then leave the patient there for another three minutes; then, have the patient sit up again and the lie over on the left side, with the ear against the cot again (laterally tilted to 30 degrees) with the nose rotated up to 45 degrees. Have the patient sit this way for 3 minutes, then sit up straight for three minutes. + if this didn't work, have the patient sit up for three minutes, then repeat the procedure in a mirror image pattern on the other side. þ Diagnostic Testing for Vertigo: - Nylen-Ba'ra'ny test (Ba'ra'ny maneuver, also known as the Hall-Pike maneuver): sudden sitting -> lying with head hyperextended 30 degrees over edge of bed, with head to 2 minutes each side, usually positive with affected ear down. Positive indicates an organic vestibular disorder. - fistula test: + patient's head tilted back 60ø + apply pressure with pneumatic otoscope in ear. + positive test for vertigo or nystagmus indicates: - labyrinthitis from a cholesteatoma eroding the bone over the lateral semicircular canal, or - perilymphatic fistula - corneal sensation: often absent with acoustic neuroma. - Tullio phenomenon: vertigo worsened by loud noises; sign of perilymphatic fistula. þ Central vs. Peripheral Vertigo - Central: usually continuous, insidious onset. - Peripheral: + discontinuous + latent period of up to 25 seconds + shows fatiguability + suppressed by fixation + usually postural - peripheral vertigo usually more severe central Ref: Tintinalli 3rd ed. p 801 - Jeffrey Mann's table: þ Meniere's Disease - fluctuating hearing loss - tinnitus - episodic vertigo - sensation of ear fullness þ PICA Syndrome = Wallenberg Syndrome - occlusion of the posterior inferior cerebellar artery þ Benign Positional Vertigo: - some recommend repeated head-turnings to fatigue the response and break up recalcitrant otoliths. þ Acute Vestibular Vertigo - prednisolone 32 mg daily tapering over 8 days to 4 mg effective (equivalent to 40 mg taper to 5 of prednisone) in symptomatic relief. [Ariyasu L, Byl FM, Sprague MS, Adour KK. The beneficial effect of methylprednisolone in acute vestibular vertigo. Arch Otolyngol Head Neck Surg. 1990;116:700-703.] - from above study, 9/20 had evidence of other cranial neuritis: + hypesthesia of trigeminal nerve (corneal sensation) + C2 (angle of jaw) + posterior pharyngeal wall (glossopharyngeal n.) + palatine or superior laryngeal brances of C10. - most (17/20) had + herpes simplex CF titres but the titres didn't change during the study, but that's characteristic of the population as a whole (80-90%). - one patient relapsed during taper and responded to postponing taper. - "The division of acute vestibular vertigo into such entities as vestibular neuritis, epidemic vertigo, and acute labyrinthitis represents a semantic difference."[sic] Wrong word to use but his point is taken. - increased CSF protein without evidence of blood-brain barrier damage suggests demyelination as cause. þ Treatment of Vertigo - meclizine (e.g., Antivert, Bonine) 25 mg PO TID - diazepam (e.g., Valium) 2-10 mg IV - atropine - droperidol 1 mg IV increase as needed - other antihistamines: + According to Tintinalli (3rd ed. p 802-3), the antihistamines with anticholinergic effects tend to be the most effective in treating peripheral vertigo. Promethazine (Phenergan) and hydroxyzine (Vistaril) have potent anticholinergic and antihistaminic effects and are felt to be effective for the treatment of vertigo. - prednisolone 32 mg daily tapering over 8 days to 4 mg effective (equivalent to 40 mg taper to 5 of prednisone) in symptomatic relief. [Ariyasu L, Byl FM, Sprague MS, Adour KK. The beneficial effect of methylprednisolone in acute vestibular vertigo. Arch Otolyngol Head Neck Surg. 1990;116:700-703.] - solumedrol 25 mg IV then prednisone 20 PO BID for 4 days then 4-day taper. [Ariyasu Arch POHNS June 90] þ Labyrinthitis vs. Vestibular Neuronitis - Both cause peripheral vertigo, and are most commonly caused by a viral illness (though bacterial labyrinthitis can occur and can be devastating). - Vestibular neuronitis characterized by peripheral vertigo without hearing loss - labyrinthitis characterized by peripheral vertigo WITH hearing loss. Ref: Tintinalli 3rd ed. p 800 þ GI symptoms from peripheral vertigo: - can cause not only nausea and vomiting but also diarrhea. Ref: Tintinalli 3rd ed. p 800.