Vertigo

Data gathering

• Red flags
  • acute onset hearing loss + vertigo -> contact ENT on call
  • CN symptoms, limb weakness, cerebellar signs, severe headache -> urgent HASU review

•  History
  
  • Menieres – ear fullness, tinnitus
  • BPPV – head movement triggers vertigo
  • Vestibular neuronitis – prodromal viral URTI, continuous spinning, vomiting
  • Vestibular migraine – recurrent episodes of vertigo, nausea, photophobia, phonophobia, often normal examination

• Dysequilibrium (unsteadiness)
  • multisensory imbalance – elderly patient, vision, proprioception

• Examine
  • ENT exam
  • CN exam
  • Cerebellar exam
  • L/S BP
  • Dix-Hallpike
  • Head impulse test (negative in central causes)

Clinical management

• Investigations
  • • Bloods – FBC, U+Es, TFTs, HbA1c
    • Bedside BM
    • Audiometry

• Treatment
  • BPPV
    • Epley manoeuvre, Brandt-Daroff exercises, refer if not settled after 4 weeks
  • Vestibular neuronitis
    • Prochlorperazine (max 3 days), refer if not settled after 4 weeks
  • Vestibular migraine
    • Only treat if known vestibular migraine – prochlorperazine 5mg TDS, refer if symptoms persist more than 6 weeks
  • Multisensory imbalance
    • Refer to falls clinic

Notes

• Cerebellar examination
  • DANISH
    • Dysdiadochokinesia
    • Ataxia (gait and posture)
    • Nystagmus
    • Intention tremor
    • Slurred, staccato speech
    • Hypotonia/Heel-shin test

• Dix-Hallpike test for BPPV
  • Patient in a sitting position
  • Rapidly lay the patient down flat on a couch with head turned to the side and neck extended (ensure no neck pathology)
  • A nystagmus occurs if BPPV present