Approach to Vertigo 🎧
❓ True vertigo or not
Yes ➭ แยก CNS ?🍇
Yes ➭ complete neuro exam, Hx of should < 4 wk if no bedridden or no drug; muscle tone, Cranial nerve, nystagmus
No ➭ Peripheral เอาเคสที่เจอบ่อย
90% is BPPV
9% is Meniere’s
1% Vestibular neuritis
⚔ Overview
- Anatomy & physiology
- Definition
- Approach
- Common peripheral vertigo
- Mx
Vertigo = Illusion of movement eg. อยู่เฉยๆแล้วบ้านหมุน
🌟 should ddx fr Tension headache & Anxiety first
🕐When to refer?
Evidence of CNS cause
Persisting vertigo > 4 wk
Recurrent vertigo
Sensorineural hearing loss
Physiological cause of vertigo
- Inadequate rest
- Hypoglycemia
- Unfamiliar position
- Staring at fast moving object
- Mismatch among sensation
What can be confused with Vertigo??
Dizziness (sensation in the head)
Light headedness (sensation of Flying head)
Unsteadiness/Instability (sensation in the Legs)
Oscillopsia (oscillating image in the eyes)
Central cause (CNS)
M/C are Brainstem & Cerebellar lesion
Ischemia
Hemorrhage
Tumor
Degenerative change
⭐ test for Cerebellar signs & pronator drip test are the must for the sake of Silent ds
🍡Make Provisional Dx fr Hx
Duration
mins ⇨ TIA
hours ⇨ Meniere ds, Vertiginous migraine
days ⇨ Vestibular neuritis
secs ⇨ BPPV
Specific aggravating cause
🍡 Make provisional Dx fr Hx then ⇨
Specific position ⇨ BPPV
Pressure change ⇨ 3rd window phenomenon
(perilymphatic fistula, SCDS, LVA)
Walking ⇨ Bilateral vestibulopathy
Oscillopsia ⇨ Bilateral vestibulopathy
🍡 Confirm with selected PE
BPPV
👓Positioning test
👓Positional test
Meniere ds
Gaze-evoked nystagmus
Head shaking nystagmus
💮Direct to AAO-HNS criteria 1995
Vestibular neuritis
Spontaneous nystagmus
Past-pointing test, Stepping test
Perilymphatic fistula/SCDS
Pneumatic otoscopy
Supine position
Lateral lying position
Dix-Hallpike maneuver
Side-lying test
Certain Meniere ds
Definite Meniere ds with 'histopathology'
Definite Meniere ds
2 episodes of vertigo last > 20 mins
Proved audiogram SNHL cochlear type
Probable Meniere ds
1 episode of vertigo > 20 mins
Proved audiogram
Possible Meniere ds
One of Criteria
Diagnosis
Meniere ds
Depends on Clinical criteria
Audiometry is mandatory
PE is only a support
Present when?
During attack
Look for Spontaneous nystagmus
After attack
🐰 Look for Submerged nystagmus
Special Ix not included in criteria
Electrocochleography (ECoG)
Vestibular-evoked myogenic potentials (VEMP)
10% glycerol test
symptoms
Severe & lasts for Days
Vertigo without any auditory symptoms
🍡 Confirm with selected PE
Hx of Tullio phenomenon
Positive pressure
Negative pressure
Nystagmus induced by Valsava maneuver
Glottic closure
Nostril closure
results
Horizontal nystagmus to the tested ear ⇨ Perilymph fistula
Downward/Rotatory nystagmus to the other ear ⇨ SCDS
Head shaking test
Gaze-evoked nystagmus
Head thrust test/Halmagyi test
🕯Romberg/Sharpened Romberg test
Tandem gait
🕯Unterberger test
🍊Past pointing test
Clinical Vestibular Func Tests
Test Vestibulospinal tract🕯
Romberg Test
Unterberger test/Stepping test
Gait test
Test Vestibulocerebellar tract 🍊
Dysmetria/Past Pointing
Asynergia
Dysdiadochokinesia
Rebound arm test
Test for Vestibuloocular pathway 👓
Spontaneous nystagmus
Head shaking test
Positional test
Positioning test
Supine
Upright
Dix-Hallpike maneuver