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Approach to Vertigo :headphones: (:crossed_swords: Overview (Definition…
Approach to Vertigo
:headphones:
:question:
True
vertigo or not
Yes ➭ แยก
CNS
?:grapes:
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
:dango: Make provisional Dx fr Hx then ⇨
:dango: Confirm with selected PE
:crossed_swords:
Overview
Anatomy & physiology
Definition
Vertigo = Illusion of movement eg. อยู่เฉยๆแล้วบ้านหมุน
:star2: should ddx fr Tension headache & Anxiety first
Approach
Common peripheral vertigo
Mx
:clock1:
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
:star: test for
Cerebellar signs & pronator drip
test are the
must
for the sake of Silent ds
:dango:Make Provisional Dx fr
Hx
Duration
mins ⇨ TIA
hours ⇨ Meniere ds, Vertiginous migraine
days ⇨ Vestibular neuritis
secs ⇨ BPPV
Specific aggravating cause
Specific position ⇨ BPPV
Pressure change ⇨ 3rd window phenomenon
(perilymphatic fistula, SCDS, LVA)
Walking ⇨ Bilateral vestibulopathy
Oscillopsia ⇨ Bilateral vestibulopathy
:dango:
Confirm with selected
PE
BPPV
:eyeglasses:Positioning test
Supine position
Lateral lying position
:eyeglasses:Positional test
Dix-Hallpike maneuver
Side-lying test
Meniere ds
Gaze-evoked nystagmus
Head shaking nystagmus
:white_flower:Direct to AAO-HNS
criteria
1995
Certain
Meniere ds
Definite Meniere ds with 'histopathology'
Definite
Meniere ds
2 epi
sodes 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
Vestibular neuritis
Spontaneous nystagmus
Past-pointing test, Stepping test
symptoms
Severe & lasts for Days
Vertigo
without any auditory symptoms
Perilymphatic fistula/SCDS
Pneumatic otoscopy
Positive pressure
Negative pressure
results
Horizontal nystagmus to the tested ear ⇨ Perilymph fistula
Downward/Rotatory nystagmus to the other ear ⇨ SCDS
Hx of Tullio phenomenon
Nystagmus induced by
Valsava maneuver
Glottic closure
Nostril closure
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
:rabbit: Look for
Submerged
nystagmus
Head shaking test
Gaze-evoked nystagmus
Head thrust test/Halmagyi test
:candle:Romberg/Sharpened Romberg test
Tandem gait
:candle:Unterberger test
:tangerine:Past pointing test
Special Ix
not included
in criteria
Electrocochleography (ECoG)
Vestibular-evoked myogenic potentials (VEMP)
10% glycerol test
Clinical Vestibular Func Tests
Test Vestibulo
spinal
tract:candle:
Romberg Test
Unterberger test/Stepping test
Gait test
Test Vestibulo
cerebellar
tract :tangerine:
Dysmetria/Past Pointing
Asynergia
Dysdiadochokinesia
Rebound arm test
Test for Vestibulo
ocular
pathway :eyeglasses:
Spontaneous nystagmus
Head shaking test
Positional test
Supine
Upright
Positioning test
Dix-Hallpike maneuver