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

  1. Anatomy & physiology
  1. Definition
  1. Approach
  1. Common peripheral vertigo
  1. 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

  1. Inadequate rest
  1. Hypoglycemia
  1. Unfamiliar position
  1. Staring at fast moving object
  1. 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