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Peripheral Vertigo The rotational sensation of the environment around us -…

- - - - How long do these "attacks" last?
        
        How sever do these symptoms feel to you?
        
        Do you notice triggers, such as positional changes (head motions), prior to vertigo sensation?
        
        Any associated symptoms such as hearing loss and/or weakness?
        
        Any associated symptoms such as nausea/vomiting?
        
        Have you started any new medications?
        
        1 more item...
    - - History of hypertension, diabetes mellitus, smoking, and a history of vascular disease support a diagnosis of vertebrobasilar ischemia
        
        Past head trauma is a common antecedent to BPPV and persistent postural perceptual dizziness.
        
        Medication history; risk for toxicity: associated with vestibular (eg, cisplatin, aminoglycosides) or cerebellar (eg, phenytoin) toxicity.
  - - - Recurrent, brief (seconds)
        
        Predictable head movements or positions precipitate symptoms
        
        Peripheral characteristics of Nystagmus
        
        No associated neural nor auditory abnormalities
        
        Dix Hallpike maneuver: Positive for BPPV if Nystagmus is observed at a rotational or horizontal
    - - Ataxia
        
        Cranial Nerve Dysfunction: palsies-hemiparesis-sensory loss or dysmetria
        
        Numbness/Weakness
        
        Nystagmus is direction changing or vertical during a Dix Hallpike maneuver
        
        CNS etiology affecting the cerebellum or brainstem must be investigated
    - - Rule out Otitis Media
      - Rule out Shingles infection
      - Hearing test to include whisper, Weber, Rinne
    - - Asses 12 cranial nerves
      - Test balance and gait with : Romberg's Test - Pronator Drift - Natural Gait - Tandem Walking - Toes & Heels
    - - Sustained - single episode, acute onset, lasts days
        
        Viral syndrome may accompany or precede vertigo
        
        Peripheral characteristics of Nystagmus
        
        Neuro symptoms: Gait instability; falls toward side of lesion, no brainstem symptoms
        
        No auditory changes
        
        Head Impulse Test: positive
    - - Recurrent episodes, last minutes to several hours
        
        Spontaneous onset
        
        Peripheral characteristics of Nystagmus
        
        No associated neuro findings
        
        Auditory triad symptoms : preceded by ear fullness/pain, accompanied by vertigo, unilateral hearing loss, tinnitus
        
        Audiometry shows unilateral low-frequency sensorineural hearing loss
    - - Possibly described as dizziness, fainting, falling, light-headedness, or ill-defined
        
        May present with postural changes such as standing up to fast
        
        Accompany s/s may include: pallor, dyspnea, tachycardia, palpitations, fatigue, hypotension, blurred vision and diaphoresis
        
        These s/s should be evaluated further for anemia, cardiovascular disease, hyperventilation, drug reactions, endocrine disorders, fluid & electrolyte imbalances and orthostatic hypotension
    - - Nausea/vomiting
        
        Tilt illusion
        
        Drop attack
        
        Spatial disorientation
        
        Oscillopsia
  - - - Motion is identified when the head is tilted right or left causing the labyrinths to be excited or inhibited, leading to a left-right difference in eighth nerve activity
        
        A false left-right differences that result from an acute unilateral peripheral vestibular disorder are also interpreted by the central nervous system creating a sensation of motion or vertigo.
        
        (BPPV) - caused by dislodged otoliths calcium debris within the posterior semicircular canal, known as canalithiasis
        
        Vestibular neuritis - viral or post-viral inflammatory disorder, affecting the vestibular portion of the VIII cranial nerve.
        
        Meniere disease - excess endolymphatic fluid pressure, which causes episodic inner ear dysfunction.
- - - - Medications are not useful for brief episodes of vertigo. If the patient has frequent episodes Betahistine 24mg BID for one week along with Epley Maneuver can be beneficial.
    - - Vestibular suppressants in acute attacks
        
        First Generation Antihistamines: Mecliizine, Dimenhydrinate, Diphenhydramine, Benzodiazepines, Lorazepam, Clonazepam
      - Bilateral Progressive Meniere's
        
        Treat with Strepomycin or Gentamicin
      - Intratympanic Dexamethasone
    - - Vestibular Suppressants, corticosteroids
  - - - Treated most effectively using Canalith repositioning procedures including: Epley and Semont maneuver, Lempert 360 degree log roll, and Gufoni maneuver
      - Brandt-Daroff Exercises at home self-treatment
      - Vestibular rehab along with particle repositioning patients have less recurrence and better balance at two weeks compared to those who have repositioning alone.
    - - Dietary modifications including low salt diet, no alcohol or tobacco use
      - Surgery in severe cases
        
        Inner Ear Ablation
      - Rest with eye's closed and protection from falling
    - - Vestibular Rehab
  - - - History, Dix Hallpike Maneuver and/or supine head roll test
    - - History and fluctuating low-frequency sensorineural hearing loss on audiometry
    - - History and physical with positive head thrust test and negative neurological findings
    - - Electronystagmography
        
        MRI
        
        Magnetic resonance angiography
        
        Brainstem-evoked responses
        
        Lab screenings as guided by history and physical exam
  - - - Central vertigo is due to a problem in the brain, usually in the brain stem or the back part of the brain (cerebellum)
        
        Causes of central vertigo:
        
        Blood vessel disease
        
        Certain drugs, such as anticonvulsants, aspirin, and alcohol
        
        Multiple sclerosis
        
        Seizures (rarely)
        
        Stroke
        
        Tumors (cancerous or noncancerous)
        
        Vestibular migraine, a type of migraine headache
      - Refer to a Neurologist or Otolaryngologist
    - - Referral if the patient has an abnormal ear exam, or hearing loss, or if symptoms last longer than 8 weeks.
      - Refer if patient is functionally debilitated or in high risk profession (roofer, painter), or if symptoms persist more
        than 6 months or if abnormal/asymmetric audiogram
      - Emergent
        
        Chronic draining ear with acute onset severe vertigo (possible cholesteatoma with labyrinthine erosion – (requires surgery)
        
        Trauma directly to the ear with acute hearing loss and vertigo. Examples: Q-Tip injury to tympanic membranes, acute barotrauma (scuba diving injury), strong valsalva (weight lifting).
        
        Trauma to the head with acute hearing loss and vertigo (possible temporal bone fracture, usually no immediate surgery, observe for CSF leak.
    - - Once the provider has confirmed a diagnosis, they may recommend physical therapy to help improve the person's symptoms
    - - Audiologists identify, diagnose, and provide treatment options for patients with vestibular disorders that lead to dizziness and imbalance. They work closely with providers and physical therapists and are an important part of the dizziness management team.
    - - Increased anxiety goes hand in hand with many balance and dizziness disorders.
        
        CBT is the most commonly recommended therapy for treating anxiety.
      - For many dizzy people, it is helpful to do CBT concurrently with vestibular rehabilitation therapy.
    - - Red Flag central vertigo
    - - Continue management for improved quality of life
  - - - These feelings can come and go, and may last for seconds, minutes, hours, or days
        
        You may feel worse when you move your head, change position (eg, stand up or turn over in bed), cough, or sneeze.
        
        You may have additional symptoms such as:
        
        Nausea or Vomiting
        
        A headache or sensitivity to light or noise
        
        Double vision, trouble speaking or swallowing, or weakness
        
        Shortness of breath, sweating, racing heartbeat
    - - New or severe headache, fever >100.4, seeing double, having trouble speaking or hearing, weakness in arm or leg, passing out, numbness or tingling, chest pain, or vomiting that won't stop.
        
        Additionally, seek help immediately if you have vertigo that lasts for several minutes or more if you:
        
        Are older than 60 years
        
        Had a stroke in the past
        
        Have risk factors for stroke such as high blood pressure, diabetes, or smoke
- - - - Affect's when and from whom they seek health care from
      - Affect's how they respond to recommendations for lifestyle change, health-care interventions, and treatment adherence.
      - Affect's how people think and feel about their health and health problems