Patient presents with vertigo Key info

Draft City and Hackney Vertigo Pathway

History Key info and Examination

Medical CauseKey info

Psychiatric CauseCheck history

for anxiety or agoraphobia.

ENT CauseNeurological Cause

Key info

Age>75Key info

Urgent Neurological signs Headache Collapse Hearing Loss (sudden onset) Chest pain Severe nausea/vomiting

Routine

CVA Cardiac ENT

<24 hours

Follow HASU

pathway

>24 hours

Urgent ED

Referral

Urgent ED

Referral

Contact ENT on-call at

HUH/RLH/RNTNE

Key info

Need further investigation

Refer to relevant specialty

Needs rehabilitation

Refer to:

Falls clinicKey info

AdultCommunityRehabilitationteamKey info

IntegratedIndependenceTeamKey info

BPPV/Repositional manoeuvre

Key info

Acute Vertigo

Key info

Episodic Vertigo

Keyinfo

Persistent & Chronic

VertigoKey info

Refer to ENTKey info

Referral for vestibular

rehabilitation if appropriate

Authors: Dr Lucy O'Rouke and Mr N Eynon-LewisReviewed by: Dr Monica Doshi (GP Lead), Mr Darren Gillett (ENT Consultant), Mr Max Whittaker (Locum ENT Consultant), July 2019. Review: July 2022

Vertigo Balance is maintained by information from the vestibular apparatus (20%), vision (60%) and proprioception

(20%) being processed by the brain In general, vertigo can be described as rotatory, usually indicating a vestibular cause, or non-rotatory, which is

less indicative of the underlying pathology. It is described as positional if it is brought on by a change in the patient s head position There are many pathological processes that can give rise to vertigo

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History The patient should be asked: To describe the exact sensation that they are complaining of (is this actually vertigo?) If there is a rotatory element If the vertigo is constant or episodic If episodic, how frequently? How long episodes last – see below What brings on the episodes About associated vestibular symptoms (eg nausea and vomiting) About associated otological symptoms - hearing impairment/tinnitus

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ExaminationThis should include an otological, neurological and medical examination as appropriate. A Hallipike test should be performed if the vertigo positional.

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Medical Cause There may be overlap between medical, otological and neurological conditions. For example,

cerebrovascular disease and diabetes can give rise to neurological and vestibular pathology. Other metabolic, endocrine and autoimmune conditions should be noted and the possibility of a drug

side effect should be considered

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Neurological Cause Ask about other neurological symptoms and remember that migraine is a cause of vertigo and that

vertiginous episodes are not always associated with headache in these patients Typically, episodes occur every few weeks or months and last for hours. Very few patients will have

neurological signs but they should not be missed. Test for nystagmus and then head impulse test (loss of vestibulo-ocular reflex or Doll s eye movement, in association with rapid sideways head movement performed by the examiner with the patient fixating directly on the examiner). Loss of fixation indicates unilateral impairment of vestibular function and a peripheral rather than central origin. Test the patient s stance and gait.

TIA or stroke are rarely causes of vertigo and are usually associated with other brainstem features e.g. diplopia, cerebellar signs, etc.

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Patients>75 years Elderly patients often have multiple pathology. The elderly are often taking several medications. Visual and proprioceptive abnormalities can lead to de-compensation from previous vestibular failure Chronic vertigo should not be treated with a vestibular sedative such as prochlorperazine as this will

impair compensation. Vestibular sedatives should only be used for the treatment of acute vertigo

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BPPV Benign paroxysmal positional vertigo (BPPV) is one of the most common causes of dizziness and isidiopathic in many cases Arises from the presence of dense particles, most likely to be otoconial debris, in the posterior semi-circular

canal (although the other canals are rarely involved) It is characterised by severe, brief (seconds) episodes of rotatory vertigo provoked by change in head

position Typically occurs when looking up and to the side, for example when getting something down from a shelf or

when turning in bed or getting up in the morning About 15% of patients have a history of relatively minor head injury The remainder probably represent a residual effect of a variety of vestibular pathologies such as vestibular

neuronitis, ear surgery and inner ear ischaemia

Hall Pikes positional test provokes rotatory vertigo and horizontal torsional nystagmus and is diagnostic of BPPV. With the patient sitting, the neck is extended and turned 45 degrees to one side The patient is then placed supine rapidly, so that the head hangs over the edge of the couch, 30 degrees

below the horizontal Nystagmus can occur with a latency of up to 30 seconds and lasts less than 30 seconds. The test is positive

on the side to which the head is turned. The patient is then sat up and they usually then develop further vertigo and nystagmus although of reduced

severity The procedure is repeated and each time it is done the symptoms become less severe as it habituates For the test to be positive all of the above features need to be demonstrated. If the nystagmus is not

characteristic or does not fatigue or habituate then it is assumed that there is a central cause for the vertigo and the patient will require a MRI of brain

Hall Pike 1 – The patient s head is rotated 45 degrees and the patient lent over the edge of the couch

Hall pike 2 – The patients head is extended 30 degrees and observed for nystagmus

Please click here for youtube video for the Dix Hall-Pike test for BPPV

Repositioning manoeuvre - Epley manoeuvre This is a re-positioning manoeuvre that aims to move the canal debris into the utricle which is a part of the

inner ear adjacent to the canal. It leads to a resolution of symptoms in 80% of patients Home re-positioning techniques can also be helpful in some patients

Epley 1 – the first step is the same as the Hall Pike test (above)

Epley 2 – the second part of the manoeuvre involves turning the patients head through 90 degrees (below)

Epley 3 – the patient is then rotated through a further 90 degrees

Epley 4 – the patient is then sat up and puts chin on their chest

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Acute vertigo lasting days or weeks Acute vestibular failure: Acute vestibular failure presents with acute rotatory vertigo with associated nausea and vomiting. This

can be an extremely unpleasant experience for the patient who is often initially confined to bed Consider vestibular neuronitis which is the most common cause of acute vestibular failure Labyrinthitis refers to inflammation of the labyrinth, consisting of inner ear vestibular apparatus and the

cochlear removed and should only really be diagnosed if there is associated hearing impairment More commonly vertigo occurs without hearing loss and there is some evidence that Herpes Simplex

Vestibular Nerve ganglion infection is the cause of this condition Unlike the majority of patients who present with vertigo, they will have nystagmus Initial treatment is supportive with medication to suppress vestibular activity such as prochlorperazine

which may be given orally, sublingually, IM or suppository The vertigo gradually improves as the brain compensates for the disparity of vestibular input from the

two sides. By 6 weeks the symptoms have usually improved significantly Some patients, however, do not compensate well from acute vestibular failure and go on to develop

chronic vertigo. It is uncertain why this is but psychological factors may be important in some patients Acute vestibular failure can also be caused by head injury with or without temporal bone fracture , can be

drug induced (e.g. aminoglycosides) and can be a complication of ear surgery Acute vestibular neuronitis is relatively common. Acute cerebellar stroke is rare although may present

with isolated vertigo. In elderly patients with a high risk of vascular disease this should be considered. The majority will have a normal head thrust test (further neurological info)

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Episodic vertigo Paroxysmal episodes of rotatory vertigo associated with hearing loss and tinnitus lasting less than 24hours are typical of endolymphatic hydrops. Meniere's disease is the term used to describe primary endolymphatic hydrops. It is the most commonly over diagnosed cause of vertigo. Meniere's disease is thought to arise from an abnormal homeostasis of inner ear fluid It can only be definitively diagnosed by histopathological examination of the temporal bone Typically symptoms begin between 20 and 40 years of age. Children may present with Meniere s-like symptoms due to secondary endolymphatic hydrops

associated with congenital malformations of the inner ear. Fluctuation hearing loss may progress over time, affecting both ears and resulting in irreversible hearing

loss usually affecting the lower frequencies more severely. This may also be accompanied by a general sense of imbalance between acute episodes. It is unilateral in most cases.

It is a diagnosis of exclusion, since other pathologies such as an acoustic neuroma and osteosyphilis may present as endolymphatic hydrops (secondary endolymphatic hydrops)

Most patients can be managed conservatively. GPs can prescribe betahistine 8 or 16mg up to TDS and a low salt diet.

Hospital initiated diuretics are used less commonly as evidence of benefit is weak. Intra-tympanic dexamethasone via a grommet (both in secondary care setting only) has become an

established technique when conservative management is not successful. This can be performed at the Homerton, usually as a day surgery procedure.

Labyrinthectomy and vestibular nerve section are occasionally indicated Other causes of episodic vertigo include BPPV labyrinthine fistula (caused by

cholesteatoma), cervical vertigo (an ill defined condition associated with cervical spine osteoarthritis), migraine autoimmune disease of the temporal boneand episodes of decompensation from previous vestibular failure

further info

further info further infofurther info

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Vertigo with persistent hearing loss or associated otoalgia or otorrhoeaThere are several otological causes of vertigo including: Chronic Suppurative Otitis Media Cholesteatoma with labyrinthine fistula Perilymph fistula Chronic inflammatory conditions of the temporal bone such as syphilis Autoimmune disease of the temporal bone Temporal bone trauma Cerebellopontine angle lesions such as acoustic neuroma

Chronic Vertigo It is worth knowing that a definitive diagnosis is often not made even after vestibular investigations Psychological causes are very important in chronic vertigo and are thought to hinder rehabilitation after

vestibular failure Failure to compensate adequately may also be related to impairment of other sensory inputs, the use of

vestibular sedatives eg prochlorperzaine and systemic disease. Patients recovering from vestibular failure may develop vertigo in situations of increased visual

stimulation such as in crowded situations or near a busy road and this is thought to be related to an over reliance on visual input for maintaining balance leading to visual stimulation. This is known as visual vertigo and can sometimes be clearly elicited from the history. It is often associated with anxiety.

Patients with chronic vertigo can benefit greatly from vestibular rehabilitation as it maximises the natural ability of the nervous system to compensate for vestibular failure

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Refer to ENTRefer ENT Surgeon: Refer if vertigo is persistent or associated with middle ear pathology. Depending onthe assessment, the patient may be referred for imaging or vestibular tests ENT Advice and Guidance is available at the Homerton Referral can be made to ENT Hospital Clinic via e-RS. Enquiries can be made to ENT (020 8510 5206)

References1. Please click here for NICE guidelines for Menieres Disease

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Falls Clinic Adults who have fallen and aged over 65 years Vestibular screen carried out by Physiotherapist Vestibular assessment and treatment by Physiotherapist for patients who do not require community input

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ACRT Neuro and physical Physiotherapists screening for vestibular problems using Vestibular Screening Tool Adults with community rehab goals and vestibular symptoms can be assessed and treated in their home or as

out-patients Rehab pathways – standard (6 sessions), slow stream (10 sessions), enhanced (10 sessions + 6 RA), Ax and

advice (1-2 sessions) Urgent clients seen within one week, routine clients within 5 weeks

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IIT Rapid Response Service – supporting doctors assessing vestibular symptoms in A&E, assisting with treatment

of BPPV Home Treatment Team: Neuro and physical Physiotherapists screening for vestibular problems using Vestibular Screening Tool Adults with community rehab goals and vestibular symptoms can be assessed and treated in their home if

they have intermediate care needs (discharged within 6 weeks)

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