Dr Fin O’Reilly

GP Dolphin House Ware

Aims What are the four types of “dizziness”

Vertigo

What are the differentials for vertigo

How to get the history right

What do we examine

Hallpikes

How do we treat

What is Epleys?

Epidemiology Common

0.5% of the population consult their GP each year with vertigo

1% of the population consult their GP each year with dizziness or unsteadiness

Women are more commonly affected than men.

It’s all about the history

“It’s Hard to explain doctor”

“Dizzified”

“Any old how “

“Just Whoops a daisy”

“Giddy”

“Giddified”

Spinny

“Floppsy”

“Heady”

“Vertigoey”

Lightheaded

Fainty

“”Whoosy”

Forget RCGP/Roger Neigbour/ Cambridge Calgary for 30 seconds…

Closed Questions

Vertigo Vertigo is an illusion of movement, often horizontal

and rotatory.

Other Questions:

o Do you get the feeling of rotation?

o Does the surroundings spin around?

o Is there a tendency to fall to one side with the spinning?

Associated nausea and vomiting indicate a peripheral rather than central cause.

Third to half of cases of dizziness are vertigo.

Presyncope Caused by cardiovascular disorders reducing cerebral

perfusion. “ I feel faintish” Main causes: low BP

o “blame yourself” first ie. medications… o “Fainter..” o Mixed picture Parkinsons, neuropathies..

Bradycardia o “blame yourself” first betablockers, digoxin, verapamil,

diltiazem.. o Sinus pauses, complete heart block etc.

Dysequilibrium occurs when the brain receives inadequate

information about the body's position from the somatosensory, visual, and vestibular systems.

Common causes

o peripheral neuropathy

o eye disease

o peripheral vestibular disorders.

Lightheadedness is non-specific and hard to find true diagnoses

Causes:

It may result from panic attacks with hyperventilation

Dysfunctional breathing

Lung function tests…

What’s your differential?

1. benign paroxysmal positional vertigo 2. vestibular neuronitis (no auditory Sx) 3. Ménière's disease

BPPV Commonest cause of vertigo

Number one vestibular disorder accounting for a 20-30% of referrals to vertigo clinics.

BPPV – What is it? Otoconia (crystals) float

about in the fluid of the labyrinth

Then escape into posterior semi-circular canal

Crystals then rub against the cilia and bombards messages down the vestibular nerve

Aetiology Idiopathic – vast majority, elderly linked to

?degeneration of vestibular system

Other – head trauma, mastoid surgery, vestibular neuronitis

Life time prevalence of 2.4%

Any Age group

Most common after 40 years (50-70 commonest)

Woman 2:1 Men

Clinical Features Brief (< 1 minute) recurrent attacks of vertigo

Provoked by changes in head position – classically: rolling over in bed

bending over

looking upward

Nausea common vomiting rare

Occur in spells – several attacks in a week or over course of 1 day

Usually self limiting but may last week to months +…

Presence of hearing loss, tinnitus, or feeling of fullness of the ears indicates another diagnosis

“Vestibular Neuritis”

“Acute Vestibular Failure”

“Labyrinthitis” - officially different as has associated deafness

Acute inflammation of the vestibular nerve. the cause unknown - thought to be precipitated by

sinusitis, influenza, and upper respiratory tract viral illnesses in the young or vascular disease in the elderly

commonly seen in previously well young or middle aged adults (usually between 20 and 40 years old).

Clinical Features incapacitating sustained (non-positional) vertigo in a

previously healthy young or middle aged adult. vertigo may be abrupt (in 73%) or increase over a few hours

(27%)

commonly occurs on first awakening the patient may feel very unwell and they often lie still in bed

unidirectional, predominantly horizontal nystagmus and an unsteady gait

nausea and vomiting are common

absent tinnitus or deafness

no other neurological symptoms or signs

After 2-5 days of the acute attack, a steady resolution usually occurs over a period of 6 to 12 weeks.

Clinical Features Attacks of:

o vertigo.

o fluctuating, progressive, unilateral or bilateral hearing loss.

o tinnitus.

o a sensation of fullness or pressure in one or both ears

o loud noises unpleasant and distorted

Meniere’s Disease Idiopathic (10% have Family Hx)

Usually affects only one ear but in around 30% cases both ears may be affected

The incidence is between 1:1000 and 1:2000 of the population

Both sexes are affected equally

Generally common in the fourth to sixth decades of life and consequently the incidence of new onset disease is low

A GP may expect to come across a new case only a few times in their career

Clinical Features Attack 20 minutes to several hours. (always less than 24

hours)

often sleepy afterwards and unsteady next day

Ear sx first then onset of vertigo. Intensity of vertigo increases rapidly and patients may be forced to lie still.

some patients can predict an acute attack while in others a random pattern can be observed

an attack may be triggered by diet, menstrual cycle or psychosocial stresses

Attacks may be frequent, or occur only every few months or longer.

Sometimes they come in clusters of several attacks in quick succession.

On average, there may be 6-11 clusters a year.

Central Causes

Peripheral Causes

The central causes of dizziness include: cerebellar degeneration

multiple sclerosis

brain stem vascular disease

Arnold-Chiari malformation

vestibular epilepsy

congenital nystagmus

episodic ataxia

multisystem atrophy

vestibular aura of migraine

The peripheral causes of dizziness include: middle ear disease:

perilymph fistula

glomus tumour

peripheral vestibular dysfunction:

Ramsay Hunt syndrome

ischaemia

basal meningitis

concussion

Acoustic Neuroma

More History…..

3 Questions

Duration? Lasts for several seconds to a few minutes include:

benign paroxysmal positional vertigo

Lasts for several minutes to one hour include:

transient ischemic attack, perilymphatic fistula

Lasts for several hours include

Meniere's disease, perilymphatic fistula, migraine, acoustic neuroma

Lasts for days include

acute vestibular neuronitis (labrynthitis), CVA, migraine, multiple sclerosis

Precipitating Factors? spontaneous episodes are

acute vestibular neuronitis;

cerebrovascular disease,

meniere's disease,

migraine,

multiple sclerosis

changes in position of the head

acute vestibular neuromits

benign positional paroxysmal vertigo,

perilymp fistula

acoustic neuroma

multiple sclerosis

Hearing affected? Deafness o Meniere’s

o Labyrinthitis

o Acoustic Neuroma

o Perilymph fistula

Not Deaf o vestibular neuronitis

o benign positional vertigo

o acute vestibular dysfunction

o stroke

o multiple sclerosis

o Cerebella tumour

What’s the diagnosis?

Scenario 1 45 year old lady

Got up to go to toilet this morning, had to sit straight back down as whole head went round

Fine when lies flat

If moves head then room spins again

Spinning lasts for 30 seconds

Feels sick but not vomited

No hearing sx

Had a similar episode 5 years ago. Went away on its own

Scenario 2 28 year old man

Requesting home visit as keeps being sick, room spinning

Worse if moves head but even if lies still its bad

Cold for last few days

Not obviously deaf

“You don’t understand doctor….I feel awful”

Scenario 3 56 year old man

Recurrent episodes of room spinning lasts a few hours never more than a day

Not related to head movement

Does feel a bit deaf to r ear

Often feels ringing in ear

Marked pressure feeling to right ear

Stressed at work

Scenario 4

78 year old man

Previous MI and TIA

Sudden onset of dizziness, feels unsteady and struggling to walk since the night before

Vomited a few times

Not related to head movement

No hearing problem

Not getting better

Scenario 5 44 year old man

c/o on off dizziness for last few months

Dizziness can last seconds but can go on for minutes at a time or longer

Also feels dizziness becoming more frequent

Seen last month Epleys did not help

Now feels going more and more deaf to R ear

Well otherwise no vomiting with it – still working etc.

Scenario 6 72 year old lady

Last two weeks getting dizzy lasting 20-30 seconds if moves head feel sick on off most of day but no vomiting

Felt was getting better but now worse again

No ear symptoms

Diagnosis Made!

Give the patient a minute.. Ideas:

Inner Ear infection

Blood Pressure

Concerns: Brain tumour

Stroke

Deafness

Expectations: Look in ears

Check BP

MRI Scan

Anti-sickness Jab

Examine – confirm the diagnosis

Examination Patient’s ICE

?BP

?Look in ears

?Neurology

Eyes – obvious nystagmus at rest or moving?

Ears – Weber’s and Rinne’s

Hallpikes

Cure the patient

Treatment

1. Acute

2. Prevention

3. Long Term

Treatment – Acute Attack Supportive:

o the patient should lay down on a firm surface during the acute attack o drinking or sipping water should be avoided (this may cause vomiting) o the patient should be kept like this until the severe vertigo is passed o may get up very slowly, once the vertigo disappears.

Medical:

o oral medication used to suppress the symptoms of acute vestibular attacks (vestibular sedatives) include o cinnarizine, 15-30 mg t.d.s. or o prochlorperazine 5-10mg tds - regular long term basis is not

recommended, or o promethazine, cyclizine, or, metoclopramide, or, o benzodiazepine – can be used with caution for short periods

Prevention of acute attack Measures for prevention of acute attacks lifestyle interventions (dietary control) - the goal is to provide

stable body fluid/blood levels to avoid secondary fluctuations in the inner ear fluid food and fluid intake should be even throughout the day foods or fluids that have a high salt content should be avoided there should be adequate intake of fluids daily

may contain water, milk and low-sugar fruit juices

caffeine-containing fluids and foods (coffee, tea and chocolate) should be avoided.

alcohol intake should be limited to one glass of beer or wine each day

foods containing MSG (monosodium glutamate)also should be avoided

reducing or stopping smoking

Treatment – Long Term betahistine

a starting dose of 16 mg three times a day will result in a reduction of the frequency and severity of attacks

however there is limited evidence for a strong effect of betahistine in preventing attacks

diuretics although there is lack of evidence to support their use, diuretics may

sometimes be offered to patients

corticosteroids both oral steroids and intratympanic steroid injections have been used

in the treatment of acute and chronic symptoms

medical ablation used in patients with intractable vertigo intratympanic use of aminoglycosides (gentamicinin) to relieve vertigo

and preservation of hearing s

When To Refer? Refer if:

frequent severe attacks not responding to medical management e.g. use of prophylaxis in meniere's disease with betahistine 16mg tds

Red flag signs – unilateral deafness, atypical neuro signs etc.

Mean time consider trying vestibular compensation… Cawthorne Cooksey Exercises

Treatment

Vestibular Neuronitis Supportive:

o Reassurance

o Explanation

o Advice – Patient.co.uk PILS

Symptomatic treatment

o antivertiginous medications (e.g. prochlorperazine 5mg tds) should be given only in the first few days since they may delay recovery by affecting central compensation mechanisms.

When to refer? Dehydration – needed IV support.

associated auditory and/or neurological symptoms and signs

spontaneous nystagmus persists after 48 hrs

symptoms persist after a month

Mean time consider trying vestibular compensation… Cawthorne Cooksey Exercises

Treatment

1. Medical

2. Positional Manoeuvres

BPPV - Medical Treatment 1. Vestibular sedatives

(e.g. the calcium channel antagonist cinnarizine (adult dose 30mg tds) or the histamine analogue betahistine)

2. Anti-emetics

(e.g. prochlorperazine or promethazine or cyclizine)

BUT: no evidence in literature to suggest that these are effective in the treatment of BPPV or as a substitute for repositioning manoeuvres

BPPV – Re-Positioning the aim of this treatment is to redirect the otoconial

particles back to the utricle

GP treatment Epley manoeuver

home treatment

modified Epley manoeuver

Brandt-Daroff exercises

80% Cured

Post Epley Advice Debatable – Cochrane says do!

Standard Advice:

o Do not lie on the affected side for 1 week

o Avoid bending eg tying shoe laces etc for 1 week

o Do not lie flat for 48 hours

Medication:

o Betahistine

o Prochlorperazine

o Cinnarizine

PILS Leaflet