Vertigo

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Vertigo
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Case

• A 58 year old presenting to us, stating that she
  awoke that day feeling that the room was
  spinning . She Had vomited twice. She seemed
  anxious was unsteady in her feet and was
  hyperventilating. She didnt have fever, but had
  a sore throat, slight difficulty swallowing,
  slight hoarseness and a red throat. Hallpikes
  test induced vertigo and nystagmus.

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Terms

• Vertigo is defined as the illusory sense of
  movement or disorientation, indicates disorder
  of the labyrinth or brainstem
• Presyncope is defined as a sense of near faint
  typically due to transient hypotension
• Disequilibrium in the elderly is often described
  as nonspecific slight unsteadiness, particularly
  in turning and indicates poor balance and
  strength
• Lightheadedness is often associated with
  dysfunctional breathing or anxiety

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Is it common?

• Vertigo is a common condition in the community
• A fulltime GP can see 10-20 cases/year
• The diagnostic challenge is to differentiate
  peripheral from very uncommon but very serious
  central causes such as brainstem stroke

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Main clinical features to be elicited in the
presence of acute vertigo are

• No history of hearing loss or tinnitus?
• No headache?
• Onset and duration of vertigo?
• Whether it is positional or sustained?

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Examination

• Nystagmus during Hallpikes manoeuvre,
• eye movement normal (except horizontal
  nystagmus)
• No Horners, TMs normal, No new onset deafness, No
  facial weakness , dysphagia, dysphonia, must be
  able to walk even with unsteadiness, no limb
  paresis, objective ataxia or sensory loss
  

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Red flags to look for on examination

• Any central neurological symptoms or signs
• Anew type headache
• Acute deafness
• Vertical nystagmus

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• A 40 year old lady presenting with, sudden onset
  of vertigo on turning the head, with nausea.
  Halpikes shows rotatory nystagmus. No headache,
  no vomiting, no deafness, Rhombergs negative,
  gait normal
• A 45 year old lady presenting with sustained
  vertigo, with unidirectional horizontal
  nystagmus, no hearing loss or tinnitus or
  neurological signs, has nausea and vomiting
• What is the main differential diagnosis?

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• Cerebellar stroke, of a case study of 240
  patients with cerebellar stroke, 25 had vertigo
  as sole feature. A simple test called the head
  thrust test tests the vestibuloocular reflex and
  is always abnormal in vestibular neuronitis. It
  was normal in 24/25 of the cerebellar strokes.
• A 25 year old man presenting with vertigo,
  hearing loss and tinnitus with symptoms of urti,
  no neurological symptoms, head thrust is
  positive, what is the likely diagnosis, what will
  you do?

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• A 80 year old man presenting with vertigo
  unilateral hearing loss, tinnitus, headache,
  facial pain and tingling, what needs to be ruled
  out
• A 50 year old presenting with vertigo, tinnitus
  and fluctuating hearing loss with a sensation of
  aural pressure