QuestionSBA
QuestionChoice
A CT head would be indicated if a central cause of vertigo (e.g. stroke) was suspected. Signs of central vertigo on a HINTS exam are a negative head impulse test, bidirectional nystagmus and an abnormal test of skew. The fact he is young and has no cardiac risk factors makes the diagnosis of stroke less likely
32464
b
Urgent CT head
QuestionChoice
There is no indication for treatment with antibiotics. Vestibular neuronitis is often a sequelae of a viral upper respiratory tract infection
32467
e
Start amoxicillin
QuestionChoice
The likely diagnosis is vestibular neuronitis. This is a peripheral cause of vertigo, and the findings described on the HINTS (head impulse, nystagmus and test of skew) examination are suggestive of this. Vestibular neuronitis is characterised by inflammation of the vestibular nerve, often after a viral infection. Common symptoms include acute, spontaneous vertigo, nausea, vomiting and unsteadiness. Prochlorperazine is often used for symptomatic treatment
32463
a
Oral prochlorperazine
QuestionChoice
Aspirin would be indicated if an ischaemic stroke was suspected as the cause of vertigo following exclusion of haemorrhage on a CT head
32465
c
Start aspirin 300mg
QuestionChoice
Vestibular neuronitis usually self-resolves spontaneously; however, the symptoms can be debilitating. Treatment is therefore recommended if symptoms are troublesome
32466
d
Reassure with safety-net advice
Concept
Chapter
# Summary

Vertigo is a sensory misperception or illusion of motion, often characterised as rotatory dizziness. The sensation can arise from various conditions such as Benign Positional Paroxysmal Vertigo (BPPV), Acute Labyrinthitis, Ménière's Disease, Acoustic Neuroma, Ramsay Hunt Syndrome, and Ototoxicity. Key investigations include the Hallpike manoeuvre for BPPV and hearing evaluation for conditions such as Acute Labyrinthitis and Acoustic Neuroma. Management strategies differ across conditions, and can include repositioning manoeuvres, use of sedatives, and antiviral therapy.

# Definition

Vertigo is a sensory phenomenon where an individual perceives a false sensation of movement or spinning. This perceived motion frequently gives the impression of a tilting or spinning environment.

# Epidemiology

Vertigo is a common presenting symptom in medical practice. The prevalence of vertigo increases with age and is more common in women than in men. The most common cause of vertigo is BPPV, followed by Ménière's disease and vestibular migraine. 

# Signs & Symptoms

The following table from NICE can help differentiate between central and peripheral causes:

| **Clinical features**                | **Peripheral**                                                                                                                                                                                                 | **Central**                                                                                                                                                                                                                                                                                  |
|--------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| **Postural stability**               | Can walk, although may be unstable and may not wish to mobilise.                                                                                                                                               | Inability to stand up or walk even with the eyes open.                                                                                                                                                                                                                                        |
| **Hearing loss or tinnitus**         | Possible with some causes (for example Meniere's disease, labyrinthitis).                                                                                                                                      | Uncommon but may occur (for example stroke or intracranial tumour).                                                                                                                                                                                                                           |
| **Other neurological symptoms**      | No.                                                                                                                                                                                                           | Usually (for example cranial nerve dysfunction, visual disturbance, speech defects, dysarthria, weakness, sensory changes, memory loss, and gait ataxia). However, not all people with vertigo due to a stroke will have focal neurological signs.                                            |
| **Nystagmus**                        | Horizontal nystagmus with a torsional component that does not alter in direction when the gaze changes. Beats away from the affected side. Disappears with fixation of the gaze. Large amplitude nystagmus is usually only seen early in the course of Meniere's disease or vestibular neuronitis. | Direction-changing nystagmus on lateral gaze (right beating on right gaze, left beating on left gaze). Purely vertical or torsional. Not suppressed by visual fixation. Non-fatiguable. Commonly large amplitude nystagmus.                                                                |
| **Head impulse test**                | May be positive with acute unilateral vestibular loss.                                                                                                                                                         | Negative, indicating a normal vestibulo-ocular reflex.                                                                                                                                                                                                                                        |
| **Dix-Hallpike manoeuvre**           | In BPPV: latency of symptoms and nystagmus with fatiguability and habituation; severe vertigo.                                                                                                                 | Abnormal response (for example vertical nystagmus without latency or fatiguability; direction not classical horizontal towards the downward ear).                                                                                                                                            |
| **Alternate cover test**             | Normal.                                                                                                                                                                                                       | Slight vertical correction (up on one side, down on the other) suggestive of a central lesion such as stroke.                                                                                                                                                                                 |



# Differential Diagnosis

The differential diagnosis for vertigo includes:

- BPPV: Characterised by vertigo with positional change and fatiguable nystagmus.
- Acute Labyrinthitis: Presents with severe, acute vertigo, associated with nausea and vomiting. Hearing loss and tinnitus may be present.
- Stroke: Sudden onset vertigo, tends to present with other focal neurology, usually with cardiovascular risk factors
- Ménière's Disease: Features recurrent episodes of vertigo, sensorineural hearing loss, tinnitus, and a feeling of fullness in the ear.
- Acoustic Neuroma: Usually presents with unilateral hearing loss and cranial nerve dysfunction.
- Ramsay Hunt Syndrome: Characterized by facial nerve palsy, which may be accompanied by vertigo, tinnitus, and hearing loss.
- Ototoxicity: Presents with hearing loss or vertigo following exposure to ototoxic drugs.

Other causes include systemic causes such as:

- Orthostatic Hypotension
- Cardiac Arrhythmias
- Medications (e.g., aminoglycoside antibiotics and loop diuretics).



# Investigations


- Dix-Hallpike Manouvre
	- This test is crucial for diagnosing BPPV. 
	- The patient is seated with their head turned 45 degrees to one side, and then quickly laid back so the head hangs slightly off the edge of the bed. 
	- The test is positive if vertigo and nystagmus are elicited, indicating a peripheral cause like BPPV.
	-  Nystagmus typically lasts a few seconds and fatigues with repeated testing.

Other investigations may include:

- Audiometry: For suspected cases of Ménière's Disease or Acoustic Neuroma.
- Imaging (MRI/CT): To rule out central causes such as cerebrovascular disease or tumours.
- Vestibular function tests: To further characterise and monitor vestibular dysfunction 

# Management


Stemetil (Prochlorperazine) is commonly used for symptomatic relief of vertigo, particularly in the acute setting.

In terms of specific conditions: 

- BPPV: Treated effectively with repositioning manoeuvres such as the Epley or Brandt-Doroff exercises, which aim to move the displaced otoliths back into the utricle.
- Acute Labyrinthitis/Vestibular Neuritis: Managed with vestibular suppressants (e.g., antihistamines like cinnarizine or meclizine) and possibly corticosteroids.
- Ménière's Disease: Managed with a combination of diuretics, low-sodium diet, and vestibular suppressants. Intratympanic steroid injections or surgery may be required in refractory cases.
- Ramsay Hunt Syndrome: Treated with antiviral agents (e.g., acyclovir) and corticosteroids.

For patients with chronic vestibular disorders, vestibular rehabilitation can be considered. This nvolves exercises that aim to improve balance and reduce dizziness.
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Vertigo and Dizziness
Topic
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Ear, Nose & Throat
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Oral prochlorperazine is used to manage the vertigo and nausea in vestibular neuronitis by blocking dopamine receptors, typically for short-term symptom relief.
A 35-year-old man with presents to the Emergency Department with persistent dizziness since waking up four hours ago. He reports the room spinning around him and associated nausea but no vomiting.

Full systems review is otherwise unremarkable; however, the patient does reveal having some mild coryzal symptoms a few days ago. On examination, there is a positive head impulse test, unidirectional nystagmus and no abnormal test of skew.

Given the likely diagnosis, which of the following is the most appropriate management?
a