The following document was written by Mr Vik Veer MBBS(lond) MRCS(eng) DoHNS(eng) in Dec 2007. You may use the information here for personal use but if you intend to publish or present it, you must clearly credit the author and www.clinicaljunior.com
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Vertigo - History, Examination, and Treatment

Introduction

Patients who present with dizziness can be challenging to manage as there are often many reasons why they may have dizziness and they can be difficult to treat.

This is a brief guide to some of the points to remember when faced with a dizzy patient as an ENT doctor.

History

The first thing to remember is that particularly in the elderly there is often a multi-factorial cause for their dizziness, and so each component should be chased and corrected. This is often better done with the help of an elderly care physician or in a ‘Falls Clinic’. It is sometimes useful to remember that the vestibular organs account for 15% of our balance system (between the two), 15% is maintained by joint position sense in the legs, trunk etc. and the rest by visual indicators. Hence the relief one feels from sea sickness when looking to the horizon.

The first thing to do is find out what they mean when they say they are dizzy? Does the world spin round and round? Or do they feel light-headed and nothing else? Vertigo typically involves the room spinning round and round as if the patient was on a fast merry-go-round. Light-headed, or feeling like they are about to faint is more typical of hypotension or other non-ENT causes.

Then you should ask – how long does the dizziness last for? The length of time is quite important in differentiating between the different types of vertigo.

Only lasting a few seconds = Benign Positional Paroxysmal Vertigo
Lasting longer up to hours = Meniere’s syndrome
Lasting days = labyrinthitis
Longterm – slowly progressing = central pathology? – acoustic neuroma?

What symptoms are associated with this vertigo?

Migraine can present with vertigo – and these patents have headaches, photophobia etc.

Hearing loss with or without tinnitus can present with Meniere’s syndrome – although beware of Lermoyez variant of Meniere’s that is when the hearing and tinnitus IMPROVES with the onset of vertigo.

Was there any history of a flu or any viral illness before the onset of vertigo – which would point towards a labyrinthitis, especially if associated with nausea and vomiting.

Is the vertigo associated with movement of the head? BPPV sufferers tend to report that they get their vertigo worst when rolling over in bed. There is occasionally a history of minor trauma in these cases as well.

Rarely you might find patients who have vertigo when walking outside in the cold (Hennebert sign), or vertigo induced by loud noises (Tullio phenomenon). These are very important symptoms and could represent a perilymphatic fistula – requiring ENT specialist otology care.

One should complete the history paying particular attention to any medications that they may be on (atenolol etc.) surgery (middle / inner ear surgery), trauma (temporal bone fractures), history of cardiovascular disease (poor LV function, strokes) etc.

Examination

Careful attention should be made to various medical causes of dizziness – consider visual acuity, joint position sense, cardiovascular disease (all of which are prevalent in the diabetic patient). You should perform a lying / standing BP and see a greater than 20/10mmHg drop during the first 3 minutes of standing for it to be considered significant enough to warrant the diagnosis of postural hypotension.

Examine the Ears (see ear examination topic) as previous surgery, haemotympanum, and cholesteatoma can all be seen easily and may require CT scan to diagnose a middle / inner pathology.

Romberg’s Test

Standing with feet together and arms out to the sides with eyes closed. If they begin to fall – catch them and note which side they fell. The side they fell tends to be the side that is bad. If one larbyrinthine system is not functioning correctly the opposite side tends to ‘push’ patients over as it has nothing to counter it on the affected side. If they don’t fall over move on to the Unterberger’s Test.

Unterberger’s Test

Feet together, hands out in front with eyes closed – you’ve already done the Romberg’s test and you know that the patient will manage this part of the test. Now ask the patient to march on the spot with knees raised high. Normal people are able to maintain their position but those with a pathology will either walk forward greater than 1 metre or rotate more than 30 degrees towards the affected side. When you ask the patient to open their eyes they seem shocked that they have ended up in a different position to what they started with.

Hallpike Test

Sit the patient on a bed with their hands crossed over their chest. Explain to then that they should always look at your nose and at nothing else – even if they feel dizzy at any time. They must keep their eyes open all times. Explain also what you are about to do as well. You have to swiftly lie the patient down on their back with their head over the end of the bed and then twist the head to either the right or the left. Ensure that this is explained to the patient before you do this, and direct the patient through this manoeuvre by holding their head with your hands. You should aim for at least 45 degrees rotation and 20 degrees of extension.
When in the final position look at the eyes for any nystagmus – particularly rotational nystagmus which is seen in BPPV. Once you have completed one side – sit the patient up – wait for them to settle again and repeat on the other side.

You should be careful with patients with bad necks as this could cause injury if done aggressively.

You should complete your examination by performing a full cranial nerve and neurological assessment. Remember to check for cerebellar signs, in-coordination, past pointing, etc.

Investigations

Hearing test – pure tone audiogram is invaluable in these cases, and can point one to a diagnosis of age-related hearing loss, Meniere’s syndrome, acoustic neuroma etc. A full description of this is beyond the scope of this article.

If you think there is a mass (cholesteatoma, acoustic neuroma etc.) then an CT or MRI of the temporal bones may be required.

Treatment

BPPV

This is treated with the Epley’s Manoeuvre. The idea is that otolithic crystals have fallen into the semicircular canals and that by careful and slowly methodical positioning of the head one can convince these crystals back into place. Some doubt has been placed on this theory, however the manoeuvre still works whatever the pathophysiology.

There are a number of ways this can be done – a good example is shown in the ‘You Tube’ video here.

Tapping the affected mastoid bone is sometimes done – and was in the initial description of the manoeuvre.

Viral Labyrinthitis

This is commonly seen and is only really managed in the acute stages with prochloperazine which is a vestibular sedative. After this patients tend to still experience vertigo due to loss of one vestibular system. Providing the patient with Cooksey Cawthorne exercises will help them rehabilitate themselves to normal functioning.

Meniere’s Syndrome

Endolymphatic hydrops is managed by anything that will reduce the fluid pressure in the inner ear.
A management plan could include:

Low salt diet – to reduce sodium retention in the inner ear.
Betahistine 16mg TDS PO is used to reduce the number of attacks of Meniere’s
Prochloperazine 12.5mg TDS for acute attacks
In the end stages if hearing has completely gone some surgeons use middle ear gentamicin to chemically ablate the inner ear to rectify ongoing vertigo symptoms.
There is growing evidence for the use of steroids given transtympanically in the treatment of this condition
Nearly everyone improves with time (however this can take 10 years or so)

Acoustic Neuroma

This is treated in 3 ways

Conservative – watch and wait as many neuromas do not increase in size and many have minimal symptoms.
Radiotherapy – using a single gamma knife session can be effective in particularly small (<2cm) neuromas
Surgery – normally reserved for large tumours and only in specialist hands.