Vertigo

Vertigo

Acute

Ongoing symptoms that can worsen with triggering movements but do not go away entirely – CVA, labyrinthitis (hearing loss), vestibular neuritis (no hearing loss), FB ear, acoustic neuroma, migraine, MS, dysrhythmia

Triggered

Resolves entirely between triggering – BPPV, FB ear, MS

Episodic

Intermittent episodes that resolve entirely between episodes – Menieire’s, TIA, panic attacks, cardiac dysrhythmia, migraine, MS, neuroma

Other DDx: Wernicke’s, tertiary syphillis

 

BPPV

  • Most common cause
  • 25% have no nystagmus
  • Usually last less than 1 minute
  • Consider half-somersault maneuver vs Epley

HINTS Exam

  • Only for patients with ongoing dizziness and nystagmus
  • In literature outperforms MRI
  • Head impulse
    • Rapid 20-30 deg rotation from side to side
    • Head impulse peripheral – eyes lag than saccade to center
    • Head impulse central – eyes stay fixed on nose
  • Nystagmus
    • Horizontal only is ok
    • Concern for CNS lesion if vertical rotational, vertical, bidirectional, non-fatiguing, not relived by gaze fixation
  • Test of Skew
    • Cover one eye then the other and look for change in vertical gaze

Sudden Sensorineural hearing loss

  • Sudden onset of hearing loss
  • May have associated dizziness
  • Needs urgent ENT f/u (e.g. w/in 24 hrs)
  • Oral prednisone, intratympanic steroid injection, ?HBO
  • Often needs MRI (r/o neuroma) and audiogram as part of w/u