Acute vertigo

this explains how to approach to a patient present with acute vertigo to emergency department. It mainly focus on management of benign positional paroxysmal vertigo, menieres disease, vestibular neuritis, acute labyrinthitis and brainstem stroke.

1. Acute vertigo Dr ktd priyadarshani Registrar in emergency medicine National hospital- kandy

2. outline Introduction & pathophysiology classification Assessment Management options

3. introduction Vertigo- an illusion of either oneself or the environment rotating when there is none Incidence 5-10% 40% in patients older than 40 yrs - falls due to dizziness 17.8% 25% in patients older than 65 yrs – falls due to dizziness 31%

4. pathophysiology

5. Vestibule ocular reflex

6. classification

7. etiology Peripheral Central Benign paroxysmal positional vertigo Brainstem infarction- stroke, TIA Meniere’s disease Cerebellar hemorrhage Vestibular neuritis Acoustic neuroma Acute labyrinthitis Cerebellopontine tumors Otitis media Cholesteatoma Vestibular migraine

8. Assessment

9. history Vague term Presyncope, imbalance, lightheadedness Positional vs postural- Orthostatic hypotension, New medications Pattern Single episode Multiple episodes Chronic dizziness

10. Peripheral Central Onset Sudden Gradual- SOL Sudden- stroke Duration Usually <48 hr Persist >48 hr (except TIA) Nausea & vomiting Severe Often mild Auditory symptoms Aural fullness, tinnitus, hearing loss Usually absent except in acoustic neuromas Triggers Often exacerbate by head movement Little effect from head movement Neurological symptoms None Usually present (dysarthria, diplopia, dysphagia, dysdiadochokinesia, dysmetria, hemiparesis) Past hx / risk factors Previous hx of paroxysmal vertigo Recent ear infection AF, HT, HD, Prev stroke

11. EXAMINATION Dix hallpike test- For BPPV HINTS Indication- Persistent ongoing vertigo + Spontaneous or gaze evoked nystagmus Use- vestibular neuritis vs cerebellar/ brainstem stroke HINTS- MORE SENSITIVE AND SPECIFIC THAN EARLY MRI TO DETECT STROKES SENSITIVITY – 100% SPECIFICITY- 94%

12. Head impulse test Check integrity of vestibule ocular reflex 20 degree movement- in random fashion Abnormal in the affected side- nystagmus in the direction of unaffected ear + catch up saccade

13. Nystagmus Direction of nystagmus- fast phase Note spontaneous or gaze evoked nystagmus In vestibular neuritis- affected ear is opposite the direction of nystagmus

14. nystagmus Peripheral vestibular nystagmus Central nystagmus Effect of fixation Decreases with fixation Persists with fixation Direction Torsional Jerk nystagmus- beats away from affected side Any (vertical, horizontal, rotational) Pendular, pure torsional , direction changing nystagmus Effect of gaze Nystagmus remains the same direction regardless of direction of gaze Velocity is greatest looking at quick side (alexander’s law) Nystagmus may change direction with direction of gaze Does not conform to alexander’s law Fatigability Fatigues Does not fatigue

15. Test of skew Eye cover test Any vertical or diagonally upward or downward movement

16. Hints- work up Acute peripheral vertigo Acute central vertigo Head impulse test + ve Head impulse teat - ve Peripheral nystagmus Central nystagmus Skew deviation - ve Skew deviation + ve HINTS PLUS BED SIDE TEST FOR NEW HEARING LOSS NEW HEARING LOSS- SUGGEST CENTRAL CAUSE AICA- ABNORMAL HEAD IMPULSE DUE TO INFARCTION OF LABYRINTH+ CEREBELLUM

17. investigations Look for central cause CT/ MRI Brain Exclude other causes of dizziness/ look for risk factors ECG ECHO Audiological testing

18. Management options

19. Benign paroxysmal positional vertigo Most common cause Spontaneous Positional Nystagmus- relative hyperstimulation Common- posterior canal

20. Etiology Idiopathic- 39% Ear diseases- 29% Trauma- 21% Vertebral basilar insufficiency- 9% Otitis media- 9%

21. Dix- hallpike test For diagnosis of posterior canal bppv Vertigo precipitated by position No spontaneous or gaze- evoked nystagmus Pretreatment with anti emetic sos Instructions Keep eyes open Neck movement assessment

22. Do for both sides Look for nystagmus- Up beating torsional towards affected side ( geotrophic ) Latency of 15-30 sec Crescendo – Decrescendo pattern vertigo adaptation- Fade off due to adaptation Reversal fatigability

23. management No investigations required Electronystagmography Infrared nystagmography Management options Watchful waiting Vestibular supressants Vestibular rehabilitation Canalith repositioning Surgery

24. VESTIBULAR REHABILITATION EXERCISES Cawthorne Cooksey exercises Gaze stabilization exercises Brandt daroff exercises

25. Canalith repositioning procedures ( crp ) Epley maneuver Hold in position for the length of time patient is having vertigo + 30 sec Repeat DHT after 10 min No symptom- discharge without restriction Still positive- repeat epley → perform at home bd until symptom settles & follow up until improves do not prescribe vestibular sedatives Semont liberatory manoeuvre Multi axial positioning devices

26. Surgical management Labyrinthectomy Posterior canal occlusion Singular neurectomy Vestibular nerve section Trans tympanic aminoglycoside application

27. Horizontal canal bppv Rare Dht - negative on both sides or purely horizontal nystagmus Supine roll test Gufoni maneuver Resolve spontaneously more quickly

28. Anterior canal bppv Least common Dht - Downward vertical nystagmus Deep head hanging maneuver

29. pharmacotherapy Category Drug Dose Advantages Disadvantages Anticholinergics Scopolamine 0.5mg patch, behind ear tds Nause with vertigo Non availability Antihistamines – H1 Diphenhydramine 25-50mg IM, IV, PO 4hrly Nauses with vertigo Drowsiness Antiemetics Brainstem dopamine receptor block Metoclopramide 10-20mg, IV, PO tds Nausea with vertigo Extrapyramidal effects Ondansetrone 4mg IV bd / tds Intractable vertigo Promethasine 25mg IM, PO,PR tds Nausea with vertigo Extrapyramidal effects

30. Vestibular neuritis Viral Prolonged, continuous bout of vertigo intense for several days Resolves over days, weeks or months no investigation required Vestibular neuritis Acute labyrinthitis No sensory hearing loss Sensorineural hearing loss No tinnitus Tinnitus + PTA

31. Category Drug Dose Advantage Disadvantage Corticosteroids Methylprednisolone 100mg/d tapered by 20mg every 4 th day Vestibular neuritis Adverse effects of steroids Antivirals Valacyclovir 1000mg tds – 7d Vestibular neuritis Efficacy unknown

32. labyrinthitis Complication of acute otitis media Less common Continuous vertigo and nystagmus for days Investigation Viral- none Bacterial- mri

33. Meniere’s disease (idiopathic endolymphatic hydrops) History Sudden onset, Duration 20 min- 12 hrs Usually unilateral, but can be bilateral over time Associated nausea, vomiting, diaphoresis, tinnitus, hearing loss, ear fullness Frequency several/ week- months Well between attacks No investigation required

34. Management – symptomatic Salt restricted diet Labyrinthine sedatives- Antihistamine Vasodilators- Betahistidine , Triamterene & hct , CCB Systemic & Intratympanic injections of corticosteroids or gentamicin- control frequency of attacks Meniett device Category Drug Dose Advantages Vasodilators Strong H3 and weak H1 antagonist Betahistidine 48mg PO tds for 6-12 months Meniere’s syndrome Increase cochlera blood flow & decrease peripheral vestibular inputs

35. Surgical management Endolymphatic sac decompression Shunt operation Selective vestibular nerve destruction Total labyrinthectomy

36. Vestibular migraine Second most common central cause of vertigo Migraine headache, Aura No investigation required Anti migraine RX Refer to neurologist Diagnostic criteria Moderate to severe vertigo- 5min- 72hrs Past or recurrent hx of migraine 5 or more episodes of vertigo+ at least 50% has- visual aura, photophobia or phonophobia, typical migraine headaches Unilateral Pulsating mod to severe intensity aggravated by routine activity No other possible pathology

37. Anticonvulsants Topiramate 50-100mg/d Vestibular migraine prophylaxis Valproic acid 300-900 mg/day Vestibular migraine prophylaxis Beta blockers Metoprolol 100mg/day Vestibular migraine prophylaxis Calcium antagonists Not responding to anticholinergics or antihistamine Cinnarizine 25mg po bd / tds Peripheral vertigo, vestibular migraine Flunarizine 20mg bd Meniere’s syndrome Nimodipine 30mg PO bd Peripheral vertigo, vestibular migraine

38. Cerebellar/ brainstem stroke Diplopia, dysarthria, dysphagia, dysphonia & dysmetria Weakness or paresthesia If the patient is unable to stand unaided- exclude central cause Investigations CT Angiography- if intervention planned MRI- if acute intervention not planned

39. Management Need admission Stabilization and supportive care Secondary stroke prevention rehabilitation

40. Summary- peripheral causes Peripheral cause Key points Clinical course BPPV Most common < 2 min episodes Trigger by head movement DHP- Vertical upward and rotatory nystagmus Benign Particle repositioning maneuvers Vestibular neuritis Common Continuous hours/days- constant vertigo Nystagmus + use HINTS Spontaneous recovery over days/ weeks Labyrinthitis Less common Ear pain, tinnitus and hearing loss onset days before vertigo A complication of OM Serious if bacterial- rare Meniere’s disease Less common Recurrent episodes of vertigo, hearing loss, tinnitus and ear fullness Slowly progressive, can lead to profound hearing loss

41. Summary- central causes Cause Key points Clinical course Vestibular migraine most common Recurrent attacks with migraine + isolated vertigo (>50%- with migraine) As per migraine Cerebellar/ brainstem stroke Less common Other neurologic signs & symptoms Headache Nystagmus+ HINTS Hearing loss +/- Admit Risk of edema & hydrocephalus

42. references Dhingra ENT textbook Tintinali’s Emergency medicine- comprehensive study guide – 9 th edition Medscape Em rap- podcasts

43. Questions?

44. Thank you!