An approach to vertigo with flowchart algorithm

Brief approach to vertigo with algorithm

1. An approach to Vertigo ASHOK ARYAL MS (ENT)

2. Introduction Gowers “ Any movement or sense of movement, either in an individual himself or in external rotation, that involves a defect, real or seeming, in the equilibrium of the body ” Synopsis of Otolaryngology 5 th ed. Need to differentiate with Presyncope and disequilibrium

3. Classification Central Peripheral

4. Peripheral (Common- 80-90%* ) Labyrinth BPPV * * MD * Peri-lymphatic fistula * Cogan’s Syndrome *- autoimmune diz Labyrinthitis- COM, post-surgical, inner ear neoplasm Vestibular/Vestibulocochlear Nerve Vestibular neuritis (Labyrinthitis) Acoustic Neuroma Ramsay Hunt Syndrome Vestibular paroxysmia * Vestibulotoxic drugs- aminoglycoside (Streptomycin, gentamycin, kanamycin), diuretics, alchohol , tobacco, antimalarials, anticancer, analgesics (indomethacin, ibuprofen) * Most common cause of vertigo * Causes of episodic vertigo * American Medical Association

5. Central ( Uncommon 10-20%*) Vascular Stroke / TIA Non-vascular Vestibular Migraines * Multiple sclerosis (MS) * Most common cause of vertigo * Causes of episodic vertigo * American Medical Association

6. Peripheral Unidirectional (Never reverse the direction) Fast component towards the normal ear Horizontal with torsional Never pure torsional or vertical Central Bidirectional Reverse the direction when patient looks in the direction of slow component Purely vertical or torsional No horizontal Suppressed Not suppressed Unidirectional instability, walking preserved Severe instability, patient often falls when walking Absent May be present Often present Diplopia, ataxia, dysarthria, dysphagia Usually absent Nystagmus Effects of visual fixation Postural instability Deafness/ Tinnitus Neurological symptoms Characteristics

7. Diagnosis Confirm whether it is vertigo/presyncope/ dysequlibirium Time Duration: episodic vs continuous Triggering factors: Head position, Trauma, Cough, weight lift, bowel movement Associated symptoms Hearing loss, tinnitus MD Headache, photophobia Migraine Eye pain, redness Cogan’s syndrome Neurological symptoms (Diplopia, dysarthria, dysphagia, weakness, numbness ) MS, Stroke Imbalance Vertigo Bil vestibular dysfunction MD Tilt illusion, drop attacks PMH- atherosclerotic risk factors, Migraines, Head trauma (BPPV), Medications (Cisplatin, Aminoglycosides, Phenytoin) History

8. Examinations Ear Examination---------------- Otoscopy Neurological examinations-------- Balance and gait HINTS Exam Dix-Hallpike maneuver Blood tests does not provides any clue to diagnose vertigo Audiometry, Electrocochleogram if MD is suspected Brain Imaging (MRI/MRA) Videonystagmography (VNG)

9. Treatment

10. Symptoms Description Duration Symptoms (Frequently associated) Mechanism Vertigo Illusion of motion while stationary Sec to weeks Nausea Disruption of vestibular pathway Presyncope Faintness, slowed consciousness leading to syncope Sec to min Warmth, visual changes Transient reduction of brain perfusion Dysequilibirium Difficulty in maintaining balance Sec to weeks Frequent falls without loss of consciousness Multiple sensory deficits

11. Recurrent episodes Triggered by head movement Duration: Sec-min Recurrent episodes Duration: Min-Hours Single, continuous episodes Duration: days or less Associated with viral symptoms Continuous vertigo and abnormal HINTS exam Abnormal Normal Episodic HL, tinnitus Low frequency HL in audiometry Normal audiogram No audiological symptoms Resolved Persistent Old age, risk factors for stroke with neurological sign and symptoms Diagnosis made Unremarkable Algorithm

12. References Uptodate Synopsis of Otolaryngology, 5 th Edition, 1990 Vertigo and Dizziness common complaints, 3 rd edition , 2013

13. Thank You All