Vertigo

Vertigo

Vertigo is the illusion of motion

The first step in the management of vetigo is to distinguish peripheral and central vertigo.

Causes of Vertigo:

Peripheral – 93 percent are due to acute vestibular neuronitis, Benign paroxysmal positional vertigo and Meniere’s disease.

Other includes: acute labyrinthitis and drugs

Central – CVA, intracranial neoplasms and migraine.

How to differentiate:

Feature	Peripheal	Central
Nystagmus	Combined horizontal and torsional; inhibited by fixation of eyes onto object; fades after a few days; does not change direction with gaze to either side	Purely vertical, horizontal, or torsional; not inhibited by fixation of eyes onto object; may last weeks to months; may change direction with gaze towards fast phase of nystagmus
Imbalance	Mild to Moderate; able to walk	Severe; unable to stand still or walk
Nausea, vomiting	May be severe	Varies
Hearing loss, tinnitus	Common	Rare
Nonauditory neurologic symptoms	Rare	Common
Latency following provocative diagnostic maneuver	Longer (up to 20 seconds)	Shorter ( up to 5 seconds )
Head Thrust Test	Positive	Negative

Peripheral Vertigo:

History and Physical examination help to distinguish the different causes of peripheral vertigo.

Upper respiratory tract infection suggests acute vestibular neuronitis

Immunosuppression suggest herpes zoster oticus

Head trauma suggest possibility of perilymphatic fistula

Provoking factors with changes in head position suggest acute labyrinthitis, benign paroxysmal positional vertigo, cerebellopontine angle tumour, perilymphatic fistula and multiple sclerosis.

A positive Hallpike test has the following characteristics and suggests a diagnosis of BPPV:

• brief latency – in BPPV, there is usually a brief latency of several seconds before the onset of nystagmus and it usually lasts 10–20 seconds

• nystagmus – usually torsional (rotational around the anteroposterior axis of the eye globe) but may be horizontal. In BPPV, on performing the Hallpike manoeuvre, there is usually upbeating, torsional nystagmus arising from otolithic debris in the ipsilateral posterior semicircular canal. Horizontal nystagmus on positioning suggests that the lateral canal is affected. Downbeating, torsional nystagmus which occurs on positioning indicates that the ipsilateral anterior semicircular canal is affected

• reversal – upon sitting after a positive manoeuvre, the direction of nystagmus is reversed for a brief period of time

• fatigability – repetition of the test will result in less nystagmus each time.

Treatment of Peripheral Vertigo:

General Principles:

Medications are most useful for treating acute vertigo that lasts a few hours to several days. They have limited benefit in patients with benign paroxysmal positional vertigo, because the vertiginous episodes usually last less than one minute.

Gamma-aminobutyric acid (GABA) is an inhibitory neurotransmitter in the vestibular system. Benzodiazepine enhance the action of GABA in the central nervous system (CNS) and are effective in relieving vertigo and anxiety.

Vestibular rehabilitation exercises commonly are included in the treatment of vertigo.

Thumb-tracking: Hold your thumb out 1 to 2 feet in front of your face. As you look at your thumb, turn your head from right to left, then left to right, then up and down. Increase speed gradually. Do the exercise for 90 seconds. Repeat the exercise four times a day.

Target-change: Pick two objects (targets) that you have to turn your head from left to right to look at. Look at one object, blink your eyes, and then turn your head quickly to look at the other object. Go back and forth quickly between the objects. Repeat several times per session, at least two sessions per day.

Lying-to-standing: Move from a lying-down position on a sofa or bed to a standing position as quickly as possible without falling. Get up toward both right and left sides quickly. Do the exercise five times on each side per session, at least two sessions per day.

Tightrope: Walk heel to toe as if you are walking on a tightrope or a line. Do the exercise in a hallway with available support, such as a wall or railing. For 30 minutes per day, practice walking 10 steps at a time without using a support.

Walking turns: Walk toward an eye-level target on a wall (such as a picture). As you get near the wall, turn your body to one side but keep your eyes and head locked on the target. When your body cannot move any farther, close your eyes and quickly turn your head to face forward. Repeat the exercise five times for each side, turning your eyes and head to the right and left sides. Slowly increase your speed for at least 30 minutes per day.

Ball toss: While standing or sitting, toss a tennis ball at least 3 feet above your head and catch it. Practice for five to 10 minutes per day. When you can do the exercise easily, try it while walking.

Specific Treatments:

BENIGN PAROXYSMAL POSITIONAL VERTIGO

Benign paroxysmal positional vertigo is caused by calcium debris in the semicircular canals (canalithiasis), usually the posterior canal. Medications generally are not recommended for the treatment of this condition.

The vertigo improves with head rotation maneuvers that displace free-moving calcium deposits back to the vestibule. Maneuvers include the canalith repositioning procedure or Epley maneuver and the modified Epley maneuver.

VESTIBULAR NEURONITIS AND LABYRINTHITIS

Treatment focuses on symptom relief using vestibular suppressant medications, followed by vestibular exercises.

MÉNIÈRE’S DISEASE

Treatment lowers endolymphatic pressure. Although a low-salt diet (less than 1 to 2 g of salt per day) and diuretics (most commonly the combination of hydrochlorothiazide and triamterene [Dyazide]) often reduce the vertigo, these measures are less effective in treating hearing loss and tinnitus.