ent - ear nose and throat head and neck page

Amer Amen, FRCS(Eng), DLO
Consultant ENT & Head and Neck Surgeon
PAH Health Trust

Vertigo

The vestibular systems depend on

The proprioception or somatosensors

Vision

Labyrinth

All the inputs from these three groups

Pass to the Brain stem and Cerebellum

Response pass back to muscles that maintain posture and eye position

Cerebellum ensure smooth co-ordinated response

Management of vertigo

History

First is there is a spinning feelings

Vestibular disease

The patient or the surrounding is spinning

Any change in hearing

Light-headedness and vague symptoms

Related to general medical conditions

Peripheral vestibular problem are

Sudden onset

Central Vestibular disorders are

Gradual onset of continual imbalance

Precipitating factors

Looking up or turning the head

Vertebra vascular basilar insufficiency

On lying down

Benign positional paroxysmal vertigo

Usually last 30 - 40 seconds

Predisposing Factors

Upper respiratory tract infection

Labyrinthitis

viral or bacterial

Trauma

Drugs

Associated symptoms

Fluctuating hearing

Tinnitus

Feeling sick with or without vomiting

Fullness in the ear

About 24 hour duration

Meniere's disease (inner ear's hydrop)

Labyrinthitis

Deafness

Recovers in viral

Permanent in bacterial

Sever vertigo

Nausea with vomiting

Lasting many days

Past or present history of middle ear infection

Need urgent investigation

May need urgent surgical interference

C S O M ( attico antral disease)

Facial palsy

Complicated Suppurative otitis media

Acoustic neuroma

Herpes zoster

Central vestibular problems

Other cranial nerve involvement

Ataxia

Clinical examination

ENT

General medical

Full neurological

ENT

Ear , Nose, Throat,

Look for Nystagmus

Romberg's sign

Positive in CNS

Cerebellum

Corneal reflex

Reduced

Acoustic neuroma

CPA tumour

Other test

Positional test (Hallpike test)

Gait ( eye closed and open)

Tuning fork test

Rinne's

Weber's

ABC

Investigation

Audiological

Pure tone audiometry

Tympanogram

Evoked response audiometry

Investigation

Vestibular

Caloric

Rotation test

Optokinetic

Radiological

MRI scan

General investigation

Diabetes

Thyroid

Serum lipids

Serology for syphilis

Causes of Vertigo

Non vestibular

Vestibular

Peripheral

Central

Non vestibular

Cardiovascular system

Hypertensive cardiovascular disease

Postural hypotension

Cardiac arrhythmia

Non vestibular

Metabolic

Diabetes

Thyroid diseases

Hyperlipidaemia

Non vestibular

Musculo skeletal disorder

Non vestibular

Ocular system

Glaucoma

Ocular muscle disease

Non vestibular

Non organic symptoms

Vestibular

Peripheral vestibular

Labyrinthitis

Menier's disease

Vestibular Neuronitis

Benign positional vertigo

Central causes

Multiple Sclerosis

Cerebrovascular disease

Tumour of posterior fossa

acoustic neuroma

Metastasis ( intra cranial)

Cerebellar gliomata

Other central causes

Migrain

Epilepsy

Degenerative process

Syringobulbia

Basal ganglion disease

Drug intoxication

Psychogenic

Summary

In severe vertigo

Admit the patient

Rehydration

Vestibular sedative

Positional vertigo

avoid the critical position

Vestibular sedative at bed time

Cinnarazine

or Prochlorperazine

Meniers

Vestibular sedative

Mild diuretic

+_ Betahistine

avoid excessive fluid or salt

Vertigo in patient taking HRT

Treat as menier's

Avoid full dose of vestibular sedative

patient will feel drowsy from the drug.

Physiotherapy

Cawthorne & Cooksey exercises

I usually limit the investigation to

Audiogram

MRI scan in asymmetrical deafness

Treat symptom

If no response then do

Full investigation for vertigo

Written by Amer Amen FRCS (Eng) DLo




Vertigo Summary Amer Amen, FRCS(Eng), DLO Consultant ENT & Head and Neck Surgeon PAH Health Trust A short bullet point summary of Vertigo. Vertigo The vestibular systems depend on The proprioception or somatosensors Vision Labyrinth All the inputs from these three groups Pass to the Brain stem and Cerebellum Response pass back to muscles that maintain posture and eye position Cerebellum ensure smooth co-ordinated response Management of vertigo History First is there is a spinning feelings Vestibular disease The patient or the surrounding is spinning Any change in hearing Light-headedness and vague symptoms Related to general medical conditions Peripheral vestibular problem are Sudden onset Central Vestibular disorders are Gradual onset of continual imbalance Precipitating factors Looking up or turning the head Vertebra vascular basilar insufficiency On lying down Benign positional paroxysmal vertigo Usually last 30 - 40 seconds Predisposing Factors Upper respiratory tract infection Labyrinthitis viral or bacterial Trauma Drugs Associated symptoms Fluctuating hearing Tinnitus Feeling sick with or without vomiting Fullness in the ear About 24 hour duration Meniere's disease (inner ear's hydrop) Labyrinthitis Deafness Recovers in viral Permanent in bacterial Sever vertigo Nausea with vomiting Lasting many days Past or present history of middle ear infection Need urgent investigation May need urgent surgical interference C S O M ( attico antral disease) Facial palsy Complicated Suppurative otitis media Acoustic neuroma Herpes zoster Central vestibular problems Other cranial nerve involvement Ataxia Clinical examination ENT General medical Full neurological ENT Ear , Nose, Throat, Look for Nystagmus Romberg's sign Positive in CNS Cerebellum Corneal reflex Reduced Acoustic neuroma CPA tumour Other test Positional test (Hallpike test) Gait ( eye closed and open) Tuning fork test Rinne's Weber's ABC Investigation Audiological Pure tone audiometry Tympanogram Evoked response audiometry Investigation Vestibular Caloric Rotation test Optokinetic Radiological MRI scan General investigation Diabetes Thyroid Serum lipids Serology for syphilis Causes of Vertigo Non vestibular Vestibular Peripheral Central Non vestibular Cardiovascular system Hypertensive cardiovascular disease Postural hypotension Cardiac arrhythmia Non vestibular Metabolic Diabetes Thyroid diseases Hyperlipidaemia Non vestibular Musculo skeletal disorder Non vestibular Ocular system Glaucoma Ocular muscle disease Non vestibular Non organic symptoms Vestibular Peripheral vestibular Labyrinthitis Menier's disease Vestibular Neuronitis Benign positional vertigo Central causes Multiple Sclerosis Cerebrovascular disease Tumour of posterior fossa acoustic neuroma Metastasis ( intra cranial) Cerebellar gliomata Other central causes Migrain Epilepsy Degenerative process Syringobulbia Basal ganglion disease Drug intoxication Psychogenic Summary In severe vertigo Admit the patient Rehydration Vestibular sedative Positional vertigo avoid the critical position Vestibular sedative at bed time Cinnarazine or Prochlorperazine Meniers Vestibular sedative Mild diuretic +_ Betahistine avoid excessive fluid or salt Vertigo in patient taking HRT Treat as menier's Avoid full dose of vestibular sedative patient will feel drowsy from the drug. Physiotherapy Cawthorne & Cooksey exercises I usually limit the investigation to Audiogram MRI scan in asymmetrical deafness Treat symptom If no response then do Full investigation for vertigo Written by Amer Amen FRCS (Eng) DLo