An Approach to Vertigo in General Practice

CLINICAL

An approach to vertigo in general practice

Sindhu Dommaraju, Eshini Perera

Background ertigo is a common, distressing carbonate crystals. These cells control presentation in general practice vertical and non-rotational movements. Dizziness is a common and very V and constitutes approximately Receptors in the semicircular canals distressing presentation in general 54% of cases of dizziness.1 Classically, respond to the position of the head. practice. In more than half of these vertigo presents as a sensation of When the head tilts, receptors on cases, the dizziness is due to vertigo, movement of the environment around the ipsilateral ear are stimulated and which is the illusion of movement of the patient.2 Often patients describe a receptors in the contralateral ear are the body or its surroundings. It can ‘spinning’ sensation of either their body inhibited. These send impulses to the have central or peripheral causes, and or their surroundings. This sensation can brain stem and cerebellum to control determining the cause can be difficult. be confused with dizziness, which is a balance. Any disruption of this pathway Objective non-specific term, so an adequate history can lead to vertigo.7 is required to differentiate this symptom. The aim of this article is to provide Dizziness can be classified into four History a clear framework for approaching groups: Often, patients presenting with dizziness patients who present with vertigo. A • vertigo (spinning sensation) are unable to describe the sensation suggested approach to the assessment • disequilibrium (feeling of imbalance) and can be vague, particularly if it is the of vertigo is outlined. • light-headedness (sensation of initial presentation. It is important to giddiness)3 differentiate vertigo from other non- Discussion • presyncope (sensation of feeling faint). rotational forms of dizziness. Once the The causes of vertigo may be central Vertigo can be classified as central or diagnosis of vertigo is determined, this (involving the brainstem or cerebellum) peripheral on the basis of vestibular needs to be differentiated into a central or or peripheral (involving the inner ear). A symptom pathology.4 Vestibular peripheral subtype.3 careful history and physical examination symptoms originating from pathology More serious central causes, such can distinguish between these causes. in the cerebellum or brain stem are as cerebrovascular accidents (CVAs), The most common causes of vertigo classified into the central type. Conversely, tumours and multiple sclerosis (MS), seen in primary care are benign symptoms arising in the inner ear or from need to be considered. Central causes paroxysmal positional vertigo (BPPV), the vestibular nerve are classified as are suspected if the patient presents vestibular neuronitis (VN) and Ménière’s peripheral. with associated neurological symptoms disease. These peripheral causes of Balance is controlled by the such as weakness, dysarthria, sensory vertigo are benign, and treatment cerebellum, which receives input from changes, ataxia or confusion. It may involves reassurance and management the vestibular nuclei in the brain stem.5 be difficult to distinguish between of symptoms. This in turn receives input from the visual central and peripheral causes in pathway, proprioception and inner ear. patients who present with vertigo as The vestibular apparatus of the inner ear their only symptom. Risk factors for consists of three semicircular canals, vascular disease, including smoking, and two otolith organs called the utricle diabetes, obesity, hypertension and and the saccule.6 The utricle and saccule hypercholesterolaemia, need to be contain hair cells embedded in calcium assessed to rule out CVAs, which

190 AFP VOL.45, NO.4, APRIL 2016 © The Royal Australian College of General Practitioners 2016 AN APPROACH TO VERTIGO CLINICAL

can lead to vertigo from ischemia or Physical examination papilledema. Nystagmus is quick, infarction.8 A physical examination can assist jerky, involuntary movements of the Peripheral pathology is associated in differentiating between central eye. Vertical nystagmus is only seen if with symptoms of nausea, vomiting and and peripheral subtypes of vertigo. the cause is central.7 Nystagmus due hearing loss. Vertigo can be triggered by a Examination should involve the following: to central causes may be horizontal, change in the position of the head, recent • Ear examination: an otoscopic rotational or vertical, and does upper respiratory tract infection (URTI), examination should be performed to not disappear on fixing the gaze.13 stress or trauma. Patients who experience visualise the tympanic membranes Nystagmus in the peripheral type anxiety or panic attacks can have vertigo for any vesicles that can be seen in a disappears with fixation of the gaze. as a result of hyperventilation.8 Loud Herpes zoster infection or retraction • Cardiovascular examination: pulse, blood noises can precipitate vertigo in patients pockets as seen in cholesteotoma.2 pressure, heart rate and rhythm should with peripheral causes in a phenomenon Vertigo triggered by pushing on the be checked.14 Carotid examination to called Tullio phenomenon.9 Medications, tragus or with the Valsalva manoeuvre identify bruits (in the case of a CVA) is including frusemide, salicylates and is seen in a perilymphatic fistula. necessary. Further imaging to rule out antihypertensive agents, can affect the A hearing assessment should be CVA can be performed if this is clinically vestibular system, which in turn causes performed. suspected. vertigo.10,11 Perilymphatic fistula should be • Neurological examination: initially, A number of specialised tests are required considered if there is a history of recent a focused neurological examination to determine the causes of vertigo. These head injury. including gait, balance and coordination are highlighted in Table 1. Vertigo with hearing loss is seen needs to be performed. A gait and in labyrithitis and Ménière’s disease, balance assessment (Romberg’s Causes whereas hearing loss is not seen in sign and the heel-toe test),12 and The most common causes of vertigo benign paroxysmal positional vertigo examination for cerebellar signs can seen in primary care are BPPV, VN and (BPPV) and vestibular neuronitis (VN). exclude central causes. Ménière’s disease (Table 2).2 While most A brief approach to assessing vertigo is • Eye examination: eyes need to of the causes of vertigo are benign, outlined in Figure 1. be examined for nystagmus and more serious causes, including CVAs,

Dizziness

Non-rotational Rotational

Central causes Peripheral Presyncope Disequilibrium (brain stem or causes cerebellar pathology) (inner ear)

Neurological Tinnitus, hearing Lightheaded- symptoms, vascular loss, nystagumus, ness risk factors nausea

Benign Vestibular Tumours Infection positional vertigo neuronitis

Cerebrovascular Ménière’s Labyrinthitis accidents disease

Figure 1. A brief approach to assessing vertigo

MS, tumours, psychogenic causes of vertigo, associated with nausea and Acute labyrinthitis and perilymphatic fistula, need to be nystagmus. The inner ear is composed of the considered,2 particularly in patients who The episodes of vertigo are triggered bony and the membranous labyrinth. are older or have risk factors for vascular by rapid changes in the position of the Acute labyrinthitis is inflammation of diseases. head.1 Symptoms can last for weeks this labyrinth. It presents with vertigo and recur after remission. Nystagmus and hearing loss, preceded by a viral BPPV seen in BPPV has a rotational nature.1 infection.16 Middle ear infections can BPPV is the most common cause of The Dix−Hallpike manoeuvre is used to spread to the inner ear and cause vertigo in clinical practice.15 It is caused diagnose BPPV. In contrast, the Epley labyrithitis. The duration of symptoms by an accumulation of calcium crystals manoeuvre can be used to treat BPPV ranges from days to weeks. Hearing in the posterior semicircular canal. These (Box 1).1 This procedure is performed in loss is the main distinguishing factor crystals affect the movement of the an attempt to dislodge the otoliths from between labyrithitis and BPPV. Typically, endolymph in the semicircular canals, the semicircular canals. It has a 77% no treatment is required for labyrithitis. which causes vertigo.15 The classic success rate on the initial attempt and However, if suppurative labyrinthitis is symptoms of BPPV are brief episodes 100% on further attempts.15 suspected, the patient should be referred to the emergency department for drainage of otitis media.17 Table 1. Interview schedule: key topics and questions Ménière’s disease Physical Ménière’s disease is an uncommon cause examination Description of vertigo.18 It is thought to be caused by Dix−Hallpike The patient sits at the edge of the bed and the examiner turns the increased fluid in the endolymph part of manoeuvre patient’s head 30–45 degrees to the side being tested. The patient the cochlea, which eventually affects the needs to keep their eyes open and focus on a stable point, and then 18 quickly lie supine and hyperextend the neck. Horizontal nystagmus semicircular canals. In most patients, the 18 denotes a positive test. This test can induce vertigo, so patients aetiology is unknown. Ménière’s disease should be warned about this before the test is performed.2,7 is commonly seen in women, and the incidence increases in men and women Orthostatic blood A drop in the systolic blood pressure by more than 20 mm/Hg from a 18 pressure testing lying down to standing position is significant for a postural drop. This after the age of 60 years. is seen in patients who are dehydrated or who present with autonomic Ménière’s disease classically presents dysfunction.2 Autonomic dysfunction can occur acutely and be driven with episodes of vertigo lasting longer by vertigo. than 20 minutes, tinnitus, sensorineural Head impulse test The patient is asked to look at the examiner’s nose and the examiner hearing loss and aural fullness. Eventually, quickly turns the patient’s head 10–20 degrees. It is abnormal if eyes hearing loss becomes permanent. Pure move rapidly and repetitively, failing to re-fixate to the examiner’s nose. tone audiometry is the most useful test to A positive test indicates disrupted vestibule-ocular reflex.7 assess sensorineural hearing loss.

Table 2. Most common differential diagnoses of vertigo

Differential diagnosis Onset and duration Provoking factors Special features Physical exam findings

Change Labyrinthitis Few seconds to minutes in the head position Tinnitus Hearing loss present

Imbalance, while nystagmus is horizontal or rotational, the direction of the fast Recent upper respiratory component is away from Vestibular neuronitis Seconds to minutes tract infection the side of the lesion Absence of hearing loss

Benign paroxysmal Change in the head positional vertigo Seconds position Positional Positive Dix−Hallpike

Hearing assessment for Ménière’s disease Hours Spontaneous Hearing loss and tinnitus sensorineural hearing loss

192 AFP VOL.45, NO.4, APRIL 2016 © The Royal Australian College of General Practitioners 2016 AN APPROACH TO VERTIGO CLINICAL

Box 1. Epley manoeuvre for treatment of BPPV stabilisation exercises help to regain normal activities faster.24 1. Sit the patient on the bed. Patients should be referred for 2. With the neck hyperextended and laterally rotated to 45 degrees, the patient is asked to lie supine. specialist review if they have symptoms 3. The patient is required to maintain the supine position for one minute. of continuous vertigo, progressive hearing 4. The head is turned to the opposite side with lateral rotation of 45 degrees, and remains in this loss, severe ongoing headache, cerebellar position for one minute. signs or if the diagnosis is not clear.7 5. The head, chest and pelvis are tilted downwards to 135 degrees (almost prone), and this position is maintained for one minute. Key points 6. Quickly sit the patient upright with their head tilted to the affected side. • Vertigo is a common presentation in 1 This manoeuvre should not be performed in patients with neck injury, carotid stenosis and heart disease general practice. • A careful history is required to elicit features of central or peripheral causes There is no known cure for Ménière’s be checked.21 Radiological tests including of vertigo. disease and treatment is primarily computed tomography (CT), magnetic • Serious causes including CVAs and MS symptomatic.19 Betahistine is the current resonance imaging (MRI) or magnetic need to be considered. mainstay of treatment. Surgical treatment resonance angiography (MRA) are • Physical examination involves a options exist; however, most patients indicated if: neurological, cardiovascular, eye and are adequately managed with medical • the examination is not consistent with ear examination. treatment. a peripheral lesion • Treatment is specific to the cause of • prominent risk factors for CVA are vertigo. Vestibular neuronitis present Authors VN is caused by inflammation of the • neurological signs and symptoms are Sindhu Dommaraju MBBS, FRACGP, DCH, General vestibular nerve. This inflammation present, or Practitioner, University of Newcastle, Callaghan, precedes a viral URTI or herpes zoster • symptoms of vertigo are accompanied NSW. [email protected] infection and is caused by immune- by a headache. Eshini Perera MBBS, BMedSci, MMed, MPH, FRACGP, Dermatology Registrar, University of mediated sequelae following the viral In these cases, referral to a neurologist is Melbourne, Parkville, VIC 15 22,23 illness. It is commonly seen in middle- recommended. Competing interests: None. aged adults of both sexes.8 VN often Provenance and peer review: Not commissioned, occurs in epidemics during outbreaks Treatment externally peer reviewed. 15 of respiratory infections. The main Treatment is tailored to the specific References characteristic of VN is an acute onset of causes of vertigo. Antiemetic 1. Cranfield S, Mackenzie I, Gabbay M. Can GPs vertigo without hearing loss or tinnitus. medications such as betahistine are diagnose benign positional paroxysmal vertigo Similarly to BPPV, symptoms of vertigo used for symptomatic management and does the Epley manoeuvre work in primary care? Br J Gen Pract 2010;60(578):698–99. are aggravated by a change in the position of acute vertigo. These medications 2. Labuguen RH. Initial evaluation of vertigo. Am of the head. Loss of balance is more should not be used long term. Patients Fam Physician 2006;73(2):244–51. prominent in VN, compared with other should be warned about the side effects 3. Post RE, Dickerson LM. Dizziness: A diagnostic approach. Am Fam Physician 2010;82(4):361–69. causes of vertigo, and patients may of drowsiness, dry mouth and blurred 4. Kuo CH, Pang L, Chang R. Vertigo – Part 1 – commonly present with falls. vision. Benzodiazepines are not indicated Assessment in general practice. Aust Fam Physician. 2008;37(5):341–47. Initially, the vertigo is severe, lasts and should be avoided because of their 5. Purves D, Augustine GJ, Fitzpatrick D, et al. for two to three days and is followed by addictive nature.16,24 Central vestibular pathways: Eye, head, gradual recovery, which may take two to Lifestyle changes including salt and body reflexes. Neuroscience. 2nd edn. Sunderland, MA: Sinauer Associates, 2001. 20 six weeks. Bed rest and antiemetics can restriction and avoiding alcohol and 6. Lee SC, Abdel Razek OA, Dorfman BE, be used in the first 24–72 hours. Patients coffee are recommended.24 Assessment et al. Vestibular system anatomy. New York: can be reassured that symptoms will and management of the patient’s risk Medscape, 2010. 7. A delicate balance: Managing vertigo in 20 improve with time. of falls is important in vertigo. Referral general practice. Best Practice Journal to an experienced physiotherapist for 2012;46(Sep):30–37. Investigations vestibular rehabilitation can help prevent 8. Paine M. Dealing with dizziness. Aust Prescr 2005;28(1):94–97. 16 Blood tests are not routinely ordered recurrences. Exercises prescribed by 9. Colebatch JG, Day BL, Bronstein AM, for patients presenting with vertigo. physiotherapists involve moving the et al. Vestibular hypersensitivity to clicks is characteristic of the Tullio phenomenon, However, it is recommended that glucose eye balls up and down and sideways J Neurol Neurosurg Psychiatry levels of all patients with vertigo should in a supine or sitting position. Balance 1998;65(5):670−78.

10. Drozd CE. Acute vertigo: Peripheral versus 20. Cooper CW. Vestibular neuronitis: A review of central etiology. Nurse Pract 1999;24(4):147–48. a common cause of vertigo in general practice. 11. Baloh RW. The dizzy patient. Postgrad Med Br J Gen Pract 1993;43(369):164–67. 1999;105:161–64, 167–72. 21. Herr RD, Zun L, Mathews JJ. A directed 12. Baloh RW. Differentiating between peripheral approach to the dizzy patient. Ann Emerg Med and central causes of vertigo. Otolaryngol Head 1989;18:664–72. Neck Surg 1998;119(1):55–59. 22. Wippold FJ, 2nd, Turski PA. Vertigo and hearing 13. McIntyre AK. The quick component of loss. Am J Neuroradiol 2009;30(8):1623–25. nystagmus. J Physiol 1939;97(1):8–16. 23. Gizzi M, Riley E, Molinari S. The diagnostic value 14. Karatas M. Vascular vertigo: Epidemiology and of imaging the patient with dizziness. A Bayesian clinical syndromes. Neurologist 2011;17(1):1–10. approach. Arch Neurol 1996:53(12):1299–304. 15. Mathews T. Peripheral vertigo in general practice. 24. Sura DS, Newell S. Vertigo-diagnosis and man- Continuing Medical Education 2006;33:267–70. agement in primary care. BJMP 2010;3(4):a351. 16. Swartz R, Longwell P. Treament of vertigo. Am Fam Physician 2005;71(6):1115–22. 17. Boston ME. Labyrinthitis treatment and management. New York: Medscape, 2016. Available at http://emedicine.medscape.com/ article/856215-treatment [Accessed 22 February 2016]. 18. Cruz MD. Ménière’s disease. A stepwise approach. Medicine Today. 2014;15(3):15–26. 19. Burgess A, Kundu S. Diuretics for the treatment of Ménière’s disease or syndrome. Cochrane Database of Syst Rev 2006;(3):CD003599. Updated 2010.