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How hot are you on... Dizziness and vertigo

Test your knowledge for the nMRCGP with this little GEM from GPnotebook

Test your knowledge for the nMRCGP with this little GEM from GPnotebook

• Dizziness is a non-specific term describing a sensation of altered orientation.

• Vertigo is the hallucination of rotation or movement of oneself or one's surroundings.

• Dizziness is of little diagnostic value without further information. If there is loss of consciousness this is syncope.

Q What is important in the history?
A The following points are important:

• nature of symptoms:

– is there a tendency to fall to one side?

• onset and duration provide information on the likely pathological processes• precipitating factors, including:

– standing up, suggesting of postural hypotension – head movements, suggesting benign paroxysmal positional vertigo

• associated symptoms, including:

– deafness – tinnitus – otalgia or a feeling of fullness in the ear – discharge from the ear – neurological symptoms

• any other medical problems:

– vascular disease – multiple sclerosis – drug history, especially ototoxic drugs – cardiac disease, especially arrhythmias.

Q What is important in the examination?
A Possible components include:

• peripheral auditory system – otoscopy, tuning fork tests
• eye movements – spontaneous nystagmus; any diplopia
• fundoscopy
• examination of the remainder of the cranial nerves – special attention is paid to those that pass through the cerebellopontine angle, the fifth to the seventh
• cerebellar function is tested via the finger-nose test
• assess neck movements – an arthritic cervical spine may be the source of abnormal proprioceptive signals
• auscultate the neck for bruits
• Romberg's test, Unterberger's stepping test
• Hallpike's test
• cardiovascular examination – arrhythmias, check for postural hypotension.

Q What are possible peripheral causes?
A These are divided according to the presence (or absence) of auditory symptoms.

Causes with auditory symptoms include:

• Meniere's disease:

– vertigo lasts for minutes or hours – episodic, associated with tinnitus and deafness

• acute labyrinthitis

– vertigo lasts for days

• perilymphatic fistula

– vertigo lasts for months/years

• ototoxic drugs, such as aminoglycosides
• cholesteatoma
• acoustic neuroma

– vertigo rarely prominent

• Ramsay-Hunt syndrome.

Causes with no hearing loss or tinnitus:

• benign positional vertigo:

– vertigo lasts for seconds – episodic, correlated with head position

• vestibular neuronitis

– vertigo lasts for days

• cervical spondylosis and whiplash injury may cause vertigo by interfering with proprioception and movement of the neck.

Q What about central causes?
A Central lesions usually cause additional neurological symptoms and auditory features are uncommon. In most central lesions, the vertigo develops gradually. An acute central vertigo is probably vascular.
Causes may include:

• vertebro-basilar insufficiency and thromboembolism (lateral medullary syndrome, subclavian steal syndrome, basilar migraine)
• brain tumour, for example an ependymoma or a metastasis in the fourth ventricle
• aura of epileptic attack, especially, in temporal lobe epilepsy
• plaque of demyelination in the pons in multiple sclerosis
• drugs, such as phenytoin, barbiturates
• syringobulbia.

This series is based on GPnotebook Educational Modules (GEMs) – the full version is available via GPnotebook Plus, a service free to UK medics at www.gpnotebook.co.uk

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