🩺 Vertigo

Vertigo is the symptomatic perception of abnormal self or environmental motion. It is a common complaint that typically arises from dysfunction in the vestibular system (peripheral) or the brainstem/cerebellum (central). Peripheral causes are generally more common and benign, whereas central causes can be life-threatening. A structured history focusing on the duration of episodes and associated auditory or neurological symptoms, combined with targeted bedside manoeuvres, allows for accurate diagnosis in most cases. Management varies from physical repositioning manoeuvres to vestibular rehabilitation or specialist management for chronic conditions.

Differentiate 'true' vertigo (illusion of movement/spinning) from lightheadedness or imbalance. The timing and triggers are diagnostic. Seconds/minutes and triggered by head movement? Suggests Benign Paroxysmal Positional Vertigo (BPPV). Minutes/hours with hearing loss and fullness? Suggests Ménière’s disease. Days of continuous vertigo without hearing loss? Suggests Vestibular Neuronitis. Days of vertigo with hearing loss? Suggests Labyrinthitis. Sudden onset with neurological symptoms (double vision, ataxia)? Suggests a central cause like a cerebellar stroke. Ask about associated symptoms like tinnitus and nausea.

Distinguish between peripheral and central vertigo. For episodic vertigo, perform the Dix-Hallpike manoeuvre (looking for paroxysmal nystagmus). For continuous vertigo, use the HINTS exam. Perform a full cranial nerve exam (looking for V, VII, VIII palsies) and cerebellar tests (past-pointing, dysdiadochokinesia, heel-to-shin, gait). Examine the ears (otoscopy) for vesicles (Ramsay Hunt) or cholesteatoma. Check for hearing loss using the Weber and Rinne tests. Check blood pressure for orthostatic hypotension as a vertigo mimic.

Benign Paroxysmal Positional Vertigo (BPPV), Vestibular Neuronitis, Labyrinthitis, Ménière’s Disease, Vestibular Migraine, Cerebellar Stroke/TIA, Acoustic Neuroma, Ramsay Hunt Syndrome, Multiple Sclerosis.

Sudden onset vertigo with headache or neck pain, Presence of 'D' symptoms (Diplopia, Dysarthria, Dysphasia, Dysmetria), Vertical or direction-changing nystagmus, New-onset hearing loss (without an obvious peripheral cause), Truncated ataxia (inability to stand without support).

Most cases of vertigo are diagnosed clinically. Audiometry is useful if Ménière's or Labyrinthitis is suspected. If central vertigo is suspected (e.g., failed HINTS exam, vertical nystagmus, or cerebellar signs), urgent MRI (preferred) or CT of the posterior fossa is required to rule out stroke or tumour. Bloods are generally less helpful but may include glucose and U&Es to rule out metabolic mimics. Specialist referral to ENT or Vestibular Physiotherapy is indicated for recurrent or persistent symptoms.

The Dix-Hallpike manoeuvre is diagnostic for BPPV, while the Epley manoeuvre is the treatment. In the HINTS exam (Head Impulse, Nystagmus, Test of Skew), a *normal* head impulse test in the presence of continuous vertigo is actually a 'red flag' for a central (stroke) cause, as it suggests the vestibular-ocular reflex is intact and the problem is in the brainstem/cerebellum. 'Vestibular sedatives' like prochlorperazine or cinnarizine should only be used for the first 2-3 days of acute vertigo; long-term use inhibits vestibular compensation and delays recovery.

Relevant to 'ENT' and 'Neurology'. Key MLA competencies include performing the Dix-Hallpike and understanding the difference between peripheral and central nystagmus (peripheral is typically unidirectional and inhibited by visual fixation; central can be vertical or change direction).