Thread by @DIskandarmirza

For Junior Doctors

Do you see many case of vertigo?
It is the most common case admitted under internal medical ward, with an improper diagnosis
So, do you really know how to assess vertigo?

Let us do some discussion shall we?
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There are so many causes of vertigo. So proper clinical history can examination is prudent to get proper diagnosis

Evaluation focuses on determining whether the etiology is peripheral or central.
-Peripheral are usually benign
-Central often require urgent treatment

Peripheral causes of vertigo

-Benign paroxysmal positional vertigo
-Vestibular neuritis
-Meniere disease
-Otosclerosis

Central causes

-Vestibular migraine
-Cerebrovascular disease
-Cerebellopontine angle and posterior fossa meningiomas

Other causes

-Psychiatric
-Medication induced
-Cardiovascular/metabolic
-Orthostatic

The best approach on Vertigo

TITRATE the evaluation:

Ti: Timing of the symptoms
Tr: Triggers that provoke the symptoms
And
T/E : Targeted Examination

1)Timing of the symptoms

From this you will place the dizziness into

-Episodic triggered -> second to hours
-Spontaneous episodic -> seconds to days
-Continuous vestibular -> days to weeks

2)Triggers that provoke the symptoms

-Head movement
-Hearing loss
-Movement from upright position
-Medication induced

3)Physical examination

-Cardiovascular examination
-Neurological examination
-Head/ear/nose and throat examination

How to know whether it is central or peripheral cause of vertigo?

Use the HINTS (head-impulse, nystagmus, test of skew) examination

By using HINTS examination, you can be confident enough to know whether it is central or peripheral vertigo

Head impulse
While the patient is sitting, the head is thrust 10 degrees to the right and then to the left while the patient's eyes remain fixed on the examiner's nose.

If a saccade (rapid movement of both eyes) occurs-> peripheral etiology
No eye movement -> central etiology

Nystagmus

Spontaneous unidirectional horizontal nystagmus that worsen during gazing: peripheral causes (vestobular neuritis)

Spontaneous nystagmus that is dominantly vertical or torsional -> central etiologies

Test of Skew
Ask the patient to look straight ahead, then cover and uncover the each eye.

Vertical deviation of the covered eye after uncovering -> abnormal result -> fairly specific for brain stem involvement.

BPPV is diagnosed with Dix-Hallpike maneuver

Transient upbeat-torsional nystagmus during maneuver is diagnostic of BPPV