CASE STUDY 8 Vertigo

Dated: 12 September 2007 (edited 5 December 2007)

Patient’s Name: Ng.T.H. NIRC: S04*****H

TABLE OF CONTENTS
Page
1. Patient Profile 2
2. Health Assessment 2
3. Physical Examination 3
4. Diagnosis 3
5. Management 4
6. Evaluation 9
7. Learning Points 9

Mdm Ng, a 62-year-old lady presented in the polyclinic on 10 March 2007 with chief complaint
of dizziness for 2 months. This case study focuses on the approach to a patient with vertigo and
loss of hearing.

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PATIENT PROFILE
Mdm Nellie Ng (S04*****H), a 62-year-old lady came to the polyclinic on 10 March 2007 with
chief complains of dizziness for 2 months. She was diagnosed hyperlipidemia in year 2005 on
diet control. She has no other significant medical problems or on any current medications.
Dizziness is a very common physical complaint in the primary care setting with many
differentials diagnoses. This case study will focus on managing giddiness.

HEALTH HISTORY
Chief Complains: Mdm Ng complained of having dizziness for 2 months. The dizziness was
vertiginous in nature (“rooms turning”). The frequency of these vertigo episodes was increasing
from 1 time per month to 3 or 4 times per week. The vertigo lasted for 5 to 10 minutes each time.
These episodes were associated with vomiting. She had right ear tinnitus and loss of hearing for
3 months. She had not sought any medical evaluation as she related the problem to aging
process. There is no headache. Both eyes maintain usual visual acuity.

The dizzinesss is not aggravated by change of position, head turning or motion. Gastrointestional
review is negative. No history of recent head trauma is reported. There is also no report of recent
flu. She claimed that she did not consume any new medications or Chinese traditional
medications.

Drug Allergy: Not known.

Medical History: Mdm Ng has no previous cardiovascular or cerebrovascular events. She also
has no history of migraine.

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PHYSICAL EXAMINATION
General appearance – Looks comfortable. Orientated to person, time and place. Afebrile.
Nails bed – Not cyanosed. (Implying: No peripheral cyanosis)
Eyes – Pupils equal and reactive to light. No conjunctivae pallor noted.
Tongue – Moist and pink. Not cyanosed. (Implying: No central cyanosis)
Neck – Neck does not look enlargement. Thyroid gland is not palpable/ No goiter.
a) CVS examination
Pulse – 66 beats per minute. Regular in rhythm.
Blood Pressure – 140/ 70mmHg
Heart – The apex beat palpable between 4th and 5th ribs. No thrills and heaves felt. S1 and S2
sounds heard. There are no carotid bruits.
b) Lungs examination
Lungs – Chest expansion bilaterally equal. Vesicular breath sounds heard. There is no crepitus
and rhonchi.
c) Neurological examination
All cranial nerves are intact. There is no facial weakness. Sensations of face and tongue are
preserved. There is no nystagmus. There is no pronator drift. Ataxic movements and
dysdiadochokinesis are not detected. Romberg’s test is negative.
d) Ear examination
There are no vesicles found on the pinna and external ear canals. There are no ear discharges.
Both eardrums are intact. Weber test lateralizing to the left. Rhinne’s test is positive for both ears
(Air conduction >Bone conduction). As Mdm Ng complained of right ear loss of hearing for 3
months, this highly suggests that there is sensorinueral deafness in the right ear.

DIAGNOSES
Probable diagnoses: Meniere’s disease and Sensorinueral hearing loss.
Differential diagnoses: Benign Paroxysmal Positional Vertigio (BPPV), Vestibular Neuritis,
Labyrinthitis and Acoustic Neuroma (Vestibular Schwannoma).

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MANAGEMENT
Prevalence. Dizziness is one of the most common complaints in the primary healthcare setting.
The first important step in approach to a patient with dizziness is to distinguish between actual
vertigo from other descriptions of dizziness (such as lightheadedness, unsteadiness, blackout
spells, floating, motion intolerance, imbalance or tilting sensation) that may result from vascular,
metabolic or cardiac disease (Friedman & Hamid, 2006, NUS, 2006 and Swartz & Longwell,
2005). Figure 1 shows a classification of dizziness (NUS, 2006).

Dizziness

Vertigo Pseudo-vertigo

-- a sense of rotation, that

is either the patient or his
surroundings are spinning
around. Unsteadiness Lightheadedness Giddiness
“hing hing”
-- characterized by -- presyncopal
a tendency to fall; feeling. -- nonspecific;
cannot be easily
dysequilbrium
put into any
recognizable
pattern,
Figure 1: Classification of Dizziness and their Definitions.
Proper history taking to elicit medications, pleasure drugs or alcohol that will cause vertigo is
important as eliminating the causative agent will resolve the problem. Table 1 shows a list of
medications that can result in dizziness (Murtagh, 2006). Other differential diagnosis of vertigo
can be broadly categorized into peripheral vestibular cases, central causes and other conditions
(Labuguen, 2006) as shown in Table 2.

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Alcohol
Aspirin and salicylates
Antibiotics: streptomycin, gentamicin, kanamycin, tetracyclines
Anti-epileptics: phenytoin
Antidepressants
Antihypertensives
Antihistamines
Cocaine
Quinine-quinidine
Tranquillisers: phenothiazines, phenobarbitone, benzodiazepines
Diuretics in large doses
Glyceryl trinitrate
Table 1: Drugs that can cause Dizziness

Causes
Peripheral causes
Ø Acute labyrinthitis
Ø Acute vestibular neuronitis (vestibular neuritis)
Ø Benign positional paroxysmal vertigo (benign positional vertigo)
Ø Cholesteatoma
Ø Herpes zoster oticus (Ramsay Hunt syndrome)
Ø Meniere’s disease (Meniere’s syndrome, endolymphyatic hydrops)
Ø Otosclerosis
Ø Perilymphatic fistula

Central Causes
Ø Cerebellopontine angle tumor/ Cerebellar lesions
Ø Cerebrovascular disease such as transient ischemic attack or stroke
Ø Migraine
Ø Multiple sclerosis

Other Causes
Ø Cervical vertigo
Ø Drug-induced vertigo
Ø Psychological
Table 2: Differentials that cause Vertigo

Determining the duration of vertiginous episode, provoking factors and associated symptoms
during history taking can help to narrow the differential diagnoses (Swartz & Longwell, 2005
and Labuguen, 2006). These differentials are shown in Table 3 and Table 4.

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Duration of Episode Suggested Diagnosis
A few seconds Peripheral cause: unilateral loss of vestibular function; late stages
of acute vestibular neuronitis; late stages of Meniere’s disease
Several seconds to BPPV; perilymphatic fistula
a few minutes
Several minutes to Posterior transient ischemic attack; perilymphatic fistula
one hour
Hours Meniere’s disease; perilymphatic fistula from trauma or surgery;
migraine; acoustic neuroma
Days Early acute vestibular neuronitis; stroke; migraine; multiple
sclerosis
Weeks Psychogenic (constant vertigo lasting weeks without
improvement)
Table 3: Typical Duration of Symptoms for Different Causes of Vertigo

Provoking factors Suggested Diagnosis

Changes in head position Acute labyrinthitis; BPPV; cerebellopontine angle tumor;
multiple sclerosis; perilymphatic fistula
Spontaneous episodes Acute vestibular neuronitis; cerebrovascular disease; Meniere’s
(i.e. no consistent provoking disease; migraine, multiple sclerosis
factors)
Recent upper respiratory viral Acute vestibular neuronitis
illness
Stress Psychiatric or psychological causes; migraine
Immunosuppression Herpes zoster oticus
(e.g. immunosuppressive
medications, advanced age)
Changes in ear pressure, Perilymphatic fistula
head trauma, excessive
straining, loud noises
Table 4: Provoking Factors for Different Causes of Vertigo

Sudden onset of vertiginous episodes is often due to inner-ear disease, especially if hearing loss,
ear pressure or tinnitus is also present (Friedman and Hamid, 2006). As demonstrated in this case
of Mdm Ng, of the vertiginous episodes with the presence of hearing loss and tinnitus increase
the index of suspicion that the cause is peripheral due to inner-ear disorder.

Physical examination. A full general physical examination is appropriate with particular attention
being paid to the central nervous system and auditory system. Even though that cardiovascular
cause for vertigo is lower in index of suspicion compared to one presenting with dizziness, it is
still wise that proper cardiovascular examination to be done. This is in view that some patients
are still not able to distinguish between vertigo and non-vertiginous dizziness accurately.

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Observe patient’s gait as she enters the consult room. Patients with peripheral vertigo have
impaired balance but are still able to walk. Patients with central vertigo have more severe
instability and often cannot walk or even stand without falling (Labuguen, 2006). Presence of
dysdiadochokinesis and ataxic movements are more likely due to cerebellar diseases, especially
in the elderly population (Friedman and Hamid, 2007). Other neurological physical examinations
include inspection for nystagmus.

Dix-Hallpike maneuver may be a more helpful test to perform on patients with vertigo. It has a
positive predictive value of 83% and a negative predictive value of 52% for the diagnosis of
BPPV (Labuguen, 2006). Characteristics of the nystagmus produced in a Dix-Hallpike maneuver
that suggest a peripheral cause include: (a) fatigability (b) latency of 3 seconds and more and (c)
combined horizontal and torsional nystagmus. If a purely vertical or torsional nystagmus without
a latent period of at least a few seconds, and does not wane with repeated maneuvers, highly
suggest a central cause for vertigo.

As Mdm Ng complained of tinnitus and hearing loss, physical examination of the auditory
system is warranted. The condition of the external auditory canal and the nature of the tympanic
membrane should be determined. The presence of vesicles on the external auditory canal and
tympanic member indicates Herpes Zoster Oticus as the diagnosis. Weber’s test and Rhinne test
are 2 hearing tests that can be conducted easily in the polyclinic setting. In unilateral conductive
hearing loss, the sound will be best heard in the affected ear in the Weber’s test. If the loss is
sensorineural, the sound is best heard in the normal ear. For Rhinne’s test, in both normal
hearing and sensorineural hearing loss air conduction is better than bone conduction. Conductive
hearing loss will have the opposite effect (Isaacson and Vora, 2003).

For Mdm Ng, she complained of right ear loss of hearing and tinnitus. Weber’s test resulted in
sound lateralizing to the left (normal ear). And air conduction is better than bone conduction
when Rhinne’s test is performed. The combination of signs points towards sensorineural hearing
loss of Mdm’s Ng right ear.

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Treatment and Plans.
Mdm Ng was referred to Tan Tock Seng Hospital Ear Nose and Throat department for further
investigation to the cause of her vertigo.

Although during that consult no medications were prescribed for Mdm Ng as an early Ear Nose
Throat specialist appointment was arranged on the 25th April 2007. Upon reflection, some oral
medications can be tried on Mdm Ng to help her decrease the discomfort of her symptoms before
her specialist appointment date. Antihistamines: Dimenhydrinate. Calcium Antagnoist:
Cinnarizine, Phenothiazines: Promethazine and Prochlorperazine, and Histamine analogue (H3
antagonist): Betahistine dihydrochloride. Proclorperazine can be tried for Mdm Ng starting from
a small dose of 5mg three times a day. This is in view of Mdm Ng’s age of 60, as elderly patients
are susceptible to centrally acting drugs, hence lower initial dosage should be recommended.
This antidopaminergic drug blocks at the central nervous system reticular activating system
reducing nausea and vomiting symptoms. The rest of the medications usual dosage and
precautions can be seen in Table 5 (Friedman and Hamid, 2007, Swartz and Longwell, 2005 and
Oosterveld, 1999).

Medications Dosage Precautions

Antihistamines
Dimenhydrinate 50 to 100mg TDS or May impeded diagnosis of conditions such as brain
QDS tumours, IO and appendicitis. Not to give if any of
the above is suspected as probable diagnosis. May
cause drowsiness.
Histamine analogue
(H3 antagonist)
Betahistine 8 to 16mg TDS Caution in patients with phaeochromocytoma or
dihydrochloride (48mg daily) bronchial asthma.
Phenothiazines
Promethazine 12.5 to 25mg TDS Caution in patients with cardiovascular or hepatic
disease. Cause drowsiness.
Prochlorperazine 5 to 10mg TDS Drug-induced Parkinson syndrome can occur.
Akathisia is most extrapyramidal reaction in
elderly. Lowers seizure threshold, caution with
history of seizures.
Calcium Antagonist
Cinnarizine 50 to 255mg daily Cause drowsiness, weight gain and listlessness.
Unsuitable for long term usage.
Table 5: List of anti-vertigo medications, usual dosage and precautions

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EVALUATION
Mdm Ng will be followed up at the ENT specialist clinic.

APN RFLECTION AND LEARNING POINTS

Dizziness and giddiness are very common complains handled in the polyclinic setting. The
overall incidence of dizziness, vertigo, and imbalance is 5-10%, and it reaches 40% in patients
older than 40 years ( Friedman and Hamid, 2007). It is important that an APN know the serious
disorders e.g. neoplasia, cerebrovascular events, cardiovascular arrhythmias, cardiac valvular
disorders can underlie a complaint of vertigo/ giddiness.

REFERENCES
Friedman, M. and Hamid, M. (2007). Dizziness and vertigo. Retrieved from http://www.
emedicine.com/neuro/topic693.htm

Isaacson, J.E. and Vora, N.M. (2003). Differential diagnosis and treatment of hearing loss.
American Family Physician, 68(6), p. 1125- 1132.

Labuguen, R. (2006). Initial Evaluation of Vertigo. American Family Physician, 73(2), p. 244-
251.

Murtuagh, J. (2006). General Practice. 2nd edition. Australia: McGraw-Hill Professional

Publishing.

NUS (2006). 20 common symptoms. NUS: College of Family Medicine.

Oosterveld, W.J. (1999). Dizziness and vertigo, a guide for General Practitioners. 2nd edition.
Solvay Pharmaceuticals.

Swartz, R. and Longwell, P. (2005). Treatment of Vertigo. American Academy of Family

Physicians, 17(6), p. 1115-1122.

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Annex A
Cause
Peripheral causes
Acute labyrinthitis
Acute vestibular neuronitis
(vestibular neuritis)
Benign positional paroxysmal
vertigo (benign positional
vertigo)
Cholesteatoma
Herpes zoster oticus (Ramsay
Hunt syndrome)
Meniere’s disease (Meniere’s
syndrome, endolymphyatic
hydrops)
Otosclerosis
Perilymphatic fistula
Central Causes
Cerebellopontine angle tumor
Cerebrovascular disease such
as transient ischemic attack or
stroke
Migraine
Multiple sclerosis
Other Causes
Cervical vertigo
Drug-induced vertigo
Psychological
Elizabeth Ho Moon Liang
Description
-- Inflammation of the labyrinthine organs caused by viral or
bacterial infection
-- Inflammation of the vestibular nerve, usually caused by viral
infection
-- Transient episodes of vertigo caused by stimulation of
vertibular sense organs by canalith; affects middle-age and
older patients; affects twice as many women as men
-- Cyst-like lesion filled with keratin debris, most often
involving the middle ear and mastoid
-- Vesicular eruption affecting the ear; caused by reactivation of
the varicella-zoster virus
-- Recurrent episodes of vertigo, hearing loss, tinnitus, or aural
fullness caused by increased volume of endolymph in the
semicircular canals.
-- Hardening or thickening of the tympanic membrane caused
by age or recurrent infections of the ear
-- Breach between middle and inner ear often caused by trauma
or excessive straining.
-- Vestibular schwannoma (i.e. acoustic neuroma) as well as
omfratentorial ependymoma, brainstem glioma,
medulloblastoma, or neurofibromatosis
-- Arterial occlusion causing cerebral ischemia or infarction,
especially if affecting the vertebrobasilar system.
-- Episodic headaches, usually unilateral, with throbbing
accompanied by other symptoms such as nausea, vomiting,
photophobia or phonophobia; may be preceded by aura
-- Demyelinization of white matter in the central nervous
system.
-- Vertigo triggered by somatosensory input from head and neck
movements
-- Adverse reactions to medications
-- Mood, anxiety, somatization, personality or alcohol abuse
disorders.
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