Central Philippine University

Jaro, Iloilo City, 5000 Iloilo

College of Medicine
Section of Preventive Community &
Family Medicine

SPINS AND TURNS

A Case Discussion
on Vertigo
In partial fulfillment of the requirements in
Preventive Community & Family Medicine 2

Submitted by:
Joher Bolante Mendez, Jr.
MD-II

Submitted to:
Dr. Remo Benliro, Jr.
Dr. Agnes Segunda Gerasmo
Dr. Henry Gonzales
Instructors
 THE CASE

I. Vital Information
• Age: 40 y/o
• Sex: Male
• Occupation: Farmer; Barangay Councilor

II. Chief Complaint: Dizziness

III. History of Present Illness:

He had recurring dizziness for several months already. At times it was relieved by
resting especially if he had good sleep. There was no history of trauma. He also complained that
at times he had difficulty of hearing and there seemed to be something bothering in his ears like
the sound of a gushing water or something buzzing. It was getting frequent that he cannot go to
the farm already, thus the consult.
Pertinent Negatives:
(-) fever (-) diplopia
(-) vomiting (-) weakness
(-) blurring of vision (-) facial asymmetry
(-) Loss of appetite
(-) weight loss

IV. Past Medical History

(-) Hypertension
(-) Diabetes Meliitus
(-) Bronchial Asthma

V. Personal and Social History

He is an occasional alcoholic drinker of 2-3 bottles of beer during occasions. He is not a
smoker.
VI. Family Background
He has 4 children and his wife is a school teacher. He contributes to the Family income
with what-ever he can produce in his farm.
VII. Physical Examination

Vital Signs
• BP: 120/80 mmHg
• Cardiac Rate- 85 bpm
• RR: 18 cpm
• Temp: 37.0 degrees centigrade

General Assessment: Conscious coherent ambulatory not in cardio-pulmonary disease.

PE Findings:
• Anicteric sclerae pinkish conjunctivae
• No nasal congestion or polyp
• Intact ear drum both ears, (-) cerumen
• (-) Cervical Lymph Adenopathy or neck bruit
• (-) enlarged tonsils; Symmetrical Chest Expansion
• (-) rales (-) wheezing
• Cardiac findings with regular cardiac rate and rhythm no murmur
• Abdomen flat NABS (-) tenderness (-) masses
• Both upper and lower extremities unremarkable findings.
Neuro Exam:
• Intact other Cranial nerves, (-) horizontal Nystagmus
• Motor 5/5 on all extremities and 100% sensory on all areas.
• Reflexes ++
• Visual Acuity 20/20
 INTRODUCTION

Dizziness
• “dizzy” (“hilo”, “liyo”)
• general term that describes sensations of imbalance and unsteadiness
• 4 Categories (Post & Dickerson, 2010)

PRESYNCOPE DISEQUILIBRIUM LIGHTHEADEDNESS VERTIGO

feeling that one is Note:

about to faint
loss of stability or feeling of falling, All cases of
presyncopal balance floating, or general vertigo is a form
sensations due to brain weakness of dizziness.
hypoperfusion
Not all
experiences of
dizziness is
vertigo.

• Differentials: • Differentials: • Differentials:

• Cardiac, • Parkinson’s • Anxiety
• Neurologic Disease • Depression
• Metabolic; • Peripheral
Disorders Neuropathy
• Musculoskeletal
Conditions

Vertigo
• sensation of spinning, whirling, or falling, either of the self (I’m spinning) or the environment
(the room is spinning)
• a symptom, rather than a disease
• onset is abrupt and accompanied by nausea, vomiting, and disequilibrium
• type of dizziness that involves a false sensation that one's self or the surroundings are
spinning, swaying or tilting, usually accompanied by loss of balance & nystagmus
• Physiologic Vertigo: sustained head rotation
• Pathologic Vertigo : vestibular function
• Types and Causes
TYPE STRUCTURES INVOLVED CAUSES / ETIOLOGIES
• Benign paroxysmal positional
vertigo (BPPV)
• Vestibular neuritis
lesions affecting the • Meniere's disease
PERIPHERAL VERTIGO inner ear and cranial nerve • Acoustic neuroma
• Aminoglycoside toxicity
(Subjective Vertigo) VIII
• Semicircular canal dehiscence
I’m spinning
syndrome
• Perilymphatic fistula
• Herpes zoster oticus
(Ramsay Hunt syndrome)

• Vestibular migraine
• Brainstem stroke
lesions affecting the • Multiple sclerosis
CENTRAL VERTIGO brainstem and cerebellum • Ischemic or hemorrhagic
damage to the cerebellum
(Objective Vertigo)
The room is spinning

Epidemiology
• Studies show that about a third of cases of dizziness are vertigo.
• Most common are viral, BPPV or Meniere's disease.
• Prevalence estimates for vertigo are ~5%, for BPPV 1.6%. Meniere's disease
~0.5%
• Philippine General Hospital (2015)
• Department of Otorhinolaryngology, there were 103 cases out of 3056 new
patients seen are related to vertigo
• Department of Family Medicine, out of 20, 902 new patient consults, there were
528 related to to dizziness and vertigo
• Department of Neurosciences, out of 4547 patients, there were 42 consults for
vertigo and dizziness
• University of Santo Tomas, OPD (2014)
• 688 patient visits for dizziness
 APPROACH TO DIAGNOSIS

A. SIGNIFICANT FINDINGS

PATIENT’S HISTORY

• recurring dizziness for several months

• relieved by resting
• no history of trauma
• difficulty of hearing
• sound of a gushing water or something buzzing
• (+) frequency of occurrence

PHYSICAL EXAMINATION

• Intact ear drum both ears

• (-) horizontal Nystagmus

PERTINENT NEGATIVES

• (-) diplopia
• (-) vomiting
• (-) weakness
• (-) blurring of vision
• (-) facial asymmetry
Differential diagnostic characteristics of central versus peripheral vertigo. Brainstem signs
may include motor and sensory deficits, hyperreflexia, positive Babinski sign, dysarthria, and
limb ataxia.

SIGNS AND SYMPTOMS CENTRAL LESIONS PERIPHERAL LESIONS

Vertigo • often constant • often intermittent
• less severe • severe

Nystagmus • sometimes absent • always present

• uni- or multi directional • unidirectional
• may be vertical • never vertical

Hearing loss or tinnitus • rarely present • often present

Brain stem signs • typically present • never present

Algorithm for the Initial Evaluation of a Patient with Dizziness.

(American Family Physician, 2017) (refer to next page)

B. DIFFERENTIAL DIAGNOSES

• Vestibular Neuritis
• Labyrinthitis
• Benign Paroxysmal Positional Vertigo
• Meniere’s Disease

• Vestibular Neuritis
• inflammation of the inner ear and/or the nerve connecting the inner ear to the brain.
• generally caused by a viral infection, usually, Herpes Viruses.

RULE IN RULE OUT

(+) persistent vertigo (-) nausea and vomiting
(-) No History of viral illness
(-) signs of central dysfunction:
-diplopia
-weakness or numbness
-dysarthria
(-) spontaneous nystagmus: contralateral
(+) signs of hearing loss
Labyrinthitis
• Labyrinthitis is inflammation of the part of the inner ear called the labyrinth consist of
fluid-filled channels which control balance and hearing.

RULE IN RULE OUT

(+) persistent vertigo
(+) signs of hearing loss
(-) nausea and vomiting
(-) No History of viral illness
(-) signs of central dysfunction:
-diplopia
-weakness or numbness
-dysarthria
(-) spontaneous nystagmus: contralateral

Benign Paroxysmal Positional Vertigo

• Benign paroxysmal positional vertigo (BPPV) is considered the most common peripheral
vestibular disorder
• Episodes are brief(<1 min and typically 15–20 s) and are always provoked by changes in head
position relative to gravity, such as lying down, rolling over in bed, rising from a supine
position, and extending the head to look upward. The attacks are caused by free-floating
otoconia (calcium carbonate crystals) that have been dislodged from the utricular macula and
have moved into one of the semicircular canals, usually the posterior canal.
• Modified Epley maneuver for treatment of BPPV.

RULE IN RULE OUT

(+) persistent vertigo (-) horizontal rotary nystagmus (hallmark of
(-) nausea and vomiting BPPV)
(-) position changes related to vertigo attacks
 MENIERE’S DISEASE

RULE IN

(+) DIAGNOSTIC TRIAD:

• (+) hearing loss
• (+) persistent vertigo
• (+) tinnitus (sound of a gushing water or something buzzing)

(+) symptom experience: months

(+) temporary relief from rest
(+) Age: 40 y/o
Sex: Male

• Meniere’s disease also known as idiopathc endolymphatic hydrops, is a disorder of the inner
ear resulting in the clinical triad of vertigo, tinnitus, and hearing loss. There is an abnormal
inner ear fluid balance caused by a malabsorption in the endolymphatic sac or a blockage in the
endolymphatic duct.

• Endolymphatic hydrops, a dilation in the endolymphatic space, develops, and either increased
pressure in the system or rupture of the inner ear membrane occurs, producing symptoms
Meniere’s disease.

Stages of Meniere’s disease

▪ Early stage 
▪ sudden and unpredictable episodes of vertigo.
▪ nausea, dizziness and vomiting during the episodes
▪ may last from about 20 minutes to a full 24 hours.
▪ hearing loss, which returns to normal after it is over

▪ Middle stage 
▪ vertigo episodes continue, but are usually less severe.
▪ tinnitus and hearing loss, get worse
▪ some patients during this stage may experience periods of complete remission
▪ periods of remission can last several months.
▪ Late stage 
▪ vertigo episodes become even less frequent, and in some cases never come back
▪ balance problems, though, and may continue
▪ Patients will feel especially unsteady when it is dark and they have less visual input to
help maintain balance.
▪ Hearing and tinnitus typically get progressively worse.

PATHOPHYSIOLOGY

Obstruction of endolymphatic duct/sac

Alteration in production and absorption

of endolymph

Distension of endolymphatic sac

Increased in pressure and rupture of

inner membranes

Hearing Loss

Vertigo Tinnitus
 EVALUATION / WORK-UP

A. Supine Roll Test

• considered more diagnostic for the less common lateral canal BBP.
B. Pure Tone Audiometry
• PTA may reveal low frequency sensorineural hearing loss early on.
• The course is progressive until any compressed hearing loss becomes total, at which
point the vertigo begins to go away until it finally disappears.
C. Dix-Hallpike Maneuver Tests
• determines whether vertigo is triggered by certain head movements.

D. C-Spine X-Rays
• An X-Ray of the cervical spine may be performed to check for broken bones or any neck
injuries.

E. Imaging Tests (CT Scan, MRI)

• may be performed if brain injury is suspected to be a cause of vertigo
F. Electronystagmosgraphy
• is a diagnostic test to record involuntary movements of the eye caused by a condition
known as nystagmus. It can also be used to diagnose the cause of vertigo, dizziness or
balance dysfunction by testing the vestibular system.
• this assesses eye movement to evaluate balance function. Muscles that control eye
movement are linked to balance-related sensors in the inner ear - it is this link that
allows people to turn their head while focusing their eyes steadily on a single point.
Electrodes are placed on the skin near the eyes and on the patient's forehead.
• Warm and cool water or air is introduced into the ear canal. Involuntary eye movements
in response to this simulation are measured. Abnormalities may indicate an inner ear
problem.

G. Spinal Tap
• This test involves the removal of fluid from the spinal cord to test for infection, bleeding
in the brain and spinal cord or

H. Positional testing

• We try to move the patient's head in different directions to check for inner ear problems.
A physical exam may also confirm Nystagmus. Tests on balance and coordination may
also be executed to see if the brain is performing properly.

I. Hearing test.

• This is to assess if the middle ear, cochlea and auditory nerve are functioning properly.
(Weber-Rinnetest)

J. Gait and Cerebellar function. (Romberg’s Test)

K. Blood test

• Blood sugarlevels may be checked to see if this contributes to the patient's vertigo; CBC.

L. Electrocardiogram(ECG)
• This is to check for damage in different areas of the heart.
•
M. Rotary-chair testing 
• This test also measures inner ear movement by assessing eye movement. It is usually
better tolerated than the ENG.
• The patient sits in a chair in a small, dark booth. Electrodes are placed near the eyes and
a computer-guided chair rotates gently back and forth at varying speeds.
• The movement stimulates the inner balance system and causes nystagmus (eye
movements) that are recorded by a computer and monitored with an infrared camera.
• Rotary chair testing does not provide specific diagnostic information about each ear
individually - unlike the ENG.
 APPROACH TO MANAGEMENT

1. Nonsurgical Management

• Teach patients to move the head slowly to prevent worsening of the vertigo.
• Nutrition and lifestyle changes can reduce the amount of endolymphatic fluid.
• Encourage the patients to stop smoking because of the blood vessels constricting
effects.
• Stress Reduction
• Changing positions slowly to avoid disorientation.
• Controlling high blood pressure and high cholesterol through a low salt diet.
• Focusing on distant objects instead of one's feet while walking.
• When riding a car, sitting in the front seat and focusing on distant objects.
• Updating eye glasses and hearing aid prescriptions.
• Avoiding activities that involve moving the head up and down repetitively or keep the
head tilted back a long time, such as painting.

Physical therapy
• Repositioning maneuvers.

2. Pharmacologic Management

• Motion sickness drugs - examples include Meclizine (Antivert) or Diazepam (Valium).

They may help with the spinning sensation, as well as nausea and vomiting.

• Drugs for nausea - prochlorperazine has been shown to be effective in the treatment of
nausea during a vertigo episode.

• Diuretics - a combination of Triamterene and Hydrochlorothiazide (Dyazide, Maxzide)

will reduce fluid retention.

• Nicotonic Acid
• Antihistamines
• Diphenhydramine hydrochloride (Benadryl, Allerdryl)
• Dimenhydrinate (Dramamine, Gravol)
• Antiemetics
• Chlorpromazine hydrochloride (Thorazine, Novo- Chlorpromazine)
• Droperidol (Inapsine)
• Promethazine (Phenergan)
• Ondansetron (Zofran)
 3. Surgical Management
• Endolymphatic sac decompression - a small portion of bone is removed from over the
endolymphatic sac. Occasionally, a shunt is placed (a tube that drains excess fluid from
the inner ear).
• Hearing aid - a patient with Meniere's disease who has suffered hearing loss from the
affected ear may benefit from a hearing aid. A hearing aid is an instrument to help in
hearing.
• Labyrinthectomy - a portion of the inner ear is surgically removed. This takes away
both the hearing and balance function of the affected ear. This procedure is only done if
the patient is either totally, or almost totally deaf in that ear.
• Vestibular nerve section - the vestibular nerve is cut. This nerve connects the balance
and movement sensors in the inner ear to the brain. A vestibular nerve section is aimed at
preserving hearing in the affected ear, while addressing the problems with vertigo.
 SUMMARY OF CARE / APPROACHES

PATIENT CENTERED
• Avoid hazardous activities when you are dizzy, such as driving an automobile or operating
dangerous equipment, or climbing a step ladder, etc.

• Avoid rapid changes in position, especially from lying down to standing up or turning around
from one side to the other.

• Avoid extremes of head motion (especially looking up) or rapid head motion (especially
turning or twisting).

• Eliminate or decrease use of products that impair circulation, e.g. nicotine, caffeine, and salt.

• Minimize your exposure to circumstances that precipitate your dizziVness, such as stress and
anxiety or substances to which you are allergic.

• Get enough fluids.

• Annual Audiometry.

• Treat infections, including ear infections, colds, flu, sinus congestion, and other respiratory
infections.

• Encourage good oral hygiene to address poor dentition.

FAMILY FOCUSED

• Education of the family and primary care givers or caregivers.

• Counseling for the entire family, including the sufferer.

• “Fall-proofing” their home by covering sharp corners with foam and removing rugs and
masts from slippery areas and stair landings.

• Encourage or help the patient to stop in smoking.

• Encourage or help in motivating the patient to stop drinking alcohol or if not then reduce the
alcohol intake.

• Try to communicate openly with the patient with regards to use of illicit drugs.

• Routinely assess the blood pressure of the patient.

• Watch out for early S/Sxof Vertigo to avoid fall accident.

• Take part in promoting good health and a harmonious relationship within

 COMMUNITY ORIENTED

• Inform or give the people from the neighborhood an idea about what is the present condition
of the patient. With this, they could help the patient to change his lifestyle and be guided if
an episode of vertigo happens outside their house.

• Promote a smoke free environment for the community.

• Promote a drug-free community to barangay officials as well as to the people.

• Recommend to the LGU or barangay officials to have a program that will entertain or
conduct a program that aims for awareness, information, and participation that will benefit
debilitated people or has a condition like Tomas in the community.

IMPACT OF ILLNESS

FARMER AND HUSBAND

Occupation as a farmer requires a lot of endurance especially due to long hours of work
under the scorching heat of the sun. With regards to the patient who suffers recurrent
dizziness, his work will be greatly affected and production as well as income will be
reduced. There will be more hours of rest and absences. This change has great impact
to the family especially that he provides most of the portion for their daily living.

HUSBAND AND PARTNER TO WIFE (TEACHER)

Dizziness can be very debilitating that most of the time patients who suffer from this
tend to be irritable. The relationship as a husband and wife can be affected especially
they prefer to rest to alleviate the sympton. Less interaction in the family can bring up
conflicts that would trigger misunderstanding.

BRGY COUNCILOR
As a brgy coucilor, social interaction and duties come together. Their role is to act as
peace officers in the maintenance of public order and safety. If symptoms come on and
off, work will be affected and duties as a peace-officer will be at stake.

DUTIES TO THE COMMUNITY

Each individual in the community plays a role starting from their own houses to the
barangay and community. It requires cooperation, respect and participation. These
duties will not be carry-through by the patient due to the recurrent attacks of the
dizziness.