More MS news articles for July 2002

How Should I Assess and Manage a Patient With Acute Vertigo?

http://www.medscape.com/viewarticle/437103

07/02/2002
from Medscape Nurses

Question
What is the best way to evaluate a patient, without other known health problems, who presents with an acute episode of vertigo?

Response
from Judith Shannon Lynch, MS, MA, 07/02/2002

More than 90 million Americans aged 17 years and older experience vertigo or problems with balance.[1] This common symptom originates from a disturbance in the orientation-detecting system and is frequently seen in clinical practice, accounting for 2.4% of visits to physicians annually.[2]
The prevalence of vertigo increases with patient age, leading some researchers to identify a "geriatric syndrome," which often reveals associations between vertigo and cardiovascular, neurologic, psychological, and sensory disorders.[3]

In about 10% of all patients, no definite etiology is ever established.[4] Vertigo imposes many limitations on the patient's ability to meet daily responsibilities and, when prolonged, will result in reduced quality of life as well as frequent falls leading to serious morbidity.

Defining the Problem

The initial evaluation question must be one that establishes the patient's perception of the word "dizziness." Once a precise subjective statement has been made, this early clue will lead the clinician to appropriate treatment strategies. Knowledge of the 4 most common types of complaints will help to guide this assessment[2]:

Physiology of Vertigo

Spatial orientation is largely automatic but complex. Continued sensory monitoring assesses the position of the body in space, in relation to the surrounding environment. The 5 sensory modalities constantly sample position and motion: vision, vestibular sensation, proprioception, touch and pressure, and hearing.[2] Normally the brain integrates the input from each of these sensory modalities giving a comprehensive image of position and motion in space. This process enables us to maintain balance, move about, and interact with other objects. When the orienting image is unreliable, we become uncertain of position and the result is a sensation of spinning or vertigo. When a patient presents with this type of dizziness, the clinician must next determine whether the symptom is central (brain) or peripheral (inner ear, 8th cranial nerve) in origin.

Central Vertigo

Central vertigo is the least common type of vertigo and is usually caused by[5]:

Peripheral Vertigo

The most common peripheral vestibular disorder causing vertigo results from inner ear pathology and is known as benign paroxysmal positional vertigo (BPPV). Other less common causes of peripheral vertigo include:

BPPV

BPPV is almost always sudden in onset. A main characteristic of BPPV is nystagmus, a rapid involuntary oscillation of the eyeballs. Patients will often complain of abrupt awakening with a spinning sensation while turning in bed. Other triggers include sudden head movements, changes in position (bending over, straightening up), and riding in a fast car or on an amusement park ride. Episodes usually last for several seconds only and are always precipitated by sudden movements of the head.[5] Etiology is uncertain but symptoms are thought to result from the formation of small crystals (usually calcium carbonate) that become loosened from the otolithic organs in the inner ear. These crystals begin to float in the posterior semicircular canal causing the perception of dizziness. The problem may be unilateral or bilateral. Frequently there is associated nausea and vomiting. After a few seconds, the symptoms abate and can often be easily controlled by a simple steadiness of head position. Over 50% of patients will have no identified etiology for these episodes.

Thus, the diagnosis of vertigo must be based on a thorough collection of historical data and on a physical examination to rule out other types of peripheral vertigo. It is helpful to have a patient questionnaire in the chart to simplify the patient history.[1] (A sample dizziness questionnaire is available in Blair[1] or at http://www.medscape.com/viewarticle/422863_2)

Physical examination must include all of the following components:
 

Diagnosis can be made on history and physical examination results. No laboratory or radiologic testing is needed for an acute episode of BPPV unless an underlying cause is suspected.

Treatment for BPPV

If the patient is acutely ill, supportive treatment is necessary. The following measures are helpful:

If symptoms continue, the Epley canalith repositioning maneuver may be performed by a trained audiologist. The patient is placed in the head-hanging position, with the affected ear to the floor. At 30-second intervals, specific head rotations permit the misplaced otolithic material to transit through the posterior semicircular canal and be returned to the utricle, removing the cause of the problem.[2]

After the Epley maneuver, the patient should be given the following instructions:

The Epley maneuver eliminates vertigo in about 80% of patients after 1 treatment. There may be frequent vertigo recurrence over the next 6-10 weeks and the maneuver can be repeated a second time if necessary. Symptoms usually taper off gradually with no episode matching the intensity of the original attack. The Epley maneuver may be performed in the primary care setting only with proper instructions.[1,2] Traditionally, an audiologist integrates this maneuver as part of a complete audiometric evaluation.

Physical therapy is also valuable when vertigo improves but does not disappear. A vestibular rehabilitation program can be easily ordered and is covered by most third-party payers.

Refractory Vertigo

If vertiginous episodes last longer than 2 weeks without improvement, become more intense, or occur with greater frequency, the patient will need further evaluation. If a central cause is suspected, immediate referral to the appropriate specialist is indicated.

With cases of prolonged vertigo, blood analysis is sometimes helpful. The following tests should be included in a vertigo screen:

If the above screening fails to reveal an etiology, referral to an otolaryngologist is warranted. The patient will need a complete audiometric evaluation as well as possible advanced testing to differentiate between central and peripheral vertigo.
 

Conclusion

Although a patient who presents with vertigo may seem initially puzzling to the primary care provider, a systematic approach to this common symptom can successfully uncover the majority of causes in a cost-effective manner. Although not usually life-threatening, vertigo is certainly life-altering and patients will be grateful for a quick response to therapy.

References

  1. Blair C. The dizzy patient. Am J Nurs. 1999;99:61-65, 67. [A helpful dizziness questionnaire can be found on p. 62.]
  2. Drachman DD. Clinical crossroads: a 69 year-old man with chronic dizziness. JAMA. 1998;280:2111-2118.
  3. Tinetti ME, Williams CS, Gill TM. Dizziness among older adults: a possible geriatric syndrome. Ann Intern Med. 2000;132: 337-344.
  4. Drachman DD. Occam's razor, geriatric syndromes, and the dizzy patient [editorial]. Ann Intern Med. 2000;132: 403-405.
  5. Ruckenstein MJ. Managing dizziness and vertigo in older women. Womens Health Primary Care. 2001;4:241-250.


About the Panel Members

Judith Lynch, Assistant Clinical Professor of Nursing, Yale School of Nursing, New Haven, Conn; and Nurse Practitioner, ENT and Facial Plastic Surgery Associates, Fairfield and Trumbull, Conn.

Links


Medscape Nurses 4(2), 2002. © 2002 Medscape