As the World Turns: Vertigo in As the World Turns: Vertigo in the Emergency Departmentthe Emergency Department

Andrew K. Chang, MD, FACEPDepartment of Emergency Medicine Albert Einstein College of Medicine

Montefiore Medical Center

Andrew K. Chang, MD

Teaching points to be addressedTeaching points to be addressed• What differentiates peripheral from

central vertigo?• What differentiates benign paroxysmal

positional vertigo (BPPV) from other causes of peripheral vertigo, such as labyrinthitis and vestibular neuritis?

• What is the treatment of choice for BPPV?

Andrew K. Chang, MD

Case PresentationCase Presentation• 67 year-old man• Rolled over in bed• After a few seconds delay, he developed

nausea and felt as if the room was spinning• Symptoms resolved within 30 seconds• Room spun in the opposite direction when

he rolled back to his original position

Andrew K. Chang, MD

Past Medical History & Social HistoryPast Medical History & Social History

• Hypertension, on atenolol• No surgeries• Nonsmoker, occasional alcohol

Andrew K. Chang, MD

Physical ExamPhysical Exam• VS: 37.2, 145/85, 90, 18, sat 98%• Alert, anxious• Head, eyes, ears, neck exam: normal• Cardiac exam: normal• Rest of exam: normal

• Neurologic exam (detailed): normal

Your Differential Diagnosis?Your Differential Diagnosis?

Andrew K. Chang, MD

Differential DiagnosisDifferential Diagnosis

• Peripheral Vertigo• Benign paroxysmal positional vertigo (BPPV)• Vestibular neuritis• Labyrinthitis • Meniere’s disease

• Central Vertigo• Stroke/Vertebrobasilar insufficiency

Andrew K. Chang, MD

ED CourseED Course

• A diagnostic Hallpike test was performed• Torsional nystagmus and reproduction of

symptoms in the right head-hanging position

• Asymptomatic in the left head-hanging position

Andrew K. Chang, MD

Hallpike TestHallpike Test

Hallpike Video ClipHallpike Video Clip

Nystagmus video clipNystagmus video clip

Andrew K. Chang, MD

ED courseED course• The Epley maneuver was performed at

the patient’s bedside with complete resolution of symptoms

• No imaging or lab tests done• No intravenous line placed• Length of stay 20 minutes• Patient very grateful

Andrew K. Chang, MD

BPPVBPPV• Benign Paroxysmal Positional Vertigo• Age• Head trauma

Andrew K. Chang, MD

Characteristic storyCharacteristic story

• Turn head• After a few seconds delay, vertigo occurs• Resolves within 1 minute if you don’t move• If you turn your head back, vertigo recurs in

the opposite direction

Andrew K. Chang, MD

Dissecting the acronym “Dissecting the acronym “BBPPV”PPV”• “B” = Benign• Not a brain tumor• Can be severe and

disabling

Andrew K. Chang, MD

Dissecting the acronym “BDissecting the acronym “BPPPV”PV”

• “P” = Paroxysmal• Episodic, not persistent• Helpful feature in the differential diagnosis

Andrew K. Chang, MD

Dissecting the acronym “BPDissecting the acronym “BPPPV”V”

• “P” = Positional• Occurs with position of head• Turning over in bed• Looking up• Bending over

Andrew K. Chang, MD

Dissecting the acronym “BPPDissecting the acronym “BPPVV””

• “V” = Vertigo• An illusion of motion• “The room is spinning”• Other descriptions• Rocking• Tilting• Somersaulting• Descending in an elevator

Andrew K. Chang, MD

VertigoVertigo• Peripheral• CN VIII• Vestibular apparatus

• Central• Brain stem

• Vestibular nuclei in medulla and pons

• Cerebellum

Andrew K. Chang, MD

VertigoVertigo

Onset Sudden Slow, gradualIntensity Severe Ill definedDuration Paroxysmal ConstantNausea/Diaphoresis Frequent InfrequentCNS signs Absent Usually presentTinnitus/hearing loss Can be present AbsentNystagmus Torsional/horizontal VerticalNystagmus Fatigable Non-fatigable

PERIPHERAL CENTRAL

Andrew K. Chang, MD

Anatomy: Membranous labyrinthAnatomy: Membranous labyrinth

• Semicircular canals• Utricle• Endolymph

Andrew K. Chang, MD

Anatomy: Semicircular canalsAnatomy: Semicircular canals• Semicircular Canals (SCC)• Horizontal• Anterior• Posterior

• Cupula• End organ receptors

• Endolymph

Andrew K. Chang, MD

Anatomy: UtricleAnatomy: Utricle• Utricle• Connected to SCC• Contains endolymph• Otoliths (otoconia)

• Calcium carbonate• Attached to hair cells• Macule (end organ)

Andrew K. Chang, MD

Vestibular systemVestibular system• Tells brain which way the head moves

without looking• SCC: angular acceleration• Utricle: linear acceleration

Andrew K. Chang, MD

Pathophysiology of BPPVPathophysiology of BPPV• Otoliths become

detached from hair cells in utricle

• Inappropriately enter the posterior semicircular canal1

1. Parnes LS, McClure JA. Laryngoscope 1992;102:988-92.

Andrew K. Chang, MD

PhysiologyPhysiology• Normal situation• As one turns head to the right• Endolymph moves SCC receptors fire

“head turning right”• Stop turning head endolymph stops

moving SCC receptors stop firing “head has stopped moving”

Andrew K. Chang, MD

Pathophysiology of BPPVPathophysiology of BPPV• BPPV• Stop turning head otoliths keep moving

drag endolymph receptors continue to fire inappropriately “head is still moving”

• Eyes “head is NOT moving”

• Brain room must be spinning in the opposite direction

Andrew K. Chang, MD

The Epley ManeuverThe Epley Maneuver

• First described in 19922

• Bedside• > 80% cure rate 2,3

• Immediate relief

2. Epley J. Otolaryngol Head Neck Surg 1992;107:399-4043. Lynn S, et al. Otolaryngol Head Neck Surg 1995;113:712-20.

Andrew K. Chang, MD

Epley maneuverEpley maneuver

• Canalith repositioning maneuver• 5 step head hanging maneuver

• Moves otoliths out of the posterior semicircular canal and back into utricle where they belong

Andrew K. Chang, MD

Epley maneuverEpley maneuver• 1. Repeat Hallpike • Previously performed

diagnostic Hallpike test tells you the starting position (right or left)

Andrew K. Chang, MD

Epley maneuverEpley maneuver

• Turn head 90 degrees in the other direction

Andrew K. Chang, MD

Epley maneuverEpley maneuver• 3. Patient rolls onto

shoulder, rotates head and looks down towards floor

Andrew K. Chang, MD

Epley maneuverEpley maneuver• 4. Patient sits back

up• 5. Head forward

Andrew K. Chang, MD

Epley maneuverEpley maneuver

Epley maneuver (video clip)Epley maneuver (video clip)

Andrew K. Chang, MD

Epley maneuverEpley maneuver

• Repeating the Epley maneuver• Post procedure• Remain upright for 8-24 hours

Andrew K. Chang, MD

The Epley ManeuverThe Epley Maneuver• Contraindications4

• Unstable heart disease• High grade carotid stenosis• Severe neck disease• Ongoing CNS disease (TIA/stroke)• Pregnancy beyond 24th week gestation

(relative)

4. Furman JM, Cass SP. N Engl J Med 1999;341:1590-96

Andrew K. Chang, MD

ComplicationsComplications

• Vomiting• IV promethazine

• Converting to horizontal canal BPPV• Bar-b-que maneuver

Andrew K. Chang, MD

Lab studiesLab studies

• In a straightforward case, no lab studies are needed!

• Hemoglobin• Fingerstick glucose • Electrolytes if prolonged vomiting

Andrew K. Chang, MD

MedicationsMedications• Sensory Conflict Theory

• Class A: benzodiazepines• Prevents process of vestibular rehabilitation

• Class B: anticholinergic• Scopolamine: takes 4-6 hrs; not effective in ED

• Class C: antihistaminic• IV promethazine (Phenergan)• PO meclizine (Antivert)

Andrew K. Chang, MD

ConsultationsConsultations• Will depend upon institution (neurology

vs. otolaryngology)

• If not better with Epley maneuver• If focal neurologic exam

Andrew K. Chang, MD

SummarySummary• BPPV may be a severe and incapacitating

disease• Diagnosis via history, nonfocal neurological

exam, and a positive Hallpike test• Treatment is with the Epley maneuver• IV promethazine (Phenergan) is probably

the best ED medication if one is needed

Andrew K. Chang, MD

Teaching pointsTeaching points• What differentiates peripheral from central

vertigo?• What differentiates benign paroxysmal

position vertigo (BPPV) from other cause of peripheral vertigo, such as labyrinthitis and vestibular neuritis?

• What is the treatment of choice for BPPV?

Andrew K. Chang, MD

Teaching pointsTeaching points• What differentiates peripheral from

central vertigo?

• Peripheral vertigo is more intense, has a sudden onset, is paroxysmal, has fatigable and rotatory nystagmus, and has a nonfocal neurological examination

Andrew K. Chang, MD

Teaching pointsTeaching points• What differentiates peripheral from central

vertigo?• What differentiates benign paroxysmal

position vertigo (BPPV) from other cause of peripheral vertigo, such as labyrinthitis and vestibular neuritis?

• What is the treatment of choice for BPPV?

Andrew K. Chang, MD

What differentiates BPPVWhat differentiates BPPV from labyrinthitis from labyrinthitis and vestibular neuritis (VN)?and vestibular neuritis (VN)?

• BPPV• Requires head

movement• Duration of seconds• Usually in elderly• No relation to viral

syndrome• Responds to Epley

maneuver

• Labyrinthitis/VN• No head movement

needed• Duration of hours/days• Any age• Viral syndrome usually

precedes• Epley maneuver is

ineffective

Andrew K. Chang, MD

Teaching pointsTeaching points• What differentiates peripheral from central

vertigo?• What differentiates benign paroxysmal

position vertigo (BPPV) from other cause of peripheral vertigo, such as labyrinthitis and vestibular neuritis?

• What is the treatment of choice for BPPV?

Andrew K. Chang, MD

Teaching pointsTeaching points

• What is the treatment of choice for BPPV?

• The Epley maneuver (canalith repositioning maneuver)

Questions???Questions???

FERNE www.ferne.org

andrewkennethchang@hotmail.com