---

Management of Acute Vertigo — 50 Marks

---

DEFINITION

---

CLASSIFICATION OF DIZZINESS (DIFFERENTIATE BEFORE MANAGING)

"Patient history accounts for 85% of the information considered in the diagnosis of the dizzy patient." — Cummings Otolaryngology, Ch. 137

---

ANATOMY RELEVANT TO ACUTE VERTIGO

• 3 Semicircular Canals (SCC): detect angular acceleration
  • Superior (anterior), Posterior, Lateral (horizontal)
• Otolith organs: Saccule and Utricle — detect linear acceleration and gravity
• Cristae ampullaris: hair cells in ampulla of each SCC
• Macula: hair cells in saccule/utricle bearing otoliths (otoconia — calcium carbonate crystals)

---

AETIOLOGY — DIFFERENTIAL DIAGNOSIS OF ACUTE VERTIGO

A. PERIPHERAL (More common, 70–80%)

B. CENTRAL (Less common but dangerous — must exclude)

C. SYSTEMIC CAUSES

• Drug-induced (aminoglycosides, loop diuretics, aspirin, quinine)
• Cervicogenic vertigo
• Migrainous vertigo (vestibular migraine)
• Orthostatic hypotension

---

APPROACH TO THE ACUTELY VERTIGINOUS PATIENT

🔷 FLOWCHART 1: Initial Triage of Acute Vertigo

ACUTE VERTIGO
      │
      ▼
STEP 1: Obvious neurological findings?
  (diplopia, dysarthria, dysphagia, limb ataxia, facial palsy, headache)
      │
   YES ──────────────────► CENTRAL CAUSE — STROKE PROTOCOL
      │                    ► Urgent MRI brain/posterior fossa
      ▼
     NO
      │
STEP 2: Is dizziness CONTINUOUS or EPISODIC?
      │
      ├─── CONTINUOUS (persists at rest)
      │         │
      │         ▼
      │    ACUTE VESTIBULAR SYNDROME (AVS)
      │    ► Distinguish Vestibular Neuritis from Stroke
      │    ► Use HINTS exam (see below)
      │
      └─── EPISODIC
                │
                ├── Triggered by head position → BPPV
                │   (Perform Dix-Hallpike)
                │
                ├── Spontaneous episodes 20min–24h
                │   + SNHL + Tinnitus → MÉNIÈRE DISEASE
                │
                ├── Spontaneous < 1h + headache → VESTIBULAR MIGRAINE
                │
                └── Spontaneous < 24h + vascular RF → TIA

---

HISTORY TAKING (Key Points — Cummings Ch. 137)

---

CLINICAL EXAMINATION

1. General

• Vital signs, cardiovascular (orthostatic BP)
• Nystagmus: type, direction, gaze dependence

2. Nystagmus Assessment

3. HINTS Exam (High-sensitivity bedside test for AVS — separates stroke from neuritis)

• Peripheral (neuritis): Corrective saccade present → VOR impaired → REASSURING
• Central (stroke): Normal HIT → NO corrective saccade → DANGEROUS

• Peripheral: Unidirectional horizontal
• Central: Direction-changing or pure vertical/torsional → DANGEROUS

• Peripheral: No vertical skew
• Central: Vertical skew deviation → DANGEROUS

HINTS = HIT normal + direction-changing nystagmus + skew deviation → STROKE (more sensitive than early MRI)

4. Dix-Hallpike Maneuver (for BPPV)

• Patient seated, turn head 45° to suspected side
• Rapidly lower to supine with head 20° extended (affected ear down)
• Observe for torsional upbeating nystagmus (latency 5–20 s, duration < 1 min, fatigable)
• Positive = posterior canal BPPV

5. Supine Roll Test (Head Roll / Pagnini-McClure)

• For horizontal canal BPPV
• Supine, roll head 90° to each side
• Geotropic (direction-changing toward ground) nystagmus = canalolithiasis (more common)
• Apogeotropic = cupulolithiasis

6. Romberg/Fukuda Stepping Test

• Fall toward affected side in peripheral disease
• Ataxic in all directions → central

7. Cerebellar Tests

• Finger-nose, heel-shin, dysdiadochokinesia
• Truncal ataxia → cerebellar stroke

8. Otoscopy + Tuning Fork Tests

• Herpes zoster vesicles (Ramsay Hunt)
• Conductive vs sensorineural deficit

---

INVESTIGATIONS

Audiological

Vestibular

Imaging

Laboratory

• CBC, blood sugar, lipid profile, TFT
• Syphilis serology (FTA-ABS) — tertiary syphilis can mimic Ménière
• ANA, ANCA — autoimmune labyrinthopathy

---

MANAGEMENT OF ACUTE VERTIGO

🔷 FLOWCHART 2: Management Algorithm

ACUTE VERTIGO PRESENTING TO CLINIC/ER
              │
              ▼
     RED FLAGS PRESENT?
   (severe headache, focal neuro signs,
    gait ataxia, diplopia, dysarthria)
              │
         YES  │  NO
          ▼          ▼
    CENTRAL CAUSE    PERIPHERAL CAUSE
    MRI Brain         │
    Neurology ref.    ▼
    Thrombolysis   CHARACTER ASSESSMENT
    if stroke          │
                  ┌────┴──────────┐
              Positional       Spontaneous
                  │                │
                  ▼                ▼
              BPPV           ACUTE VESTIBULAR
         Dix-Hallpike           SYNDROME
             (+ve)          (continuous vertigo)
                  │                │
                  ▼                ▼
          CANALITH         With       Without
       REPOSITIONING     Hearing       Hearing
        (Epley/Semont)     Loss         Loss
                                │           │
                           LABYRINTHITIS  VESTIBULAR
                                │          NEURITIS
                           Viral/bacterial     │
                                │         Corticosteroids
                           Antibiotics/     Vestibular
                           Steroids       Rehabilitation

---

SPECIFIC MANAGEMENT

I. SYMPTOMATIC (Vestibular Suppressants — Acute Phase)

"The goal of acute management is suppression of acute symptoms while preserving the ability of the brain to compensate."

A. Antihistamines (First Line)

B. Benzodiazepines (Second Line)

Caution: Prolonged use of vestibular suppressants delays central compensation. Must be limited to ≤72 hours in most cases.

C. Antiemetics

D. Phenothiazines

• Chlorpromazine 25 mg IM — for severe nausea/vomiting unresponsive to above

E. Corticosteroids

• Prednisolone 1 mg/kg/day tapered over 3 weeks
• Indicated in vestibular neuritis, labyrinthitis (viral), sudden SNHL
• Evidence: Cochrane review — corticosteroids improve long-term recovery in vestibular neuritis (Strupp et al. 2004, NEJM)

F. Antiviral Therapy

• Acyclovir/Valacyclovir — if Ramsay-Hunt syndrome (Herpes Zoster Oticus)
• 800 mg Acyclovir 5x/day × 7 days; add prednisolone

---

II. SPECIFIC CONDITION MANAGEMENT

🔷 A. BPPV (Most Common Cause)

Epley Maneuver (Posterior Canal BPPV)

1. Patient seated, head turned 45° to affected side
2. Quickly lower patient supine with head hanging 20° below horizontal — wait 30–60 seconds (nystagmus settles)
3. Turn head 90° to opposite side — wait 30–60 seconds
4. Patient rolls onto shoulder of healthy side, head turned 45° down toward floor — wait 30–60 seconds
5. Patient sits up slowly

Success rate: 80–90% with single maneuver; repeat if needed Post-procedure restrictions are NOT recommended (AAO-HNS Strong Recommendation Against)

Semont (Liberatory) Maneuver

• Alternative for posterior canal BPPV
• Less evidence than Epley

Barbecue Roll (Lempert Maneuver)

• For horizontal canal BPPV
• Sequential 360° rolling in 4 steps, each 90°, toward healthy ear

AAO-HNS BPPV Algorithm:

---

🔷 B. VESTIBULAR NEURITIS

1. Acute phase (1–3 days): Vestibular suppressants (meclizine/diazepam) + antiemetics
2. Corticosteroids: Methylprednisolone 100 mg → taper over 3 weeks (improves peripheral VOR recovery — Strupp NEJM 2004)
3. Antivirals: Not proven beneficial alone; may combine with steroids
4. Vestibular Rehabilitation Therapy (VRT): Start as early as possible (day 3–5); Brandt-Daroff exercises, Cawthorne-Cooksey exercises
5. Patient reassurance: Central compensation occurs in weeks–months

---

🔷 C. MÉNIÈRE DISEASE (Endolymphatic Hydrops)

• ≥2 episodes spontaneous vertigo (20 min–24 h)
• Audiometrically documented low/mid-freq SNHL ≥1 occasion
• Tinnitus or aural fullness in affected ear
• Other causes excluded

• Vestibular suppressants (meclizine 25–50 mg / diazepam 5 mg oral)
• Antiemetics (prochlorperazine, ondansetron)
• Bed rest, reassurance

• Low-salt diet (< 2g NaCl/day) + diuretics:
  • Hydrochlorothiazide 25 mg + amiloride (Diamox/Moduretic)
  • Acetazolamide 250 mg BD
• Betahistine (16 mg TDS or 48 mg BD) — H3 antagonist/H1 agonist; improves cochlear blood flow; widely used (European standard); AAO-HNS: "May offer"
• Avoid: caffeine, alcohol, tobacco, stress
• Vestibular rehabilitation for interictal imbalance

• Intratympanic Corticosteroids (IT-Dexamethasone 4mg/mL):
  • For hearing preservation + vertigo control
  • Injected through TM into middle ear; diffuses to inner ear via round window
  • Weekly × 4 injections
• Intratympanic Gentamicin (IT-Gentamicin):
  • Chemical labyrinthectomy of vestibular hair cells
  • Low-dose protocol (titration method): 26.7 mg/mL × 1–2 injections
  • Effective vertigo control: 74–90%
  • Risk: sensorineural hearing loss (10–30%) — reserved for non-serviceable or unserviceable hearing

• Endolymphatic Sac Surgery (Decompression/Shunt):
  • Posterior fossa approach, decompress or drain ELS
  • Controversial efficacy; Cochrane: insufficient evidence of superiority over sham surgery
• Vestibular Nerve Section (Neurectomy):
  • Retrolabyrinthine or middle fossa approach
  • Cuts vestibular division of CN VIII → permanent vertigo control with hearing preserved
  • Success: > 90%

• Labyrinthectomy:
  • Total destruction of membranous labyrinth
  • Only when hearing is non-serviceable (SDS < 50%, PTA > 50 dB)
  • Success: near 100% vertigo control

---

🔷 D. LABYRINTHITIS

• Emergency: IV antibiotics (ceftriaxone 2g IV BD + metronidazole)
• Mastoidectomy if CSOM with labyrinthine fistula
• Risk: total sensorineural deafness, meningitis

---

🔷 E. RAMSAY HUNT SYNDROME (Herpes Zoster Oticus)

• Acyclovir 800 mg oral 5×/day × 7–10 days (or Valacyclovir 1g TDS)
• Prednisolone 1 mg/kg/day × 7 days, taper
• Eye protection (tarsorrhaphy if corneal exposure)
• Vestibular suppressants for acute vertigo
• Physiotherapy for facial palsy

---

🔷 F. ACUTE POSTERIOR CIRCULATION STROKE

• Activate stroke protocol
• MRI DWI — gold standard (CT may miss posterior fossa infarct in first 24–48 h)
• Thrombolysis (rtPA) within 4.5 hours if no contraindications
• Mechanical thrombectomy if large vessel occlusion
• Aspirin 300 mg + statin + anticoagulation if cardioembolic
• Neurology / neurosurgery referral
• ICU care for cerebellar haemorrhage (may need urgent suboccipital craniectomy)

---

III. VESTIBULAR REHABILITATION THERAPY (VRT)

• Progressive: eye movements → head movements → sitting balance → walking
• Promotes CNS compensation (neuroplasticity)

• Self-administered particle dispersal exercises
• Alternative to Epley in motivated patients

• Gaze stabilisation exercises (VOR × 1 and × 2 exercises)
• Balance training (foam surface, eyes closed)
• Walking and ADL training
• Evidence: Cochrane 2015 — VRT is safe, effective for unilateral peripheral vestibular dysfunction

---

🔷 FLOWCHART 3: Stepwise Acute Dizziness Assessment (Emergency Setting)

---

RECENT ADVANCES (As per 2022–2024 Literature)

1. vHIT (Video Head Impulse Test)

• Portable bedside tool; detects catch-up saccades showing semicircular canal hypofunction
• Supplements caloric testing; better for high-frequency VOR assessment
• HINTS Plus: Addition of audiometry (sudden SNHL) to HINTS battery improves stroke detection sensitivity to ~99%

2. Intratympanic Therapy Refinements

• Low-dose IT Gentamicin titration protocol — single injection + reassessment reduces hearing loss risk
• IT Dexamethasone gel formulation — sustained release, fewer injections needed

3. Betahistine HIGH DOSE Trial (BEMED Trial — 2016, JAMA)

• Failed to show superiority of high-dose (144 mg/day) vs placebo in preventing Ménière attacks
• Ongoing controversy; still widely prescribed in Europe and India

4. VEMP Advances

• oVEMP (ocular VEMP) for utricular function assessment
• cVEMP (cervical VEMP) for saccular assessment
• Useful in Ménière disease, SCD, bilateral vestibulopathy

5. Endolymphatic Sac Tumour (ELST)

• Rare; associated with Von Hippel-Lindau syndrome
• MRI characteristic: heterogeneous posterior petrous mass

6. Gene Therapy / Biologics (Experimental)

• AAV-mediated gene delivery to restore hair cell function (Phase I trials)
• Not yet clinical standard

7. Persistent Postural-Perceptual Dizziness (PPPD)

• Functional vestibular disorder; follows acute vestibular event
• Managed with SSRIs/SNRIs (sertraline, venlafaxine) + VRT + CBT

8. Telerehabilitation

• App-based VRT for BPPV and vestibular neuritis — non-inferior to supervised VRT in several RCTs (2020–2022)

---

DRUG SUMMARY TABLE

---

SURGICAL MANAGEMENT SUMMARY

---

REFERENCES / STANDARD TEXTS

1. Cummings Otolaryngology Head and Neck Surgery, 7th ed. — Flint PW et al. — Ch. 137 (Otologic History & Examination), Ch. 166–167 (Vertigo, Ménière Disease)
2. KJ Lee's Essential Otolaryngology, 11th ed. — Vestibular disorders section
3. Rosen's Emergency Medicine — Ch. (Vertigo: Antihistamines, Epley maneuver)
4. Bradley and Daroff's Neurology in Clinical Practice — Ch.: Management of Patients with Vertigo
5. Dhingra's Diseases of Ear, Nose and Throat — Peripheral vestibular disorders
6. Hazarika's Textbook of Ear, Nose, Throat and Head-Neck Surgery — Vertigo and vestibular disorders
7. Strupp M, Zingler VC, et al. — Methylprednisolone, Valacyclovir, or the Combination for Vestibular Neuritis. NEJM 2004;351:354–361
8. AAO-HNS CPG — BPPV (2017 Update); Ménière Disease (2020)
9. Bárány Society — International Classification of Vestibular Disorders (ICVD) 2015
10. BEMED Trial — Adrion C et al. JAMA 2016 — Betahistine in Ménière Disease

---

SYNOPSIS FOR QUICK REVISION (RGUHS Exam Points)

---

Note on Image Generation: The generate_image tool is currently unavailable (monthly plan limit reached). The institutional flowcharts requested from Dhingra, Hazarika, Stell & Maran, Zakir Hussain, and Scott-Brown cannot be reproduced as newly generated diagrams at this time. Please upgrade your subscription for diagram generation. The clinical guideline flowcharts from Cummings/AAO-HNS (Figs. 2–4 above) serve the same purpose and are referenced in your answer.