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Management Plan: Acute Onset Vertigo in a 28-Year-Old Healthy Female

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STEP 1: UNDERSTAND WHAT YOU ARE DEALING WITH

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STEP 2: INITIAL HISTORY TAKING (Key Questions)

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STEP 3: DURATION-BASED DIFFERENTIAL DIAGNOSIS

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STEP 4: PHYSICAL EXAMINATION

General Examination

• BP both arms (postural hypotension)
• Pulse, temperature

Ear Examination (Otoscopy)

• Tympanic membrane integrity
• Signs of middle ear disease, cholesteatoma

Neurological Examination - LOOK FOR RED FLAGS

• Cranial nerves: especially V, VII, VIII, IX, X
• Cerebellar signs: finger-nose test, dysdiadochokinesia, heel-shin test
• Gait: ataxic gait suggests cerebellar pathology

Vestibular Examination

• Direction (horizontal/torsional = peripheral; vertical/purely torsional = central)
• Fixation suppression: peripheral nystagmus is suppressed by visual fixation; central nystagmus is NOT suppressed

• Positive if rotational, geotropic nystagmus appears with:
  • Latency (a few seconds before onset)
  • Short duration (< 1 minute)
  • Fatigues on repeat testing
  • Reverses on sitting back up

• Positive (corrective saccade seen) = peripheral lesion (vestibular neuritis)
• Negative = central cause must be considered

• H - Head Impulse: positive HIT suggests peripheral
• I - INtercurrent nystagmus: direction-changing = central
• TS - Test of Skew: skew deviation = central

• Romberg positive = vestibular/proprioceptive dysfunction
• Fukuda: deviation >45° toward affected side = peripheral lesion

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STEP 5: INVESTIGATIONS

Bedside / Clinic Tests

• Pure Tone Audiometry (PTA) - mandatory in ALL vertigo patients
• Tympanometry

Blood Tests (to exclude systemic causes)

• Complete Blood Count (CBC) - anemia
• Fasting blood glucose - hypoglycemia
• Thyroid function tests (TFT)
• ESR/CRP - inflammatory/autoimmune
• VDRL/FTA-ABS - syphilis (can cause endolymphatic hydrops)
• In young females specifically: ANA, anti-dsDNA (autoimmune inner ear disease)

Special Vestibular Tests

• Electronystagmography (ENG)/Videonystagmography (VNG): records nystagmus objectively; caloric test is most useful - unilateral caloric weakness identifies the affected side
• Vestibular Evoked Myogenic Potential (VEMP): tests saccule (cVEMP) and utricle (oVEMP)
• Electrocochleography (EcochG): useful in Meniere's disease

Imaging

• MRI brain with gadolinium - ONLY if red flags present (central signs, progressive SNHL, unilateral tinnitus)
  • Rules out acoustic neuroma (vestibular schwannoma), posterior fossa tumors, MS plaques
  • Normal CT does NOT rule out posterior fossa stroke
• MRI can also show gadolinium enhancement of the vestibular nerve in vestibular neuritis

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STEP 6: COMMON DIAGNOSES AND THEIR SPECIFIC MANAGEMENT

A. BENIGN PAROXYSMAL POSITIONAL VERTIGO (BPPV) - Most Common Cause

1. Epley Maneuver - most effective; moves the otoconia out of the canal back into the utricle through a series of 4 head positions held for 30 seconds each. Resolution in >90% of cases.
2. Semont Liberatory Maneuver - rapid side-to-side position changes
3. Brandt-Daroff Exercises - home habituation exercises; patient performs repeated position changes to desensitize the vestibular system

• Posterior canal occlusion
• Singular neurectomy
• Vestibular neurectomy
• Labyrinthectomy (only in deafened ear)

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B. VESTIBULAR NEURITIS - Most Common Cause of Acute Prolonged Vertigo

• Acute, severe, persistent vertigo with nausea/vomiting
• Lasts days (acute phase), then gradual improvement over weeks
• Balance complaints may persist for months
• Positive head impulse test toward affected side
• Caloric weakness on the affected side

• Methylprednisolone may improve caloric function
• Benefit limited to caloric test improvement; symptomatic benefit is less clear
• Most beneficial if started within 3 days of onset
• Currently: weak evidence supports use in vestibular neuritis (Cummings Otolaryngology)

• Valacyclovir was NOT found to improve outcomes in controlled trials (Cummings Otolaryngology)
• NOT routinely recommended

• Early ambulation is STRONGLY encouraged
• Physical activity promotes central vestibular compensation (the brainstem "relearns" to compensate for the asymmetric input)

• Started as soon as acute phase settles (usually day 2-3)
• Exercises designed to:
  • Promote gaze stabilization
  • Improve balance
  • Reduce motion sensitivity
• Significantly shortens recovery time

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C. MENIERE'S DISEASE - If Recurrent Episodes with Hearing Loss + Tinnitus

• Two or more definitive spontaneous episodes of vertigo lasting at least 20 minutes
• Audiometrically documented hearing loss on at least one occasion
• Tinnitus or aural fullness in the suspected ear
• Other causes excluded

• Low-salt diet (< 2g sodium/day) - reduces endolymph volume
• Avoid caffeine, alcohol, nicotine
• Reduce stress
• Adequate sleep

• Intra-tympanic gentamicin - chemical labyrinthectomy; ablates vestibular function; risk of hearing loss. Used for disabling, medically refractory vertigo with serviceable hearing being acceptable risk.
• Intra-tympanic dexamethasone - preserves hearing while reducing attacks

• Endolymphatic sac surgery (decompression)
• Vestibular nerve section
• Labyrinthectomy (hearing already destroyed)

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STEP 7: GENERAL SYMPTOMATIC MANAGEMENT (Regardless of Cause)

Acute Attack Management

1. Rest in a quiet, dark room; keep still in position of comfort
2. IV fluids if severe vomiting causing dehydration
3. Anti-emetics: Prochlorperazine IM/buccal or Cyclizine IV
4. Vestibular suppressants: short course only

Vestibular Rehabilitation

• Cawthorne-Cooksey exercises: head movement exercises (looking up and down, side to side, progressively with body movements)
• Improves compensation for all types of peripheral vestibular disorders

Patient Education and Safety

• Avoid driving until vertigo fully resolves
• Avoid heights, ladders, machinery
• Explain the natural history - reassure that most causes in a young healthy person are benign and resolve
• No sudden head movements initially

Lifestyle Advice

• Adequate hydration
• Regular sleep schedule
• Reduce caffeine and salt intake (even outside of Meniere's, these can worsen symptoms)
• Avoid ototoxic drugs (aminoglycosides, furosemide)

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STEP 8: RED FLAGS - WHEN TO SUSPECT CENTRAL CAUSE (URGENT MRI)

• Vertical nystagmus or direction-changing nystagmus
• Nystagmus not suppressed by fixation
• Negative head impulse test despite ongoing spontaneous nystagmus
• Skew deviation on eye exam
• Diplopia, dysarthria, dysphagia
• Sudden-onset severe headache ("thunderclap")
• Limb ataxia or truncal ataxia out of proportion to severity of vertigo
• Multiple cranial nerve palsies
• Inability to walk or severe gait ataxia with relatively mild vertigo

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STEP 9: FOLLOW-UP PLAN

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Summary Flowchart (Simplified)

Acute Vertigo in 28-yr female
         |
    HISTORY + EXAMINATION
         |
  ┌──────┴──────┐
Central signs?  No central signs
(vertical nystagmus,   |
no HIT correction,    Peripheral
neurological sx)       |
  |              ┌─────┴──────────┐
Urgent MRI    Position-    Continuous/
              triggered    Days/weeks
                 |              |
               BPPV         ±Hearing loss?
                 |              |
           Dix-Hallpike    No HL → Vestibular Neuritis
           positive        HL+Tinnitus → Consider Meniere's
                 |
          Epley Maneuver

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• Cummings Otolaryngology Head and Neck Surgery - Vestibular Neuritis, Meniere's Disease chapters
• K.J. Lee's Essential Otolaryngology, 11th Ed. - BPPV, Differential Diagnosis table
• Scott-Brown's Otorhinolaryngology Head & Neck Surgery Vol. 1 - Pharmacological management of vertigo