Vertigo


Vertigo Central Migrainous Vertigo Often associated with headache
Wallenberg's Syndrome (CVA) Lateral medullary infarction
– Posterior inferior cerebellar artery from vertebral artery
– Vertigo, ipsilateral Horner’s syndrome, ipsilateral limb ataxia, hoarseness and dysphagia
Loss of pain and temperature sensation on ipsilateral face and contralateral trunk
Cerebellar Hemorrhage or Infarct Sudden intense vertigo and vomiting
Markedly impaired gait – falls to the side of the lesion
Nystagmus away from the lesion
Confused with vestibular neuronitis, but gait more disturbed
Chiari malformation Congenital protrusion of cerebellar tonsils through the foramen magnum
Positionally induced vertigo
Headache, long tract signs and lower cranial nerve involvement
Cerebellopontine angle tumors  
Multiple sclerosis  
Drug-induced vertigo  



Peripheral
Benign positional vertigo Brief spinning spells (Sec.)
Nausea, but rarely vomiting
No hearing loss, ear pain or tinnitus
Vestibular Neuritis Viral or post-viral inflammation of labyrinth
With unilateral hearing loss, it is called “labyrinthitis”
Last 1-2 days before resolution
Herpes Zoster Oticus (Ramsay-Hunt Syndrome) Herpes infection of geniculate ganglion
Acute vertigo, hearing loss, ipsilateral facial paralysis and zoster vesicles in canal and auricle
Tx: anti-virals
Menier’s Disease Endolymphatic Hydrops
Associated with tinnitus, hearing loss and ear fullness
Acoustic neuroma Vertigo is minor, tinnitus and hearing loss are main complaints
Labyrinthine concussion  
Perilymphatic fistula Vertigo and/or hearing loss stimulated by sneezing, coughing, lifting, straining.
“Tullio Phenomenon” – vertigo from loud noises
Aminoglycoside toxicity  

 
Differential Diagnosis of Vertigo
Disorder Duration of episodes Auditory symptoms Prevalence Peripheral or central vertigo
Benign paroxysmal positional vertigo Sec. No Common Peripheral
Perilymphatic fistula (head trauma, barotrauma) Sec. Yes Uncommon Peripheral
Vascular ischemia: transient ischemic attack Sec. to hrs Usually not Uncommon Central or peripheral*
Ménière’s disease Hours Yes Common Peripheral
Syphilis Hours Yes Uncommon Peripheral
Vertiginous migraine Hours No Common Central
Labyrinthine concussion Days Yes Uncommon Peripheral
Labyrinthitis Days Yes Common Peripheral
Vascular ischemia: stroke Days Usually not Uncommon Central or peripheral*
Vestibular neuronitis Days No Common Peripheral
Anxiety disorder Variable Usually not Common Unspecified
Acoustic neuroma Months Yes Uncommon Peripheral
Cerebellar degeneration Months No Uncommon Central
Cerebellar tumor Months No Uncommon Central
Multiple sclerosis Months No Uncommon Central
Vestibular ototoxicity Months Yes Uncommon Peripheral
 

Background

  1. Definitions

Pathophysiology

  1. Etiologies of dizziness multiple ranging from benign to life-threatening
  2. Requires appropriate evaluation

Diagnostics

  1. Most important to differentiate central from peripheral
  2. Evaluation

Treatment

  1. See peripheral vertigo and/or central vertigo for more specific info

Follow-Up

  1. Directed to specific cause or underlying pathology

 

 

Peripheral Vertigo

Background

  1. Vertigo: a form of dizziness often as a spinning sensation
    • It may also be felt as motion sickness or leaning to one side
    • Unlike being light-headed, patients with vertigo feel as if they are moving or spinning
    • 2 forms of vertigo: Peripheral and Central Vertigo
      • Peripheral vertigo is usually more severe than central vertigo
      • Peripheral vertigo is caused by a problem with the inner ear, which controls balance
      • Central vertigo refers to problems within the brain or brainstem
  2. Other symptoms of vertigo include
    • Loss of hearing in one ear
    • Tinnitus
    • Difficulty focusing eyes
    • Loss of balance
  3. There are several different forms or causes of peripheral vertigo
  4. Many forms of peripheral vertigo can be treated with meclizine (12.5-25 mg TID) or diazepam (5-10 mg TID)

Motion sickness

  • +/- N, sweating, pallor
  • Assoc with acceleration or motion
  • Treatment
    • Diphenhydramine 25 mg QID or
    • Meclizine 1 hr before inducing activity

Ménière's dz

  • Classic triad
    • Fluctuating unilateral deafness, tinnitus, intense vertigo
  • Abrupt onset & self-limited to 0.5-24 hr
  • Rarely occurs more than once a month; over diagnosed
  • Endolymphatic hydrops leading cause
  • Otolytic Crisis of Tumarkin's has been shown to occur
    • Sudden drop attack (w/o any Meniere's symptoms), followed by immediate recovery
    • Self limited (by merely standing up)
    • Further studies needed to define assoc w/ meniere's dz
  • Treatment
    • Decr salt intake
    • Diazepam 5-10 mg TID or
    • Meclizine 12.5-25 mg TID or
    • Diuretics (furosemide, HCTZ)
    • Follow-up w/ ENT if no improvement at 48 hr

Benign positional vertigo

  • Vertigo assoc w/ change in position, typically of head
  • Brief episodes lasting 5-20 sec
  • Easily reproduced (Barany test or Dix-Hallpike test)
    • Dix-Hallpike test
      • Patient upright, legs extended, head rotated 45 degrees
      • Clinician helps patient lie down backwards quickly with head held in 20 degrees of extension
      • The patient's eyes observed for about 45 Sec. for nystagmus (characteristic 5-10 second latency prior to onset of nystagmus)
      • If rotational nystagmus occurs then the test is considered positive for benign positional vertigo
  • Less responsive to Tx
  • Treatment
    • Diazepam 5-10 mg TID or
    • Meclizine 12.5-25 mg TID or
    • Epley maneuver
      • Upright sitting position with head rotated 45 degrees to affected side
      • Patient is then forced passively down backwards into supine position with head in Dis-Hallpike position (30 degree neck extension) and affected ear facing ground
      • Observe patient's eyes for nystagmus, remains in this position for 2 minutes
      • Patient's head is then turned 90 degrees to opposite side (unaffected ear faces the ground) while maintaining 30 degree neck extension, remains in this position for 2 minutes
      • Keep head & neck in fixed position relative to the body, have patient roll onto shoulder, rotating the head another 90 degrees in direction that they are facing (now looking downwards at 45 degree angle)
      • Observed eyes for nystagmus (nystagmus should be as before); remain in this position for 2 minutes
      • Finally, slowly bring patient back to upright sitting posture while maintaining 45 degree rotation of head and remain sitting for 30 Sec.
      • Repeat 2 more times, patient may experience dizziness

Infectious labyrinthitis

  • Assoc w/ hearing loss
  • Many etiologies (viral, fungal, treponemal)
  • Mumps, measles & zoster most common viral etiologies
  • Less common w/ early Tx of otitis media
  • Can result in marked audiometric dysfunction
  • Treatment
    • Resolution of infective process
    • Supportive Tx

Acute labyrinthitis

  • Acute post-infectious progressive vertigo lasting several hrs which subsides after several days
  • Hearing usually normal
  • Treatment
    • Diazepam 5-10 mg TID or
    • Meclizine 12.5-25 mg TID

Perilymph fistula (see also→Perilymph Fistula)

  • Neurosensory hearing loss with aggravation of vertigo by pneumatic otoscopic exam ("positive" fistula test)

Vestibulotoxic & ototoxic medications

  • Aminioglycosides
  • Macrolides
  • Furosemide
  • Aspirin
  • Quinine

 

Central Vertigo

Pathophysiology

Cerebellar or brain stem location

  • Thus other S/S related to brain stem/ cerebellum

Vertebrobasilar insufficiency

  • Rarely presents w/ vertigo alone
  • Contiguous involvement→→dizziness, diplopia or visual blurring, dysarthria, dysphagia, drop attacks & focal deficits (weakness in all four limbs) on exam
  • Tinnitus & hearing loss rare
  • Management:
    • Admit & obtain vascular studies (angio or MRA). Consider anticoagulation.

 Multiple sclerosis

  • Initially presents as vertigo in 10-30% of cases

 Seizure (complex-partial temporal lobe)

  • Us. assoc. w/ staring, lip smacking, grimacing, emotional outbursts & tonic-clonic seizures
  • Any cortical irritation can affect posterior superior temporal gyrus where vertigo is perceived

Vertebrobasilar migraine

  • Women w/ H/O migraine or family hx. Visual aura uncommon
  • May include vertigo in aura phase

Ototoxic agents

  • Aminoglycosides, loop diuretics & salicylates
  • Can induce bilateral sensorineural hearing loss w/ vestibular involvement

Cerebellar CVAs

  • Occlusion of PICA or vertebrobasilar arteries
  • Sudden onset, intense vertigo
  • Cranial nerve involvement common

Cerebellopontine angle tumor

  • Unilateral tinnitus, vertigo & neurosensory hearing loss
  • CN 5, 7, 8, 9,12 also commonly involved
  • Vertigo tends to remain w/out resolution

 

 

Vertebral Art. Dissection

Background

  1. Not limited to elderly, occurring frequently in pts <50 y/o
  2. Women>men (3:1)

Symptoms

  • Severe occipital HA
  • Meningeal sx,
  • Progressive sx of vertebrobasilar artery dissection
    • Vertigo
    • Increasing difficulty swallowing
    • Dysarthria
  • Aggressive chiropractic-type neck manipulation is risk factor
    • Sx onset approx. 30 min afterwards
      • Hair dresser syndrome
      • Chiropractic manipulation
      • Sports injury, aerobics
      • Sudden neck rotation or extension
  • Diagnostic imaging
    • MRI
    • Digital subtraction angiography
    • Angiogram

Treatment

  1. Anticoagulation w/ heparin is recommended
  2. Consult Neurosurgery early if suspect this Dx: this can be catastrophic!

 

Case Discussion
A 57 year old female patient of yours presents with dizziness and a sensation that she is spinning. It occurs when she turns in bed or lifts her head to look in an upper cabinet. Episodes are brief but are becoming more frequent. She has no tinnitus or hearing loss. The most likely diagnosis would be:

A. Meniere’s Disease
B. Benign paroxysmal positional vertigo
C. Vestibular neuronitis
D. Acoustic neuroma