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Vertigo

last modified on: Sun, 04/14/2019 - 10:24

Return to Meniere's Disease Overview

see also: BPPV Patient Handout

Dizziness is a common chief complaint seen by otolaryngologists.

One of the most common types of dizziness is vertigo.

  • Feeling of motion when it is not actually present
  • Room spinning
  • Associated with disorders of the inner ear

Vestibular Organs Canals Otolith Cochlea

By NASA [Public domain], via Wikimedia Commons

 

Classification:

  • Peripheral
    • Inner Ear/Vestibular System
    • Benign Paroxysmal Positional Vertigo
    • Meniere's Disease
    • Vestibular Neuritis
    • Superior Canal Wall Dehiscence
    • Vestibular Migraine
  • Central
    • CNS lesion
    • Tumor (vestibular schwannoma)
    • Hemorrhage 
    • Brainstem/cerebellar stroke

Benign Positional Paroxysmal Vertigo (BPPV):

  • Most common cause of vertigo
  • Intense vertigo for <60 seconds
  • Can be triggered by head movements such asrolling over in bed 
  • Otoconia displaced into semicircular canals

Diagnosis: Dix-Hallpike maneuvers

  • Examines posterior semicircular canal involvement
  • Start supine with neck extended
  • Head turned 45 degrees away from affected ear
  • Examine for nystagmus, vertigo symptoms

Treatment: Repositioning maneuvers (Epley or Semont)

Meniere's Disease:

  • Recurrent vertigo episodes lasting 30 minutes to several hours
    • Commonly associated with light-headedness, nausea and vomiting
  • Fluctuating sensorineural hearing loss which worsens over time
  • Low-frequency tinnitus
  • Aural fullness
  • Increase in endolymphatic fluid volume and pressure in middle ear 

Diagnosis: clinical findings as described above and audiometric data over time

Treatment:

  • Non-surgical
    • Trigger reduction: Reduce salt, caffeine, alcoholol, nicotine
    • Acute episodes mangaged with antiemetics and vestibular suppressants
    • Long-Term management includes thiazide diuretics, vestibular therapy and hearing aids
    • Intratypmanic injections of gentamicin 
  • Surgical
    • Endolymphatic shunt
    • Labyrinthectomy
    • Vestibular neurectomy

Vestibular Neuritis:

  • Acute single episode that may last several days
  • Often precipitated by viral illness
  • Diagnosis: Abnormal head thrust test
  • Treatment: Supportive

Superior Canal Wall Dehiscence:

  • Autophony, Dizziness
  • Brain fog 
  • Tinnitus 
  • Due to thinning/abscence of superior semicircular canal wall of temporal bone
  • Diagnosis: Thin slice temporal bone CT
  • Treatment: Surgical repair

Vestibular Migraine: 

  • Vertigo symptoms associated with headache or aura
  • Recurrent symptoms with complete resolution between episodes 

CNS Tumor: 

  • Most commonly vestibular schwannoma 
    • Benign growth arising from schwann cell on vestibular portion of CN VIII
    • Hearing loss 
    • Tinnitus 
    • Fluctuating vertigo
    • Facial pain or numbness
    • Bilateral vestibular schwannoma is the hallmark of Neurofibromatosis Type 2

Diagnosis: MRI scanning with gadolinium contrast 

Treatment:  

  • Observation
    •  Since vestibular schwannomas are typically slow growing, observation with follow-up MRI scans every 6 to 12 months may be warranted in carefully selected patients.
  • Surgery 
    • Several approaches may be employed to gain tumor access
  • Radiation 

Brainstem/cerebellar Stroke:

  • Symptoms typically associated with other neurological deficits
    • Lateral medullary syndrome (PICA infarction)
      • dysphagia, slurred speech, Horner's syndrome, ataxia 
      • contralateral loss of pain and temperature sensation from body
      • ipsilateral loss of pain and temperature sensation from face
  • Very rarely vertigo is isolated sign of a lacunar stroke involving only the vestibular system 
  • Symptoms in central vertigo may not improve, or will take much longer to improve than in peripheral vertigo

Diagnosis:

  • HINTS exam
    • The presence of any one of three clinical signs suggests central rather than peripheral vertigo: 
      • a normal head impulse test 
      • Direction-changing nystagmus
      • Skew deviation
  • Imaging: CT, CT angiography, MRI 
     

Further Reading: 

  • Dickerson, LM (2010). "Dizziness: a diagnostic approach". American Family Physician. 82 (4): 361–369. PMID 20704166.