Vertigo

Administration

Abnormal result

Normal result

Dix-Hallpike test for posterior BPPV

While the patient’s head is oriented 45 degrees to the tested ear, lie them down quickly from a seated position to supine, with head extending ~30 degrees below horizontal

Nystagmus (vertical upbeating and torsional beating toward downward eye) after seconds, lasting <1 min, with associated vertiginous symptoms that are fatigable

No nystagmus or vertiginous symptoms

Head impulse test for peripheral versus central vertigo

While the patient is instructed to stare at the examiner’s nose, apply brief, high-acceleration, horizontal head impulses in the excitatory direction of each canal, >15 degrees in each direction

After a head impulse towards a lesioned/hypoactive labyrinth, the vestibulo-ocular reflex will show decreased gain, moving the eye insufficiently to compensate for head motion, leading to a rapid saccade to bring the eyes back to the intended point of fixation

Patient’s eyes remain stable on the examiner (in the setting of vertigo it indicates peripheral vertigo)

Hennebert sign for third window disease/fistula

Vertigo/nystagmus evoked by changes in pressure in the inner ear (to increase intracranial pressure: Valsalva maneuver with a closed glottis; to increase middle ear pressure: Valsalva maneuver with an open glottis and nose pinch)

Tullio phenomenon for third window disease/fistula

Vertigo/nystagmus during exposure to loud sounds

Symptom characteristics

Central vertigo

Peripheral vertigo

Sensation of circular motion

Often a vague, difficult to describe feeling of imbalance or collapse, with unstable posture and unsteady gait

Sensation of circular motion

Onset of symptoms

Often insidious and difficult to determine

More often sudden, paroxysmal

Severity

Moderate or mild

Severe

Course

Stable or slowly variable

Most severe symptoms at onset, usually resolving gradually

Duration of a single episode

A few seconds; may result in falling

From several minutes to several hours

Duration of symptoms

Months, years

Up to a few weeks

Head movements

Minor effect on symptoms

Worsening of vertigo

Closing the eyes

No effect on symptoms

Improvement of vertigo

Disturbances of consciousness

Possible

None

Seizures

Possible

None

Headache

Often

Rare

Visual disturbances

Diplopia, scotomas, impaired visual acuity

None

Symptoms of central nervous system damage

Often paresis of the limbs and cranial nerves, ataxia, dysarthria, Horner syndrome (ptosis, constriction of the pupil, sinking of the eyeball), or other neurologic deficits

Isolated peripheral paresis of the facial muscles may occur

Hearing disorders

None

Hearing loss, deafness, tinnitus, feeling of fullness in the ear

Visual fixation

Vertigo does not stop

Vertigo stops

Duration of vertigo and incidence

Pathophysiology

Clinical presentation

Diagnosis

BPPV

– Seconds

– Most common peripheral vertigo disorder

– Canalithiasis (migration of free-floating otoliths within endolymph of the semicircular canal) or cupulolithiasis (otolith attached to the cupula of the semicircular canal)

– Most commonly involves the posterior canal

– Sudden onset of severe vertigo associated with changes in head position

– Episodes of vertigo frequently clustered in time and separated by remissions lasting months or longer

Dix-Hallpike maneuver for posterior canal BPPV:

– Nystagmus: vertical upbeating and torsional beating toward downward eye

– Latent onset (seconds)

– Short duration (<1 min)

– Associated vertiginous symptoms

– Disappears with repeated testing (fatigable)

Ménière disease (idiopathic endolymphatic hydrops)

– 20 min to 12 h

– ~1/500 (United States)

Overaccumulation of endolymph due to inadequate absorption by endolymphatic sac distorts functioning of membranous labyrinth

AAO-HNS diagnostic criteria for definite Ménière disease:

– ≥2 spontaneous attacks of vertigo, each lasting 20 min to 12 h

– Audiometrically documented fluctuating low- to midfrequency sensorineural hearing loss in the affected ear on ≥1 occasion before, during, or after a vertigo episode

– Fluctuating aural symptoms (hearing loss, tinnitus, or fullness) in the affected ear

– Not better explained by another diagnosis

Vestibular neuritis

– Days

– Unknown

Vestibular nerve inflammation and degeneration after viral disease

– Sudden onset of severe vertigo and vegetative symptoms

– Balance-related complaints persisting for months

– Labyrinthitis involves hearing loss, vestibular neuritis does not

Superior semicircular canal dehiscence syndrome

– Variable

– Rare, unknown

Absence of bone over superior canal creates a third mobile window that allows movement of endolymph during loud sound, Valsalva maneuver, positive pressure in EAC

– Nystagmus: vertical and torsional rotation aligning with superior canal

– Autophony

– Conductive hearing loss

– Pulsatile tinnitus

– Tullio phenomenon

– Hennebert sign

HRCT with reconstructions in the superior canal plane and orthogonal to that plane

Vestibular migraine

– 5 min to 72 h

– Most common cause of central vertigo in adults and children

Not well understood

ICHD diagnostic criteria:

1) ≥5 episodes of vestibular symptoms of moderate/severe intensity lasting 5 min to 72 h

2) Current or prior history of migraine

3) ≥1 migraine feature with ≥50% of vestibular episodes (migraine headache, photophobia or phonophobia, visual aura)

4) Not better accounted for by another vestibular or ICHD diagnosis