Vertigo

How to Cite This Chapter: Wong A, David-Longe S, Khalid Z, Zhou K, Gupta M, Bodzioch M. Vertigo. McMaster Textbook of Internal Medicine. Kraków: Medycyna Praktyczna. https://empendium.com/mcmtextbook/chapter/B31.I.1.124. Accessed July 01, 2022.
Last Updated: March 24, 2022
Last Reviewed: March 24, 2022
Chapter Information

Vertigo is the symptom of illusionary movement. Patients may experience self-motion or motion of the environment relative to themselves. Some patients may report spinning, swaying, or tilting sensations, while others may provide nonspecific descriptors such as imbalance or dizziness.

Vertigo is often accompanied by nausea and vomiting. Other symptoms, specifically the presence of tinnitus, aural pressure, or hearing loss, may assist the clinician to identify the underlying etiology.

PathophysiologyTop

The vestibular system can be broadly categorized into peripheral and central components. The bilateral peripheral system is composed of 3 semicircular canals and 2 otolithic organs within the inner ears. When stimulated, these organs transmit afferent signals via the vestibular nerve through the internal auditory canal and synapses at the vestibular nuclei at the pontomedullary junction in the brainstem. In conjunction with the cerebellum, these sensory inputs are processed with proprioceptive and ocular sensory inputs to coordinate balance and position.

Any disease process that affects the vestibular system can result in vertigo.

DiagnosisTop

Take a history to confirm symptoms of vertigo, symptom duration, frequency of episodes, aggravating and provoking factors and associated symptoms. Past medical history may reveal risk factors related to underlying etiology (such as vascular risk factors and vertebrobasilar ischemia), and family history may suggest a hereditary cause. Current medications and prior medication history may reveal exposures to culprit medications, which can result in toxic adverse effects.

Examine the patient for peripheral nystagmus (horizontal, unidirectional, with a fast component towards the normal ear, suppressible with visual fixation) or central nystagmus (in any direction including vertical and torsional—may be bidirectional—not suppressible with visual fixation). Assess for balance, gait, hearing, and other neurologic symptoms. Perform the Dix–Hallpike maneuver to test for benign paroxysmal positional vertigo (BPPV) and HINTS (includes Head Impulse/thrust test, observing for direction-changing Nystagmus, and Test of Skew; detailed information can be accessed at www.sjrhem.ca) to help distinguish between central or peripheral causes (Table 1.38-1). A general otologic examination with the addition of a fistula test may be useful. Cerebellar testing including a finger-nose test, testing for dysdiadochokinesias, Romberg test, and test of tandem gait should be performed.

Selected aspects of differentiation between central and peripheral vertigo: Table 1.38-2. Differentiation between the most common forms of peripheral vertigo: Table 1.38-3.

Diagnostic studies may be useful in patients with a history and examination suggestive of an anatomic lesion. Magnetic resonance imaging (MRI) or magnetic resonance angiography (MRA) of the head can detect posterior fossa lesions, infarction, and stenosis or occlusions involving the posterior circulation. Audiometry can detect hearing loss.

TreatmentTop

Treat the underlying disease and eliminate any associated risk factors. Patients with BPPV without cervical spine disorder should be treated with the Epley maneuver or canalith repositioning procedure.

Symptomatic treatment with antihistamines (eg, meclizine, dimenhydrinate), benzodiazepines (eg, diazepam, lorazepam), or antiemetics (eg, metoclopramide, ondansetron) may be considered for acute episodes that last hours to days; however, medications should be discontinued as soon as possible, because they may interfere with central compensation and overall recovery.

Ablation can be considered for debilitating Ménière disease. Most commonly this is performed using intratympanic vestibulotoxic aminoglycosides.

Patients with peripheral vestibular disorders should be referred to a physiotherapist for vestibular exercises.

TablesTop

Table 1.38-1. Physical examination maneuvers

 

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

Based on Crane BT, Minor LB. Peripheral Vestibular Disorders. In: Flint PW, Haughey BH, Robbins KT, Thomas JR, Niparko JK, Lund VJ, Lesperance MM, eds. Cummings Otolaryngology. 7th ed. Elsevier; 2020:2517-2535.

Table 1.38-2. Differentiation between central and peripheral vertigo

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

Table 1.38-3. Differential diagnosis of peripheral vestibular disorders

 

Duration of vertigo and incidence

Pathophysiology

Clinical presentation

Diagnosis

BPPV

 

– Seconds

– Most common peripheral vertigo disorder

– Canalithiasis (migration of free-floating otoliths within the 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 are frequently clustered in time and separated by remissions lasting months or longer

 

The 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 in 500 (United States)

Overaccumulation of endolymph due to inadequate absorption by the endolymphatic sac distorts functioning of the 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 1 of the episodes of vertigo

– 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 while vestibular neuritis does not

Superior semicircular canal dehiscence syndrome

– Variable

– Rare, unknown

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

– Nystagmus: vertical and torsional rotation aligning with the superior canal

– Autophony

– Conductive hearing loss

– Pulsatile tinnitus

– Tullio phenomenon

– Hennebert sign

High-resolution CT scans with reconstructions in the plane of the superior canal 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) At least 5 episodes of vestibular symptoms of moderate or severe intensity lasting 5 min to 72 h

2) Current or prior history of migraine

3) One or more migraine features with ≥50% of the vestibular episodes (migraine headache, photophobia or phonophobia, and visual aura)

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

Based on Crane BT, Minor LB. Peripheral Vestibular Disorders. In: Flint PW, Haughey BH, Robbins KT, Thomas JR, Niparko JK, Lund VJ, Lesperance MM, eds. Cummings Otolaryngology. 7th ed. Elsevier; 2020:2517-2535 and Basura GJ, Adams ME, Monfared A, et al. Clinical Practice Guideline: Ménière’s Disease. Otolaryngol Head Neck Surg. 2020;162(2_suppl):S1-S55. doi:10.1177/0194599820909438. PMID: 32267799.

AAO-HNS, American Academy of Otolaryngology–Head and Neck Surgery; BPPV, benign paroxysmal positional vertigo; CT, computed tomography; EAC, external auditory canal; ICHD, International Classification of Headache Disorders.

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