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