Vertigo
Cheryl A. Glass
Definition
A.Vertigo is the illusion of self or environmental movement, typically rotating, spinning, tilting, even a sensation that you are going to fall down. Older patients have an increased risk of falls and depression secondary to vertigo.
B.Vertigo is often classified as either central or peripheral in origin.
Incidence
A.Approximately 5% to 10% of the general population experience dizziness. However the incidence increases up to 40% in persons older than 40 years of age.
B.It is estimated that approximately 0.5% of the population consults their primary healthcare provider each year regarding vertigo.
C.Both sexes, as well as all age groups, are affected.
D.Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo, excluding central nervous system (CNS) lesions:
1.The prevalence of BPPV is 2.4%.
2.BPPV rarely occurs in people younger than 35 years unless there is a history of head trauma.
3.BPPV commonly presents in the ages between 50 and 70 years.
4.BPPV recurs in approximately one third of patients after 1 year and in about 50% in all patients treated after 5 years.
Pathogenesis
A.Distinguishing between peripheral and central vertigo is critical because the evaluation, treatment, and progress vary significantly. Central vertigo suggests brainstem dysfunction affecting the vestibular nuclei or their connections. This may be secondary to a structural lesion such as neoplasm or ischemia.
B.Vertigo due to vascular insufficiency is rarely isolated, and other symptoms of brainstem involvement are usually seen, such as diplopia, dysphagia, motor weakness, or disruption in sensation. Neoplasms are usually slow growing, and the vestibular dysfunction is often insidious. Central vertigo secondary to brainstem or cerebellar ischemia usually lasts for 20 minutes to 24 hours. The patient may be unable to ambulate during acute attacks of vertigo:
1.Other considerations for causes of central vertigo include multiple sclerosis (MS), seizures, and migraines. About 20% of patients with migraines experience vertigo, motion sickness, and mild hearing loss.
2.Progressive gait difficulty, memory loss, and urinary incontinence are commonly due to normal pressure hydrocephalus (NPH). Refer to the Normal Pressure Hydrocephalus chapter earlier in this guideline for further discussion.
C.Vertigo of peripheral origin is more common and may be caused by dysfunction of the inner ear or vestibular nerve. BPPV is the most commonly diagnosed of peripheral vestibular disorders. The cause of BPPV is unknown. The most common explanation is free otoconia within the semicircular canals that are dislodged by trauma, infection, or degeneration. The debris relocates when the head is repositioned and provokes vertigo. Causes of labyrinthine dysfunction include infection, trauma, ischemia, or toxins such as drugs or alcohol.
D.Ménière’s disease causes vertigo, hearing loss, and ringing of the ears. The exact cause is unknown but a hypothesis is a buildup of fluid in the inner ear.
E.Viral infections may lead up to vestibular neuritis (labyrinthitis). The vertigo experienced with vestibular neuritis is sudden and severe and may last days.
F.Other possible causes of vertigo are psychogenic, cardiovascular, or metabolic conditions, as well as head trauma and migraines.
G.Medications that cause dizziness:
1.Anticonvulsants.
2.Antidepressants.
3.Antipsychotics.
4.Anxiolytic/sedatives.
5.Antihypertensives.
6.Nitrates.
7.Diuretics.
8.Insulin/oral hypoglycemic agents.
Predisposing Factors
A.Head or body movement:
1.Rolling over in bed.
2.Getting out of bed.
3.Bending down from the waist.
4.Looking up.
B.Fear or anxiety.
C.Stress.
D.Recent infection, usually upper respiratory in cases of vestibular neuronitis.
E.Family history, especially in cases of vertiginous migraine.
F.Head trauma.
G.Migraines.
H.Idiopathic with no cause identified.
I.Hypoglycemia.
J.Alcohol intoxication.
K.Medication side effects.
L.Cerebellar or brainstem stroke.
M.Tumors.
N.MS.
O.Dehydration.
Common Complaints
A.Dizziness with or without change in body positioning.
B.Feeling of imbalance.
C.Nausea/vomiting.
D.Tinnitus.
E.Aural fullness.
F.Hearing loss.
Other Signs and Symptoms
A.Central origin, including vascular insufficiencies, strokes, neoplasms, migraine, MS, seizures:
1.Double vision.
2.Dysarthria.
3.Dysphagia.
4.Paresthesias.
5.Changes in motor or sensory exam.
6.Mild to moderate vertigo.
7.Multiple episodes of vertigo lasting seconds to minutes in duration with vascular insufficiency and seizures.
8.Constant complaints of vertigo with neoplasms or strokes.
9.Multiple episodes of vertigo lasting hours with migraines.
10.Single episodes of vertigo with MS.
11.Dix–Hallpike test: Habituation common with delayed nystagmus.
B.Peripheral origin, including BPPV, Ménière’s disease, labyrinthitis, vestibular dysfunction, vestibular neuritis, and acoustic neuroma:
1.No associated signs of brainstem dysfunction.
2.Vertigo, usually described as severe.
3.Multiple episodes of vertigo lasting hours with Ménière’s disease.
4.Single or multiple episodes of vertigo with labyrinthitis.
5.Vestibular dysfunction, described as constant vertigo.
6.Severe nausea or vomiting.
7.Hearing loss or tinnitus; aural fullness may be present, as well as a roaring sound.
8.Triad of vertigo, tinnitus, and hearing loss is suggestive of Ménière’s disease.
9.Dix–Hallpike test: No habituation: nystagmus occurs immediately.
Subjective Data
A.Elicit onset, frequency, duration, and course of presenting symptoms:
1.Is this recurrent or new?
a.Acute vertigo is seen with trauma, stroke, meningitis, otitis media, mastoiditis, drug use, vestibular neuronitis, MS, and labyrinthitis.
b.Recurrent vertigo is seen in vestibular migraines, BPPV, motion sickness, seizures, and Ménière’s disease.
B.Elicit from the patient a verbal description of the sensation(s) experienced. Ask the patient to describe their symptoms by using words other than dizzy.
The word dizzy is nonspecific to describe vertigo, unsteadiness, generalized weakness, syncope, presyncope, or falling. Descriptions may include light-headiness, unsteadiness, motion imbalance, floating, or a tilting sensation.
C.Note triggering and alleviating factors.
D.Query the patient regarding associated symptoms such as hearing loss, tinnitus, nausea, difficulty with gait, aural fullness, or other neurologic manifestations such as nystagmus. As a result of dizziness, ask the patient if he or she has ever fallen down when symptoms are present.
E.Review the patient’s past medical history, including recent infections, trauma, and risk factors for cardiovascular disease such as smoking, diabetes, and hyperlipidemia.
F.Evaluate alcohol intake.
G.Evaluate any recent change in the dosage and polypharmacy issues (number of prescriptions [>4 medications]). Review over-the-counter (OTC), herbal products, recreational drugs, and medication use: aminoglycoside, antibiotics, diuretics, antihypertensives, and antidepressants.
H.Has the patient had any previous treatments for vertigo such as an Epley procedure?
I.Has the patient had any previous testing such as:
1.Audiometric testing.
2.Electronystagmogram (ENG)/videonystagmography (VNG) to evaluate balance.
3.Rotational/balance platform test.
4.CT or MRI.
5.Computerized dynamic posturography (CDP) to evaluate postural stability/motor control.
Physical Examination
A.Check temperature (if infection is suspected), pulse, respirations, and supine and standing blood pressures; note orthostatic hypotension.
B.Inspect:
1.Observe overall appearance. Generalized muscle weakness may be observed.
2.Note gait: Difficulty with tandem gait. Note global weakness.
3.Inspect the eyes: Assess for nystagmus; a few beats of nystagmus on extreme lateral gaze may be normal.
4.Ear examination: Rule out otitis media. Whisper and ask the patient to repeat heard words.
5.Evaluate for aphasia that may indicate a stroke.
C.Palpate:
1.Palpate extremities; note pulses and edema.
2.Perform Rinne and Weber’s tests.
D.Neurologic exam:
1.Perform complete neurologic exam.
2.Assess CNs.
Brainstem involvement is frequently seen with detailed neurologic exam. Signs of cerebellar dysfunction include difficulty with finger-to-nose testing, rapid alternating supination or pronation of hands, and gait disturbance.
3.Perform Romberg test: The patient stands with feet together and closes his or her eyes. Positive result is when the patient sways. This may be seen with vestibular disease and acoustic neuroma.
4.The Dix–Hallpike test (also called Nylen–Barany’s maneuver test) is a provocative positional test:
The Dix–Hallpike maneuver is considered the gold standard for diagnosing BPPV. However, a negative test does not rule out BPPV if the patient is asymptomatic on the date of the test. If a positive response is observed on the initial side, no further testing is required.
a.Perform the Dix–Hallpike: While the patient is seated on the middle third of the examination table, turn the patient’s head 45 degrees toward the affected side (problem ear). While holding the head in that position, assist the patient to the reclining position past the supine position. BPPV has a distinctive nystagmus in which there is involuntary eye movement (predominately in a rotating fashion) starting slowly, progressing to a fast phase, and then reaching a resetting phase. The nystagmus generally lasts less than 20 seconds and reverses itself once the patient sits upright:
i.Caution should be taken in performing the Dix–Hallpike test with patients who have cervical stenosis, severe kyphoscoliosis, spinal cord injuries, and significant vascular disease such as vertebral artery stenosis.
5.Test for nuchal rigidity if fever is present.
E.Auscultate:
1.Auscultate the heart, neck, and carotid arteries. Physical examination may reveal cardiovascular abnormalities, such as a carotid bruit.
2.Auscultate lungs: Pneumonia may cause dizziness.
3.Auscultate the abdomen.
Diagnostic Tests
A.Laboratory testing:
1.Thyroid function studies: To rule out hypothyroidism.
2.Venereal disease research laboratory (VDRL): To rule out secondary or early tertiary syphilis, which can have symptoms similar to those of Ménière’s disease.
3.Complete blood count (CBC): To rule out infection or severe anemia.
4.Electrolytes: To rule out hyponatremia, hypokalemia, and dehydration.
5.Urine drug screen (if indicated).
6.Cardiac panel (if indicated).
7.Urinalysis to rule out a urinary tract infection (UTI) in the elderly.
B.CT scan for head trauma.
C.MRI with and without contrast to assess for mass, especially if a central origin is suspected.
D.Bithermal caloric test: Definitive procedure for identifying vestibular pathology. Cold irrigation is an inhibitory stimulus and warm irrigation is excitatory. The three most important findings from the caloric tests are unilateral weakness, bilateral weakness (peripheral vestibular disease), and failure of fixation suppression (FFS) of caloric-induced nystagmus (central cerebellar disease).
E.Electronystagmography: Most useful in chronic peripheral disorders to determine the degree and progression of vestibular deficit.