PANCE Blueprint EENT (7%)

Vertigo (ReelDx + Lecture)



55 y/o male with dizziness

Patient will present as → a 29-year-old male with intense nausea and vomiting that began yesterday. He states that he ran a 5K race in the morning and felt well while resting afterward. However, when he arose, he experienced two episodes of emesis accompanied by a sensation that the world was spinning around him. This lasted about one minute and subsided. He denies tinnitus or hearing changes but feels imbalanced. He has a PMH of migraines, but he typically does not have nausea or vomiting with migraine episodes. His temperature is 98.7°F, blood pressure is 132/82 mmHg, pulse is 75/min, and respirations are 13/min. The cardiopulmonary exam is unremarkable. Cranial nerves are intact, and gross motor function and sensation are within normal limits. When the patient’s head is turned to the right side and lowered quickly to the supine position, he claims that he feels “dizzy and nauseous.” Nystagmus is noted in both eyes.

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Vertigo is the sensation of movement (spinning, tumbling, or falling) in the absence of any actual movement or an over-response to movement.

Duration and presence of hearing loss/nystagmus can help with the diagnosis

  • Peripheral vertigo is associated with sudden onset, nausea/vomiting, tinnitus, hearing loss, and nystagmus (typically horizontal with a rotatory component)
  • Central vertigo is associated with a more gradual onset and vertical nystagmus. Unlike peripheral vertigo, it does not present with auditory symptoms. Central vertigo is commonly associated with motor, sensory, or cerebellar deficits.

Vertigo and syncope = vertebrobasilar insufficiency


Disease Characteristics Symptoms Diagnostic Test Treatment
Benign positional vertigo Changes with position Vertigo without hearing loss, tinnitus, or ataxia MRI of the internal auditory canal Diagnosis: Dix-Hallpike maneuver

Treatment: Epley maneuver


Vestibular neuritis Vertigo without position changes Vertigo but no hearing loss or tinnitus (inflammation of vestibular portion of CN VIII) associated with URI Meclizine
Labyrinthitis Acute, self-resolving episode Continuous Vertigo

Hearing loss



Associated with URI

Meclizine + steroids
Meniere's disease Chronic remitting and relapsing episodes Episodic Vertigo

Hearing loss

Tinnitus and chronic remitting and relapsing manner

Not associated with URI


Salt restriction

Unilateral CN VIII ablation (severe cases)

Acoustic neuroma Ataxia

Neurofibromatosis type II

MRI findings

Facial numbness


Unilateral hearing loss

Tinnitus AND ataxia

Surgical intervention

Clinical features of peripheral versus central vertigo

  Peripheral Central
Features (direction and type) Unidirectional, fast component toward the normal ear; never reverses direction

Horizontal with a torsional component; never purely torsional or vertical

Sometimes reverses direction when patient looks in the direction of slow component

Can be any direction; note that purely vertical or purely torsional nystagmus is a central sign

Effect of visual fixation Suppressed Not suppressed
Postural instability Unidirectional instability, walking preserved Severe instability, patient often falls when walking
Deafness or tinnitus May be present Usually absent
Other neurologic signs and symptoms Absent Often present (eg, diplopia, ataxia, dysarthria, dysphagia, focal or lateralized weakness)
  • With benign positional vertigo, the Dix–Hallpike maneuver (i.e., quickly turning the patient’s head 90 degrees while the patient is in the supine position) will produce delayed fatigable nystagmus (nystagmus abates when the provocative position is held for a long time)
  • If the nystagmus is non-fatigable (not inhibited by fixation of gaze), a central cause for the vertigo is more likely
  • Other testing, such as audiometry, caloric stimulation, electronystagmography (ENG), MRI, and evoked potentials, are indicated with persistent vertigo or with suspected central nervous system (CNS) involvement
  • + Romberg Sign = central vertigo

Therapy is based on the underlying etiology

  • Vestibular suppressants (i.e., diazepam, meclizine) may help with acute symptoms
  • Benign paroxysmal positional vertigo may respond to physical therapy maneuvers (Epley Maneuver)
  • Some cases may require interventional/surgical therapies

osmosis Osmosis

Vertigo is defined as an illusion of movement that’s either self-movement or movement of the surrounding environment. Vertigo is classified into peripheral and central vertigo. Peripheral vertigo is caused by disorders like BPPV, vestibular neuritis, Ménière’s disease, and an acoustic neuroma, while the causes of central vertigo include posterior circulation stroke and brainstem or cerebellar tumors or lesions. A diagnosis can be made based on clinical presentation and patient’s history, but sometimes imaging studies should be done to rule out central causes like a posterior circulation stroke.

Play Video + Quiz
Meniere’s disease
Play Video + Quiz

Question 1
A 23 year-old graduate student presents with sudden onset of severe dizziness, with nausea and vomiting for the past couple of hours. She denies hearing loss or tinnitus. She has had a recent cold. Which of the following is the most likely diagnosis?
Ménière's disease
Ménière's disease is associated with hearing loss, tinnitus, and vertigo that lasts from seconds to hours.
Vestibular neuronitis
Benign positional vertigo
Benign positional vertigo occurs with changes in position, especially rapid movements of the head. Nausea may occur, but vomiting is not significant.
Vertebrobasilar insufficiency
Vertebrobasilar insufficiency is usually accompanied by brain stem findings, such as diplopia, dysarthria, or dysphagia, and is not common in this age group.
Question 1 Explanation: 
Vestibular neuronitis or labyrinthitis presents with vertigo, nausea, and vomiting, but not hearing loss or tinnitus. It is related to viral URIs, and develops over several hours, with symptoms worse in the first day, with gradual recovery over several days.
Question 2
A patient presents with complaint of sudden onset of recurrent episodic vertigo for one week that happens when rolling onto the left side. The patient states that this sensation lasts approximately 30 seconds and then goes away. The patient admits to associated nausea. The patient denies associated hearing difficulties or tinnitus. Which of the following is the most likely diagnosis?
Benign positional vertigo
Ménière's disease
Ménière's disease is characterized by a sudden onset of vertigo that lasts several hours to more than a day. Patients typically have sensorineural hearing loss and tinnitus.
Acoustic neuroma
Acoustic neuroma is characterized by an insidious onset of vertigo with impaired unilateral hearing and the presence of tinnitus.
Vestibular neuronitis
Vestibular neuronitis (acute labyrinthitis) has a sudden onset of vertigo lasting hours to two weeks. There is no hearing impairment or tinnitus.
Question 2 Explanation: 
Benign positional vertigo is characterized by the sudden onset of vertigo when rolling onto the affected side or tilting the head up. The typical duration is less than a minute. There can be associated nausea and vomiting. There is no hearing impairment or tinnitus.
There are 2 questions to complete.
Shaded items are complete.

References: Merck Manual · UpToDate

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