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.
- Peripheral (inner ear) causes of vestibular dysfunction include labyrinthitis, benign paroxysmal positional vertigo, Ménière syndrome, vestibular neuritis, and head injury
- Central (neurologic) causes of vertigo include brainstem vascular disease, arteriovenous malformations, tumors, multiple sclerosis, and vertebrobasilar migraine
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
Overview
| 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 Meclizine |
| 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 Tinnitus Self-limited 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 |
Diuretics
Salt restriction Unilateral CN VIII ablation (severe cases) |
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| Acoustic neuroma | Ataxia
Neurofibromatosis type II MRI findings Facial numbness |
Vertigo
Unilateral hearing loss Tinnitus AND ataxia |
Surgical intervention |
Clinical features of peripheral versus central vertigo
| Peripheral | Central | |
| Nystagmus | ||
| 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 |
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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.
| Vertigo | Play Video + Quiz |
| Meniere’s disease | Play Video + Quiz |
Question 1 |
Ménière's disease Hint: Ménière's disease is associated with hearing loss, tinnitus, and vertigo that lasts from seconds to hours. | |
Vestibular neuronitis | |
Benign positional vertigo Hint: Benign positional vertigo occurs with changes in position, especially rapid movements of the head. Nausea may occur, but vomiting is not significant. | |
Vertebrobasilar insufficiency Hint: Vertebrobasilar insufficiency is usually accompanied by brain stem findings, such as diplopia, dysarthria, or dysphagia, and is not common in this age group. |
Question 2 |
Benign positional vertigo | |
Ménière's disease Hint: 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 Hint: Acoustic neuroma is characterized by an insidious onset of vertigo with impaired unilateral hearing and the presence of tinnitus. | |
Vestibular neuronitis Hint: Vestibular neuronitis (acute labyrinthitis) has a sudden onset of vertigo lasting hours to two weeks. There is no hearing impairment or tinnitus. |
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List |
References: Merck Manual · UpToDate
