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Vertigo (ReelDx + Lecture)

VIDEO-CASE-PRESENTATION-REEL-DX

Vertigo

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

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)

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 Osmosis
Picmonic
Vertigo

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
A 60-year-old woman presents with sudden, brief episodes of vertigo triggered by specific head movements, such as rolling over in bed or looking up. There is no associated hearing loss or tinnitus. The Dix-Hallpike maneuver elicits transient nystagmus. What is the most likely diagnosis?
A
Meniere's disease
Hint:
Meniere's disease involves episodic vertigo, hearing loss, tinnitus, and aural fullness.
B
Vestibular neuritis
Hint:
Vestibular neuritis presents with prolonged vertigo but not triggered by head movements, and without hearing loss.
C
Labyrinthitis
Hint:
Labyrinthitis includes vertigo and hearing loss, not solely provoked by position changes.
D
Benign paroxysmal positional vertigo
E
Acoustic neuroma
Hint:
Acoustic neuroma typically presents with progressive unilateral hearing loss and tinnitus, not episodic positional vertigo.
Question 2
A 35-year-old man experiences sudden onset of intense, continuous vertigo lasting several days, accompanied by nausea and vomiting. He denies any hearing loss or tinnitus. The symptoms began without any preceding illness or injury. What is the most likely diagnosis?
A
Benign paroxysmal positional vertigo
Hint:
BPPV causes brief episodes of vertigo related to head position changes.
B
Vestibular neuritis
C
Labyrinthitis
Hint:
Labyrinthitis also presents with auditory symptoms like hearing loss.
D
Meniere's disease
Hint:
Meniere's disease involves episodic vertigo, hearing loss, tinnitus, and aural fullness.
E
Acoustic neuroma
Hint:
Acoustic neuroma usually presents with unilateral hearing loss and tinnitus, not acute vertigo.
Question 2 Explanation: 
Vestibular neuritis is characterized by acute, prolonged vertigo without associated auditory symptoms, often following a viral infection, though it can start without any apparent cause.
Question 3
A 45-year-old man presents with a sudden onset of vertigo, unilateral hearing loss, and tinnitus following an upper respiratory infection. The vertigo is severe and continuous, lasting for several days. What is the most likely diagnosis?
A
Benign paroxysmal positional vertigo
Hint:
BPPV is characterized by brief, positionally triggered episodes of vertigo without hearing loss.
B
Vestibular neuritis
Hint:
Vestibular neuritis presents with vertigo but without hearing loss or tinnitus.
C
Labyrinthitis
D
Meniere's disease
Hint:
Meniere's disease involves episodic vertigo, not continuous, along with fluctuating hearing loss.
E
Acoustic neuroma
Hint:
Acoustic neuroma presents with progressive hearing loss and tinnitus, typically without acute vertigo episodes.
Question 3 Explanation: 
Labyrinthitis involves inflammation of the inner ear or labyrinth, leading to vertigo, hearing loss, and tinnitus, often following a viral infection.
Question 4
A 50-year-old woman reports recurrent episodes of vertigo, each lasting several hours, accompanied by unilateral hearing loss, tinnitus, and a sensation of fullness in the affected ear. These symptoms have been occurring intermittently over the past year. What is the most likely diagnosis?
A
Benign paroxysmal positional vertigo
Hint:
BPPV involves short-lived vertigo episodes triggered by head movements, without auditory symptoms.
B
Vestibular neuritis
Hint:
Vestibular neuritis is marked by a single prolonged episode of vertigo without hearing loss.
C
Labyrinthitis
Hint:
Labyrinthitis presents with continuous vertigo and hearing loss, typically following an infection.
D
Meniere's disease
E
Acoustic neuroma
Hint:
Acoustic neuroma involves progressive unilateral hearing loss and tinnitus but not episodic vertigo.
Question 4 Explanation: 
Meniere's disease is characterized by episodic vertigo, fluctuating hearing loss, tinnitus, and aural fullness, typically affecting one ear.
Question 5
A 58-year-old woman presents with gradual onset of unilateral hearing loss and tinnitus over the past year. She also notes occasional mild imbalance. An MRI is ordered and reveals a mass arising from the internal auditory canal. Which of the following is the most likely diagnosis?
A
Acoustic neuroma
B
Benign paroxysmal positional vertigo (BPPV)
Hint:
BPPV causes episodic vertigo without hearing loss or tinnitus.
C
Labyrinthitis
Hint:
Labyrinthitis includes vertigo and hearing loss but is not associated with a mass on imaging.
D
Meniere's disease
Hint:
Meniere's disease involves episodic vertigo and hearing loss but not due to a cerebellopontine angle mass.
E
Vestibular neuritis
Hint:
Vestibular neuritis presents with acute vertigo but no hearing loss.
Question 5 Explanation: 
Acoustic neuromas (also called vestibular schwannomas) are benign tumors arising from the Schwann cells of the vestibulocochlear nerve. They characteristically present with progressive unilateral hearing loss, tinnitus, and sometimes vestibular symptoms. Imaging confirms the diagnosis.
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References: Merck Manual · UpToDate

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