PANCE Blueprint EENT (9%)

Vertigo (ReelDx)

VIDEO-CASE-PRESENTATION-REEL-DX

Vertigo

Patient will present with → a feeling like objects around them are moving when they are not

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, endolymphatic hydrops (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 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 = vertebral basilar insufficiency

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 a delayed fatigable nystagmus.

  • If the nystagmus is nonfatigable, 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

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?
A
Ménière's disease
Hint:
Ménière's disease is associated with hearing loss, tinnitus, and vertigo that lasts from seconds to hours.
B
Vestibular neuronitis
C
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.
D
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 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?
A
Benign positional vertigo
B
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.
C
Acoustic neuroma
Hint:
Acoustic neuroma is characterized by an insidious onset of vertigo with impaired unilateral hearing and the presence of tinnitus.
D
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.
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 n
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