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For further information, see CMDT Part 8-07: Diseases of the Inner Ear

Key Features

Essentials of Diagnosis

  • Either a sensation of motion when there is no motion or an exaggerated sense of motion in response to movement

  • Duration of vertigo episodes and association with hearing loss

  • Must differentiate peripheral from central causes of vestibular dysfunction

  • Peripheral: Onset is sudden; often associated with tinnitus and hearing loss; horizontal nystagmus may be present

  • Central: Onset is gradual; no associated auditory symptoms

  • Evaluation includes audiogram and electronystagmography (ENG) or videonystagmography (VNG) and MRI

General Considerations

  • Causes can be determined based on the duration of symptoms (seconds, hours, days, months) and whether auditory symptoms are present (Table 8–3)

  • Vertigo can occur as a side effect of

    • Anticonvulsants (eg, phenytoin)

    • Antibiotics (eg, aminoglycosides, doxycycline, metronidazole)

    • Hypnotics (eg, diazepam)

    • Analgesics (eg, aspirin)

    • Tranquilizing drugs and alcohol

Table 8–3.Common vestibular disorders: differential diagnosis based on classic presentations.
Positioning vertigo

  • Commonly known as benign paroxysmal positioning vertigo (BPPV) or benign positioning vertigo (BPV)

  • Associated with changes in head position, often rolling over in bed

Endolymphatic hydrops (Ménière disease)

  • Cause is unknown

  • Distention of the endolymphatic compartment of the inner ear may be part of pathogenesis of this disorder

  • Two known causes are syphilis and head trauma

Clinical Findings

Symptoms and Signs

  • See Table 8–3

  • A thorough history often narrows, if not confirms, the diagnosis

  • Triggers should also be sought

    • Diet (eg, high salt in Ménière disease)

    • Stress

    • Fatigue

    • Bright lights

  • Perform Romberg test; evaluate gait; observe for nystagmus

Peripheral vestibulopathy

  • Vertigo usually sudden; may be so severe that patient is unable to walk or stand; frequently accompanied by nausea and vomiting

  • Tinnitus and hearing loss may accompany; support otologic origin

  • Nystagmus usually horizontal with rotary component; fast phase usually beats away from diseased side

  • Visual fixation tends to inhibit nystagmus except in very acute peripheral lesions or with CNS disease

  • Dix-Hallpike test

    • Patient is quickly lowered into supine position with head extending over the edge and placed 30 degrees lower than the body, turned either to left or right

    • Elicits delayed onset (about 10 s) of fatiguable nystagmus in cases of benign positioning vertigo

    • Nonfatiguable nystagmus indicates central etiology for dizziness

  • Subtle forms of nystagmus may ...

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