Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 8-07: Diseases of the Inner Ear + Key Features Download Section PDF Listen +++ +++ 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 Graphic Jump LocationTable 8–3.Common vestibular disorders: differential diagnosis based on classic presentations.View Table||Download (.pdf) Table 8–3. Common vestibular disorders: differential diagnosis based on classic presentations. Duration of Typical Vertiginous Episodes Auditory Symptoms Present Auditory Symptoms Absent Seconds Perilymphatic fistula Benign paroxysmal positioning vertigo (cupulolithiasis), vertebrobasilar insufficiency, migraine-associated vertigo Hours Endolymphatic hydrops (Ménière syndrome, syphilis) Migraine-associated vertigo Days Labyrinthitis, labyrinthine concussion, autoimmune inner ear disease Vestibular neuronitis, migraine-associated vertigo Months Acoustic neuroma, ototoxicity Multiple sclerosis, cerebellar degeneration +++ 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 Download Section PDF Listen +++ +++ 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 be observed by using Frenzel goggles, which prevent visual fixation Fukuda test can demonstrate vestibular asymmetry when the patient steps in place with eyes closed and consistently rotates Positional vertigo Typical symptoms occur in clusters that persist for several days A brief latency period (10–15 s) follows head movement before symptoms develop Acute vertigo subsides within 10–60 s, but patient may remain imbalanced for several hours Constant repetition of positional change leads to habituation In central lesions, there is no latent period, fatigability, or habituation Ménière syndrome Classic syndrome consists of episodic vertigo, with discrete vertigo spells lasting 20 min to several hours in association with Fluctuating low-frequency sensorineural hearing loss Tinnitus (usually low-tone and "blowing" in quality) Sensation of unilateral aural pressure Symptoms wax and wane as endolymphatic pressure rises and falls Caloric testing commonly reveals loss or impairment of thermally induced nystagmus on the involved side Labyrinthitis Acute onset of continuous, usually severe vertigo lasting several days to a week, hearing loss, tinnitus During recovery (several weeks), vertigo gradually improves Hearing may return to normal or be permanently impaired in involved ear +++ Central vestibulopathy ++ Vertigo of central origin often becomes unremitting and disabling CNS causes of vertigo include Brainstem vascular disease Arteriovenous malformations Tumor of the brainstem and cerebellum Multiple sclerosis Vertebrobasilar migraine Nystagmus Not always present but can occur in any direction and may be dissociated in both eyes Often nonfatigable, vertical rather than horizontal, without latency, unsuppressed by visual fixation +++ Differential Diagnosis ++ Imbalance Light-headedness Syncope + Diagnosis Download Section PDF Listen +++ +++ Imaging Studies ++ MRI to evaluate persistent vertigo or when central nervous system disease is suspected +++ Diagnostic Procedures ++ Audiologic evaluation, caloric stimulation, ENG, VNG, vestibular-evoked myogenic potentials are indicated in patients with persistent vertigo or when central nervous system disease is suspected ENG is helpful in quantifying the degree of vestibular hypofunction Vestibular-evoked myogenic potentials help distinguish between central and peripheral lesions and to identify causes requiring specific therapy + Treatment Download Section PDF Listen +++ +++ Medications ++ Diazepam or meclizine For acute phases of vertigo only Discontinue as soon as feasible to avoid long-term dysequilibrium Ménière disease Low-salt diet Diuretics (eg, acetazolamide) For acute attacks, oral meclizine (25 mg) or valium (5 mg) Labyrinthitis Antibiotics if patient is febrile or has symptoms of bacterial infection Vestibular suppressants (eg, oral diazepam, 5 mg or oral meclizine, 25 mg) +++ Therapeutic Procedures ++ Positioning vertigo: involves physical therapy protocols (eg, the Epley maneuver or Brandt-Daroff exercises) For refractory cases of Ménière disease Intratympanic corticosteroid injections Endolymphatic sac decompression Vestibular ablation either through transtympanic gentamicin, vestibular nerve section, or surgical labyrinthectomy + Outcome Download Section PDF Listen +++ +++ When to Refer ++ Audiologic evaluation, caloric stimulation, ENG, VNG, and MRI are indicated in patients with persistent vertigo or when CNS disease is suspected + References Download Section PDF Listen +++ + +Argaet EC et al. Benign positional vertigo, its diagnosis, treatment and mimics. Clin Neurophysiol Pract. 2019 Apr 6;4:97–111. [PubMed: 31193795] + +Bronstein AM et al. Long-term clinical outcome in vestibular neuritis. Curr Opin Neurol. 2019 Feb;32(1):174–80. [PubMed: 30566414] + +Choi JY et al. Central vertigo. Curr Opin Neurol. 2018 Feb;31(1):81–9. [PubMed: 29084063] + +Sandhu JS et al. Clinical examination and management of the dizzy patient. Br J Hosp Med (Lond). 2016 Dec 2;77(12):692–8. [PubMed: 27937029] + +Gibson WPR. Meniere's disease. Adv Otorhinolaryngol. 2019;82:77–86. [PubMed: 30947172] + +Hain T et al. Migraine associated vertigo. Adv Otorhinolaryngol. 2019;82:119–26. [PubMed: 30947176] + +Instrum RS et al. Benign paroxysmal positional vertigo. Adv Otorhinolaryngol. 2019;82:67–76. [PubMed: 30947198] + +Marcus HJ et al. Vestibular dysfunction in acute traumatic brain injury. J Neurol. 2019 Oct;266(10):2430–3. [PubMed: 31201499] + +Ranalli P. An overview of central vertigo disorders. Adv Otorhinolaryngol. 2019;82:127–33. [PubMed: 30947212] + +Sorathia S et al. Dizziness and the otolaryngology point of view. Med Clin North Am. 2018 Nov;102(6):1001–12. [PubMed: 30342604] + +van Esch BF et al. Clinical characteristics of benign recurrent vestibulopathy: clearly distinctive from vestibular migraine and Menière's disease? Otol Neurotol. 2017 Oct;38(9):e357–63. [PubMed: 28834943] + +Welgampola MS et al. Dizziness demystified. Pract Neurol. 2019 Dec;19(6):492–501. [PubMed: 31326945] + +Whitman GT. Dizziness. Am J Med. 2018 Dec;131(12):1431–7. [PubMed: 29859806]