Vertigo

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 or other neurologic issues

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

General Considerations

• Vertigo can be caused by either a peripheral of central etiology, or both

• 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

Positioning vertigo

• Commonly known as benign paroxysmal positioning vertigo (BPPV)

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

Endolymphatic hydrops (Ménière disease)

• Cause is unknown

Clinical Findings

Symptoms and Signs

• See Table 8–3

• Critical elements of the history

  • Duration of discrete vertiginous episodes

  • Associated symptoms (ie, hearing loss)

• Triggers should also be sought

  • Diet (eg, increased salt intake in Ménière disease)

  • Stress

  • Fatigue

  • Bright lights (eg, migraine-associated dizziness)

• 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 central nervous system (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 sec) fatigable nystagmus in cases of BPPV

  • Nonfatigable 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 in one direction

• Ménière disease

  • Classic ...