- Dizziness can be classified into four groups:
- vertigo (spinning sensation)
- disequilibrium (feeling of imbalance)
- light-headedness (sensation of giddiness)
- presyncope (sensation of feeling faint).
- vertigo may be
- central (involving the brainstem or cerebellum)
- peripheral (involving the inner ear).
- The most common causes of vertigo seen in primary care are
- benign paroxysmal positional vertigo (BPPV)
- vestibular neuronitis (VN)
- Ménière’s disease.
These peripheral causes of vertigo are benign, and treatment involves reassurance and management of symptoms.
Cause | Description |
Peripheral causes | |
Acute labyrinthitis | Inflammation of the labyrinthine organs caused by viral or bacterial infection |
Acute vestibular neuronitis (vestibular neuritis)* | Inflammation of the vestibular nerve, usually caused by viral infection |
Benign positional paroxysmal vertigo (benign positional vertigo) | Transient episodes of vertigo caused by stimulation of vestibular sense organs by canalith; affects middle-age and older patients; affects twice as many women as men |
Cholesteatoma | Cyst-like lesion filled with keratin debris, most often involving the middle ear and mastoid |
Herpes zoster oticus (Ramsay Hunt syndrome) | Vesicular eruption affecting the ear; caused by reactivation of the varicellazoster virus |
Ménière’s disease (Ménière’s syndrome, endolymphatic hydrops) | Recurrent episodes of vertigo, hearing loss, tinnitus, or aural fullness caused by increased volume of endolymph in the semicircular canals |
Otosclerosis | [ corrected] Abnormal growth of bone in the middle ear, leading to immobilization of the bones of conduction and a conductive hearing loss; this process also may affect the cochlea, leading to tinnitus, vertigo, and sensorineural hearing loss |
Perilymphatic fistula | Breach between middle and inner ear often caused by trauma or excessive straining |
Central causes | |
Cerebellopontine angle tumor | Vestibular schwannoma (i.e., acoustic neuroma) as well as infratentorial ependymoma, brainstem glioma, medulloblastoma, or neurofibromatosis |
Cerebrovascular disease such as transient ischemic attack or stroke | Arterial occlusion causing cerebral ischemia or infarction, especially if affecting the vertebrobasilar system |
Migraine | Episodic headaches, usually unilateral, with throbbing accompanied by other symptoms such as nausea, vomiting, photophobia, or phonophobia; may be preceded by aura |
Multiple sclerosis | Demyelinization of white matter in the central nervous system |
Other causes | |
Cervical vertigo | Vertigo triggered by somatosensory input from head and neck movements |
Drug-induced vertigo | Adverse reaction to medications |
Psychological | Mood, anxiety, somatization, personality, or alcohol abuse disorders |
BPPV, Meniere’s Disease, Vestibular Neuritis, and Labyrinthitis:
Condition | Symptoms | Timing | Signs | Etiology | Diagnosis | Treatment |
---|---|---|---|---|---|---|
BPPV caused by dislodged otoliths. Brief episodes of vertigo triggered by changes in head position. Diagnosed with the Dix-Hallpike maneuver. | Vertigo triggered by head movement, nausea | Lasts seconds to minutes | Positive Dix-Hallpike test, rotational nystagmus | Displacement of otoconia in semicircular canals | Dix-Hallpike maneuver | Epley maneuver, antihistamines (Meclizine 25-100 mg daily), antiemetics (Ondansetron, Metoclopramide, Promethazine) |
Meniere’s Disease believed to be related to abnormal fluid buildup (endolymph) in the inner ear. Possible contributing factors include genetic predisposition, viral infections, autoimmune conditions, allergies, and head trauma. | Vertigo, tinnitus, hearing loss, aural fullness | Lasts 20 minutes to hours | Sensorineural hearing loss, episodic vertigo | Endolymphatic hydrops, idiopathic | Clinical diagnosis, audiometry | Betahistine (16-48 mg/day), thiazide diuretics (25-50 mg/day), salt restriction, avoid alcohol and caffeine |
Vestibular Neuritis Often follows a recent upper respiratory tract infection. that affects the vestibular nerve Presents with vertigo that can last days without hearing loss. | Vertigo, nausea, vomiting, balance problems | Lasts days to weeks | Unidirectional horizontal-torsional nystagmus, no hearing loss | Viral infection (e.g., HSV reactivation), inflammation of vestibular nerve | Clinical diagnosis, HINTS exam | Antiemetics (Promethazine 12.5-25 mg every 4-6 hours, Metoclopramide 10 mg TID), antihistamines (Diphenhydramine 25-50 mg every 4-6 hours), vestibular rehab |
Labyrinthitis often follows a recent acute otitis media (AOM). Characterized by a prolonged vertigo episode, usually associated with hearing loss and tinnitus on the affected side | Vertigo, nausea, vomiting, hearing loss, tinnitus | Lasts days to weeks | Hearing loss, spontaneous nystagmus | Viral or bacterial infection | Clinical diagnosis, audiometry | Same as vestibular neuritis plus antibiotics if bacterial, vestibular rehabilitation, corticosteroids in some cases if indicated |
True nystagmus and vertigo will never last longer than a couple of weeks if caused
by a peripheral lesion because compensation occurs; such is not true for a central lesion.
History
- associated neurological symptoms such as weakness, dysarthria, sensory changes, ataxia or confusion – consider central causes, such as cerebrovascular accidents (CVAs), tumours and multiple sclerosis
- check for Risk factors for vascular disease
- smoking, diabetes
- obesity
- hypertension
- hypercholesterolaemia
- symptoms of nausea, vomiting and hearing loss more associated with Peripheral pathology
- triggered by a
- change in the position of the head
- recent upper respiratory tract infection (URTI)
- stress
- Loud noises (called Tullio phenomenon)
- Medications, including frusemide, salicylates and antihypertensive agents
- Trauma – Perilymphatic fistula should be considered if there is a history of recent head injury.
- hearing loss and Vertigo
- seen in labyrithitis and Ménière’s disease
- No hearing loss – seen in benign paroxysmal positional vertigo (BPPV) and vestibular neuronitis (VN)
Duration of Symptoms
Duration of episode | Suggested diagnosis |
A few seconds | Peripheral cause: unilateral loss of vestibular function; late stages of acute vestibular neuronitis; late stages of Ménière’s disease |
Several seconds to a few minutes | Benign paroxysmal positional vertigo; perilymphatic fistula |
Several minutes to one hour | Posterior transient ischemic attack; perilymphatic fistula |
Hours | Ménière’s disease; perilymphatic fistula from trauma or surgery; migraine; acoustic neuroma |
Days | Early acute vestibular neuronitis*; stroke; migraine; multiple sclerosis |
Weeks | Psychogenic (constant vertigo lasting weeks without improvement) |
Provoking Factors
Provoking factor | Suggested diagnosis |
Changes in head position | Acute labyrinthitisbenign positional paroxysmal vertigocerebellopontine angle tumormultiple sclerosisperilymphatic fistula |
Spontaneous episodes (i.e., no consistent provoking factors) | Acute vestibular neuronitiscerebrovascular disease (stroke or transient ischemic attack)Ménière’s diseasemigrainemultiple sclerosis |
Recent upper respiratory viral illness | Acute vestibular neuronitis |
Stress | Psychiatric or psychological causesmigraine |
Immunosuppression (e.g., immunosuppressive medications, advanced age, stress) | Herpes zoster oticus |
Changes in ear pressure, head trauma, excessive straining, loud noises | Perilymphatic fistula |
Associated Symptoms
Symptom | Suggested diagnosis |
Aural fullness | Acoustic neuromaMénière’s disease |
Ear or mastoid pain | Acoustic neuromaacute middle ear disease (e.g., otitis media, herpes zoster oticus) |
Facial weakness | Acoustic neuromaherpes zoster oticus |
Focal neurologic findings | Cerebellopontine angle tumor; cerebrovascular disease; multiple sclerosis (especially findings not explained by single neurologic lesion) |
Headache | Acoustic neuroma; migraine |
Hearing loss | Ménière’s disease; perilymphatic fistula; acoustic neuroma; cholesteatoma; otosclerosis; transient ischemic attack or stroke involving anterior inferior cerebellar artery; herpes zoster oticus |
Imbalance | Acute vestibular neuronitis (usually moderate); cerebellopontine angle tumor (usually severe) |
Nystagmus | Peripheral or central vertigo |
Phonophobia, photophobia | Migraine |
Tinnitus | Acute labyrinthitis; acoustic neuroma; Ménière’s disease |
Associated with Hearing Loss
Diagnosis | Characteristics of hearing loss |
Acoustic neuroma | Progressive, unilateral, sensorineural |
Cholesteatoma | Progressive, unilateral, conductive |
Herpes zoster oticus (i.e., Ramsay Hunt syndrome) | Subacute to acute onset, unilateral |
Ménière’s disease | Sensorineural, initially fluctuating, initially affecting lower frequencies; later in course: progressive, affecting higher frequencies |
Otosclerosis | Progressive, conductive |
Perilymphatic fistula | Progressive, unilateral |
Transient ischemic attack or stroke involving anterior inferior cerebellar artery or internal auditory artery | Sudden onset, unilateral |
Peripheral vs. Central Causes of Vertigo
Feature | Peripheral vertigo | Central vertigo |
Nystagmus | Combined horizontal and torsional; inhibited by fixation of eyes onto object; fades after a few days; does not change direction with gaze to either side | Purely vertical, horizontal, or torsional; not inhibited by fixation of eyes onto object; may last weeks to months; may change direction with gaze towards fast phase of nystagmus |
Imbalance | Mild to moderate; able to walk | Severe; unable to stand still or walk |
Nausea, vomiting | May be severe | Varies |
Hearing loss, tinnitus | Common | Rare |
Nonauditory neurologic symptoms | Rare | Common |
Latency following provocative diagnostic maneuver | Longer (up to 20 seconds) | Shorter (up to 5 seconds) |
Physical examination
- Ear examination:
- visualise the tympanic membranes
- look for vesicles that can be seen in a Herpes zoster infection
- retraction pockets as seen in cholesteotoma.
- hearing assessment
- visualise the tympanic membranes
- Neurological examination:
- Gait
- Balance
- Coordination
- Romberg’s sign
- heel-toe test
- Eye examination:
- nystagmus and papilledema.
- Nystagmus is quick, jerky, involuntary movements of the eye.
- Vertical nystagmus is only seen if the cause is central
- Nystagmus due to central causes may be horizontal, rotational or vertical, and does not disappear on fixing the gaze.
- Nystagmus in the peripheral type disappears with fixation of the gaze.
- Cardiovascular examination:
- Pulse
- blood pressure
- heart rate and rhythm
- Carotid examination
Dix−Hallpike manoeuvre
- The patient sits at the edge of the bed and the examiner turns the patient’s head 30–45 degrees to the side being tested.
- The patient needs to keep their eyes open and focus on a stable point, and then quickly lie supine and hyperextend the neck.
- Horizontal nystagmus denotes a positive test. This test can induce vertigo, so patients should be warned about this before the test is performed
Orthostatic blood pressure testing
- A drop in the systolic blood pressure by more than 20 mm/Hg from a lying down to standing position is significant for a postural drop.
- This is seen in patients who are dehydrated or who present with autonomic dysfunction.
- Autonomic dysfunction can occur acutely and be driven by vertigo.
HINTs Exam
- is a screening tool for distinguishing a central cause of vertigo from an acute peripheral vestibulopathy (APV), such as vestibular neuritis
- Normal neurological exam cannot accurately exclude a central process
- 10% of patients with a cerebellar infarct, usually in the medial branch of the PICA, will have isolated vertigo without other associated deficit.
- In the HiNTs exam derivation paper, only 51% of those with a central process causing vertigo had a neurological sign on exam
- A positive HINTS exam has been reported to have a high sensitivity and specificity for the presence of a central cause of vertigo
- HINTS is comprised of three core components:
- head impulse test
- evaluation of nystagmus
- test of skew.
- Head impulse test
- Position of the Tester: Sitting
- Position of the Subject: Sitting in front of the tester with eyes fixed on the examiner’s nose or a distant target
- Precautions: The tester must ensure that the subject does not have any neck issues like Vertebro-basilar insufficiency and neck range of motion is adequate
- Expectation of the subject: The subject needs to keep their eyes focussed on the target(examiner’s nose) during the testing procedure and avoid premature eye closure
- Examiner action:
- Gently move the patient’s head to one side, then rapidly move it back to the neutral position.
- The patient may have a small corrective saccade (Saccadic eye movements are the rapid eye movements needed to abruptly change the visual focus on an object. In such a movement, the focus of the eye flicks from one stationary position, called a fixation, to another)
- The head impulse test is positive (consistent with peripheral vertigo) if there is a significant lag with corrective saccades
- If you can see the correction, it is abnormal
- Compare this to the contralateral side; a difference in the speed of correction should be noted
- The horizontal head impulse test is consistent with peripheral vertigo if it is positive in one direction only.
- If there is a lag in corrective saccades in both directions, it may be concerning for central vertigo.
- This test can also be performed in the vertical plane. A lag in corrective saccades in the vertical plane is always suspicious for a central etiology for vertigo
Nystagmus:
- To assess nystagmus:
- Observe the patient’s primary gaze while they look straight ahead.
- Then ask the patient to look to the left and to the right without fixating on any object (which can minimise nystagmus).
- Interpretation
- The direction of the saccadic eye movement is important.
- Unidirectional nystagmus is reassuring and more likely to be of peripheral origin. When nystagmus changes direction or is vertical, it is much more likely to be associated with central pathologies.
- Bidirectional nystagmus, in particular, is highly specific for stroke. In this case, the saccadic movement beats in the direction that the patient is looking, then changes direction with their gaze (gave-evoked nystagmus).
Skew:
- To perform the test of skew:
- Ask the patient to look at your nose and subsequently cover one of their eyes.
- Then, quickly move your hand to cover the patient’s other eye. During this process, observe the uncovered eye for any vertical and/or diagonal corrective movement.
- Repeat this manoeuvre on the other eye.
- Interpretation
- Any abnormal movement observed here, often associated with vertical diplopia, is highly specific for a central cause of vertigo.
Distinguishing peripheral vs central vertigo using the HINTS examination
Peripheral | Central | |
Head impulse test | Abnormal | Normal |
Nystagmus | None or unidirectional | Bidirectional or vertical |
Test of skew | No vertical skew | Vertical skew |
Benign Paroxysmal Positional Vertigo (BPPV)
- most common cause for episodic vertigo
- acute attacks of transient vertigo initiated by certain head positions lasting seconds to minutes, accompanied by nystagmus that fatigues on repeated testing
- It is caused by an accumulation of calcium crystals in the posterior semicircular canal.
- These crystals affect the movement of the endolymph in the semicircular canals, which causes vertigo
- may occur following a
- head injury
- viral infection (URTI)
- degenerative disease
- idiopathic
- diagnosed by history and positive Dix-Hallpike manoeuvre
- Management
- Assess patients with BPPV for factors that modify management
- impaired mobility or balance
- central nervous system disorders
- lack of home support
- increased risk for falling
- Non-Pharm
- Educate patients regarding
- reassure patient that process resolves spontaneously in weeks to months
- the impact of BPPV on their safety
- the potential for disease recurrence
- the importance of follow-up
- Particle repositioning maneuvers
- Epley’s manoeuvre or Brandt-Daroff exercises
- Educate patients regarding
- Pharm
- drugs to suppress the vestibular system may provide minimal relief for some patients
- it does not solve the problem
- it only masks the problem
- Symptomatic treatment
- persistent nausea and vomiting may require IV hydration and antiemetics e.g. prochlorperazine
- Assess patients with BPPV for factors that modify management
Epley maneuver
- (A) Patient sits on the examination table, with eyes open and head turned 45 degrees to the right
- (B) The physician supports the patient’s head as the patient lies back quickly from a sitting to supine position, ending with the head hanging 20 degrees off the end of the examination table
- (C)The physician turns the patient’s head 90 degrees to the left side. The patient remains in this position for 30 seconds
- (D) The physician turns the patient’s head an additional 90 degrees to the left while the patient rotates his or her body 90 degrees in the same direction. The patient remains in this position for 30 seconds
- (E) The patient sits up on the left side of the examination table.
- The procedure may be repeated on either side until the patient experiences relief of symptoms
Meniere’s Disease (endolymphatic hydrops)
- It is thought to be caused by increased fluid in the endolymph part of the cochlea, which eventually affects the semicircular canals
- Peak incidence (40-60 years)
- characterized by
- vertigo
- fluctuations in hearing loss
- tinnitus
- aural fullness
- +/– drop attacks (N/V)
- vertigo (lasting minutes to hours) disappears with time and patient is left only with hearing loss
- early in the disease, hearing returns to normal in the attack-free states
- later stages are characterized by a PERMANENT, unilateral, fluctuating low-frequency hearing loss and a persistence of tinnitus (most hearing loss becomes bilateral with time).
- attacks come in clusters and may be very debilitating to the patient, may be triggered by stress
- Pure tone audiometry is the most useful test to assess sensorineural hearing loss
- treatment
- acute management may consist of
- bedrest
- IV antiemetics
- antivertiginous drugs (Serc)
- low molecular weight dextrans
- longterm management
- medical
- low salt diet, K+ sparing diuretics (e.g. triamterene, amiloride)
- local application of gentamicin to destroy vestibular end-organ
- surgical
- selective vestibular neurectomy or transtympanic labyrinthectomy
- may recur in opposite ear after treatment
- medical
- acute management may consist of
Recurrent Vestibulopathy
- peak age 30-50 years old, M = F
- episodic vertigo lasting hours to minutes
- no hearing loss, tinnitus, or focal neurological deficit
- etiology unknown (?post-traumatic, ?post-viral, ?deafferentation of CN VIII)
- treatment: symptomatic, most eventually go into remission
Vestibular Neuronitis
- caused by inflammation of the vestibular nerve.
- This inflammation precedes a viral URTI or herpes zoster infection and is caused by immune-mediated sequelae following the viral illness.
- often occurs in epidemics during outbreaks of respiratory infections
- It is commonly seen in middle-aged adults of both sexes
- typical presentation of vestibular neuritis is usually with the acute onset of the following:
- Vertigo
- inability to stand or walk
- Nausea
- Vomiting
- Balance problems
- The symptoms in vestibular neuritis are typically constant
- lasts for two to three days and is followed by gradual recovery
- (in contrast to the episodic symptoms of other peripheral causes such as BPPV or Meniere’s disease)
- NO
- hearing loss
- tinnitus
- if hearing loss 🡪 think of labyrinthitis
- attacks leave patient with unsteadiness and imbalance for months
- aggravated by a change in the position of the head
- Vertigo
- repeated attacks can occur
- Bed rest and antiemetics can be used in the first 24–72 hours. Patients can be reassured that symptoms will improve with time
Labyrinthitis
- Tinner ear is composed of the bony and the membranous labyrinth.
- Acute labyrinthitis is inflammation of this labyrinth.
- Middle ear infections can spread to the inner ear and cause labyrithitis.
- The duration of symptoms ranges from days to weeks.
- preceded by a viral infection. It presents with
- sudden onset vertigo
- unilateral hearing loss
- nausea, vomiting
- whistling tinnitus
- with no associated fever or pain
- Hearing loss is the main distinguishing factor between labyrithitis and BPPV.
- Typically, no treatment is required for labyrithitis.
- However, if suppurative labyrinthitis is suspected, the patient should be referred to the emergency department for drainage of otitis media, treatment with IV antibiotics, +/– mastoidectomy, beware of meningeal extension and labyrinth destruction