VERTIGO

• 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
• 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
  • 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

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

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
• 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