Vertigo

Vertigo is defined as the perceived sensation of rotational motion while remaining still. A very common complaint in primary care and the ER, vertigo is more frequently experienced by women and its prevalence increases with age. Vertigo is classified into peripheral or central based on its etiology. Vertigo is a clinical diagnosis, differentiated through history and physical examination findings, most notably nystagmus. Further testing may be required in malignant cases. Management depends on the etiology but certain maneuvers such as the Epley maneuver can be diagnostic and therapeutic.

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Overview

Definition

Vertigo is a clinical symptom described as the perceived sensation of rotational motion while remaining still.

Epidemiology

  • The prevalence of vertigo increases with age.
  • Accounts for > 50% of the presenting complaints of “dizziness” in the ED
  • Women are 2–3 times more likely to report vertigo than men.
  • Associated with depression and cardiovascular disease

Classification

  • Peripheral: due to pathology of the vestibular labyrinth or vestibular nerve
  • Central: due to pathology of the brainstem or cerebellum

Etiology

Peripheral:

  • Benign paroxysmal positional vertigo (BPPV) (93% of cases)
  • Acute labyrinthitis (due to viral infection)
  • Ménière‌ ‌disease
  • Vestibular neuritis
  • Ramsay Hunt syndrome (also known as herpes zoster oticus)
  • Cholesteatomas
  • Otosclerosis
  • Otomastoiditis
  • Perilymphatic fistula
  • Vestibular schwannoma

Central:

  • Ischemic or hemorrhagic strokes
  • CNS tumors (cerebellopontine angle):
    • Meningioma
    • Brainstem glioma
    • Medulloblastoma
    • Metastases
  • Vestibular migraines
  • Medication-induced vertigo (e.g., phenytoin and salicylates)

Both: multiple sclerosis

Pathophysiology

To understand the causes of vertigo, it is important to understand how the human body perceives and maintains balance.

  • Vestibular nuclei receive a signal corresponding to the acceleration of the head.
    • The signal is carried to cranial nerves (CNs) III, IV, and VI → coordination of the movements of the eyes and head
    • Eyes move in a direction opposite to that of head rotation to maintain fixation.
  • Semicircular canals are involved with rotational acceleration.
    • When the head is rotated, endolymph courses through the semicircular canals.
    • Endolymph causes the cupula, which encases the hair cells, to bend in a direction opposite to that of the rotation.
    • While bending, hair cells depolarize or hyperpolarize → transmission of the signal corresponding to the rotational movement via the vestibular pathway of CN VIII to the vestibular nuclei
    • Once the endolymph reaches the same rate of acceleration as that of the rotation of the head, the cupula returns to the upright position and signal transmission stops.
  • Otolith organs are involved with linear and horizontal acceleration.
    • Head begins to accelerate in a linear direction → otoliths embedded within the endolymph are displaced in the opposite direction
    • Displacement of the otoliths makes the endolymph accelerate with them → hair cells underneath bend → hair cells depolarize or hyperpolarize
    • Results in the generation of a signal carried by the vestibular pathway of CN VIII to the vestibular nuclei
    • Once the endolymph reaches the same rate of acceleration as the rest of the head, the stereocilia of hair cells return to the upright position and signal transmission stops.

History of Present Illnesses

Chief complaint

The chief complaint is dizziness.

  • Affected individuals may misidentify a feeling of lightheadedness, near-fainting, or a lack of balance as “vertigo.”
  • Ask: “Does it feel like the room is spinning around you?”

Duration and frequency

  • A few minutes or less: BPPV
  • Minutes to hours: vestibular migraine, transient ischemic attack (TIA)
  • Hours or longer: vestibular neuritis, stroke

Associated symptoms

  • Nausea and vomiting: common and nonspecific
  • Focal neurologic deficits: indication of vertebrobasilar stroke or multiple sclerosis
  • Cardiovascular risk factors (stroke): diabetes, hypertension, and hyperlipidemia
  • Headache with aura (e.g., photophobia): indicative of vestibular migraine
  • Hearing loss: may indicate Ménière disease

Triggers

  • Positional changes
  • Pressure changes

Recent history

  • Recent use of medications:
    • Administration of aminoglycosides:
      • Preference for the cochlea: neomycin, kanamycin, dihydrostreptomycin, and amikacin
      • Preference for the vestibular system: tobramycin, gentamicin, and streptomycin
    • Anticonvulsants: e.g., phenytoin
    • Salicylates: e.g., aspirin
  • Recent intoxication: alcohol
  • Trauma: recent trauma to the head

Clinical pearl

Vertigo may apparently “decrease” in severity over time, as the affected individual adapts over days to weeks following the onset.

Related videos

Physical Examination

The main goal of physical examination is to differentiate central from peripheral vertigo. If the affected individual additionally complains of hearing loss, “Weber” and “Rinne” tests should be performed.

General exam

  • Vital signs:
    • Blood pressure
    • Orthostatic blood pressure
    • Pulse
  • Neurologic exams must be used to screen for motor/sensory/coordination impairments.
  • Mental status assessment is also recommended.

Nystagmus

  • Fast and rhythmic “beating” of the eyes returning to the point of fixation after a slight drift
  • In peripheral lesions (and causes of vertigo): beating (fast phase) toward the affected site
    • Instructing the individual to look toward the affected side will increase the amplitude and frequency of nystagmus.
    • Can also present with torsion
    • Inhibited by visual fixation
  • In central lesions: beating in any direction
    • Not suppressed by visual fixation

Head impulse test

  • Eyes are fixed on a target and the examiner quickly turns the subject’s head by 15º to the side.
  • Normal: Eyes remain on target.
  • Abnormal: Eyes drift off the target to later return with a saccade.
    • Indicates deficient vestibulo-ocular reflex → peripheral lesion
Diagram of an abnormal and normal head impulse test

Diagram of abnormal (above) and normal (below) head impulse tests:
Notice that in abnormal situations, the individual’s focal point shifts with the head to later return to the initial point of focus with a saccade.

Image by Lecturio.

Skew deviation test

  • The examiner covers 1 eye of the individual for a few seconds.
  • Normal: The covered eye remains fixed when uncovered.
  • Abnormal: The covered eye shifts vertically when uncovered.
    • Indicates central lesion

Dix-Hallpike maneuver

  • The subject sits on an examination table and quickly adopts a supine position while the examiner supports their head (to the right or to the left) at a 20º angle below the edge of the bed.
  • The position is held for 30 seconds.
  • Normal: no symptoms of vertigo or nystagmus
  • Abnormal: Vertigo with/without nystagmus is evoked.
Dix-Hallpike maneuver

Dix-Hallpike maneuver:
Both diagnostic and curative in benign paroxysmal positional vertigo (BPPV). The subject sits on an examination table and quickly adopts a supine position while the examiner supports their head (to the right or to the left) at a 20º angle below the edge of the bed. The position is held for 30 seconds. In individuals with BPPV, symptoms of vertigo with or without nystagmus become evident.

Image by Lecturio.

Romberg test

  • The subject stands with their feet together and with arms to the sides or crossed.
  • The subject is instructed to close their eyes for 30 seconds.
  • In peripheral lesions: leaning or falling toward the side of the lesion
  • In central lesions: Direction of the lean or fall is variable, and some affected individuals may not be able to stand without assistance.

Diagnostic Evaluation

Vertigo itself is a clinical diagnosis. Further studies are only carried out if more malignant etiologies are suspected.

Neuroimaging

  • Indicated in suspicion of a central lesion (e.g., stroke, focal neurologic deficits, headache)
  • MRI: preferred modality
  • CT:
    • When MRI is not available or contraindicated
    • When thin cuts focusing on the brainstem and cerebellum are needed

Audiogram

  • Performed by an audiologist or an otolaryngologist
  • Indicated in any individual with unilateral or bilateral hearing loss

Vestibular testing

  • Also called videonystagmography
  • Measures nystagmus via ocular, positional, and caloric testing
  • Used to confirm inner ear pathology

Management

Definitive management depends on the etiology.

Pharmacological management

  • Focused on symptomatic relief:
    • Antihistamines
    • Benzodiazepines
    • Antiemetics

Nonpharmacological management

  • Vestibular rehabilitation: training on maintaining balance based on visual and proprioceptive clues
  • Lifestyle recommendations: avoiding caffeine and alcohol (in Ménière disease), avoiding triggers
  • Canalith repositioning procedure: Epley maneuver can be curative in individuals with BPPV.
  • For debilitating symptoms, surgical procedures or intratympanic gentamicin injections may be used.

Complications

  • High risk for falls!
  • Some affected individuals may require home-safety evaluation and supervision.
A diagram of Epley maneuver (BPPV)

Diagram showing the Epley maneuver for the management of benign paroxysmal positional vertigo (BPPV):
Each position is carried out as shown while being held for 30 seconds.
PSC: posterior semicircular canal
UT: utricle

Image by Lecturio.

Clinical Relevance

The following conditions can cause dizziness similar to vertigo:

  • Syncope: a short-term loss of consciousness caused by inadequate cerebral blood flow. Syncope has a wide range of etiologies. Affected individuals may have prodromal symptoms associated with imminent syncope or presyncope, such as lightheadedness, sweating, palpitations, nausea, feeling warm or cold, and blurred vision. Diagnosis is clinical, and management involves the identification and treatment of the underlying disorders.
  • Anemia: a condition characterized by low hemoglobin levels that can arise due to various causes. Anemia is accompanied by a reduced RBC count and may manifest with fatigue, lightheadedness, shortness of breath, pallor, and weakness. Diagnosis is made based on CBC and peripheral blood smear. Management involves treatment of the underlying disorder and transfusion in severe cases.
  • Ménière disease: a disorder of the inner ear characterized by hearing loss, fluctuating aural symptoms (e.g., tinnitus), and spontaneous episodes of vertigo. Diagnosis is made based on a thorough history and physical examination, including a full otologic exam. An audiogram is also a key component of the evaluation. Management is centered around noninvasive techniques to maintain function; however, there is no cure.
  • Multiple sclerosis: a chronic inflammatory autoimmune disease leading to demyelination of the CNS. The clinical presentation varies widely depending on the site of lesions, but typically involves neurological symptoms affecting vision, motor function, sensation, and autonomic function. Management involves corticosteroids for acute exacerbations and disease-modifying agents to reduce exacerbations and slow disease progression.
  • Ischemic stroke: also known as a cerebrovascular accident (CVA), ischemic stroke is an acute neurologic injury resulting from brain ischemia. The clinical presentation includes neurologic symptoms with varying degrees of motor and sensory loss, which corresponds to the area of the brain affected and the extent of tissue damage. Management is with the timely restoration of blood flow and prevention of a 2nd stroke.
  • Wernicke encephalopathy: an acute, reversible condition caused by severe thiamine deficiency. Wernicke encephalopathy is most commonly seen in individuals with severe alcohol-use disorder and is characterized by the classic triad of encephalopathy, oculomotor dysfunction, and gait ataxia, although all 3 features are only present in ⅓ of the affected population. Diagnosis is made clinically. Management includes thiamine supplementation and recommendations for alcohol cessation.

References

  1. Stanton, M., Freeman, A.M. (2021). Vertigo. StatPearls. Treasure Island (FL): StatPearls Publishing. Retrieved September 15, 2021, from http://www.ncbi.nlm.nih.gov/books/NBK482356/ 
  2. Barrett, K.E., Barman, S.M., Boitano, S., Reckelhoff, J.F. (2017). Hearing & Equilibrium. In Ganong’s Medical Physiology Examination and Board Review. McGraw-Hill Education. Retrieved September 15, 2021, from http://accessmedicine.mhmedical.com/content.aspx?aid=1142554680 
  3. Wipperman, J. (2021). Dizziness and Vertigo. In Kellerman, R.D., Rakel, D.P. (Eds.), Conn’s Current Therapy 2021, pp. 9–14. Elsevier. Retrieved September 15, 2021, from https://www.clinicalkey.es/#!/content/book/3-s2.0-B9780323790062000045 
  4. Walker, M.F., Daroff, R.B. (2018). Dizziness and vertigo. Jameson, J., et al. (Eds.), Harrison’s Principles of Internal Medicine, 20 ed. McGraw Hill. Retrieved September 14, 2021, from https://accessmedicine.mhmedical.com/content.aspx?sectionid=192011330&bookid=2129&Resultclick=2
  5. Kerber, K. (2021). Dizziness. DeckerMed Medicine. Retrieved September 15, 2021, from doi:10.2310/PSYCH.6089
  6. Kroenke, K., Lucas, C.A., Rosenberg, M.L., et al. Causes of persistent dizziness. A prospective study of 100 patients in ambulatory care. Ann Intern Med. 1992, 117: pp. 898–904.

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