This article provides an overview of vertigo in clinical practice – how it presents, how to differentiate it from dizziness, common differentials, their pathophysiology, treatments and complications. It also introduces the reader to the Dix-Hallpike manoeuvre used in vertigo diagnosis and the Epley manoeuvre used in the treatment of benign paroxysmal positional vertigo (BPPV).

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dizzy thorns

Image by marcello from potenza, italy – Dizzy thorns. License: CC BY 2.0

Definition and Epidemiology of Vertigo

Patients commonly present with “dizziness”. Whilst this can be vertigo, it is not always and as such a precise definition of what is meant by “vertigo” is necessary for good clinical practice. Vertigo is defined as an illusion of movement, often rotatory, of the patient’s or his surroundings.

It is important to note that vertigo is not light-headedness, which can be caused for a multitude of reasons including anxiety, orthostatic hypotension and so on.

Vertigo is experienced by around 4.9% of the population each year. Of this 4.9%, 1 year prevalence is around 1.6% for benign paroxysmal positional vertigo and 0.89% for migraine associated vertigo. 1 year prevalence for Meniere’s disease is 0.51%.

Differential Diagnosis of Vertigo

For the patient presenting with “dizziness” consider the following common causes:

Once true vertigo is established, consider:

  • Peripheral causes:
    • Benign paroxysmal positional vertigo
    • Labyrinthitis (vestibular neuritis)
    • Can be caused by herpes simplex virus
    • Meniere’s disease
  • Central causes:
    • Vestibular migraine
    • Post-traumatic vertigo
    • Neoplasias (some)
    • Stroke
  • Mixed causes of vertigo:
    • Acoustic neuroma

Diagnosis of Vertigo

A full history and examination should be taken. As noted before, many patients initially present with generic “dizziness”. The first task is to ascertain whether the patient is suffering from true vertigo. A patient with vertigo will report feeling unsteady on their feet, as if they are constantly moving (vertigo does not always present as rotatory). Vertigo is always worse on movement.

If the patient describes episodes of vertigo last seconds (up to a few minutes), this is likely to be benign paroxysmal positional vertigo (BPPV). When the patient describes symptoms lasting minutes to hours, this is suggestive of Meniere’s disease whilst hours to days is suggestive of a central or labyrinthine pathology.

Diagnosis is usually made on the basis of examination via the Hallpike manoeuvre. In this test, the patient is lay down on their back with their head off the end of the bed, slightly lower than the horizontal line. Nystagmus can be noted when turning the head towards the affected ear. This is a positive result for the Hallpike manoeuvre and is confirmatory for a diagnosis of benign paroxysmal positional vertigo (BPPV).vertigo hallpike

Meniere’s disease is associated with recurrent episodes of vertigo lasting from around half a hour to a few hours. Ask about hearing loss as it is commonly associated with sensorineural hearing loss. The patient may also suffer from tinnitus. Typically, Meniere’s presents in middle aged adults. The key to diagnosis can often be the variable amount of hearing loss (associated with the episodes of vertigo).

It is important to differentiate between peripheral and central vertigo. Peripheral vertigo will be associated with a number of other symptoms like hearing abnormalities, tinnitus or ear pain.

Central causes of vertigo like ischaemia and migraine are relatively rare. Migraine associated vertigo will inherently present with a history of migraines (often the vertigo comes on with the migraine.)

Vertebrobasilar ischemia (stroke) is relatively rare and will present with other symptoms of brainstem involvement. In rare cases, neoplasias and strokes can cause brainstem disease leading to vertigo.

In some cases, benign tumours of the schwann cells of cranial nerve VII can cause vertigo. Patients may also present with deafness. This can be idiopathic or as a result of genetic disorders like neurofibromatosis type 2. Diagnosis is typically confirmed with MRI.

Pathophysiology of Vertigo

The vestibular system is responsible for the sensation of motion, both in linear and angular directions. The semicircular canals and otoliths are responsible for this process. Vertigo is a deficit in either the sensation of motion (i.e. an issue with the semicircular canals) or a centralised issue with the procession of information from the semicircular canals. Hence the differentiation of central and peripheral causes of vertigo.

Pathophysiology of benign paroxysmal positional vertigo (BPPV)

BPPV is due to loose otoliths in the semicircular canals (although various textbooks provide different answers. Some claim BPPV is caused by debris in the canal.) These are usually found within the posterior canal. They are disturbed by head movement and cause the brief vertigo sensations experienced in BPPV.

BPPV is a common condition with a favourable prognosis. It remits without treatment in around 30% of patients. Almost all patients do not suffer from the condition at 6 months post onset.

Pathophysiology of labrynthitis

Labyrinthitis is caused by inflammation of the labyrinthine and as such its onset is rapid. Infection of the membranous labyrinth can result in intraluminal fibrosis and ossification. Infections can spread from the middle ear (otitis media) to the inner ear and internal auditory canal. Here, inflammation can cause sensations of vertigo.

Pathophysiology of Meniere’s disease

Meniere’s disease is caused by excess endolymphatic fluid in the inner ear. This can either be caused by overproduction or underabsorption.

Therapy of Vertigo

epley maneuvre

Image: “Epley’s manoeuvre for treatment of benign positional paroxysmal vertigo of the left ear. The physician holding the head is not shown.” by C mamais – Own work. License: CC BY-SA 3.0

Therapy varies depending on the cause of vertigo.

Treatment of benign paroxysmal positional vertigo

Treatment is typically provided by repositioning maneuvers. Of these, Epley’s is used most often. Epley’s maneuvre involves the positioning of heads in different positions. Lying the patient flat, their head is tilted to the left side until nystagmus and dizziness has passed. The patient’s head is then tilted in the other direction, again allowing nystagmus and dizziness to pass. Epley’s is effective in around 70% of patients with BPPV.

Treatment of labyrinthitis

Many things can inherently cause labyrinthitis including viral diseases like HIV and HSV. In most cases, the underlying disease should be treated, as treatment for the vertigo will be purely symptomatic in nature. In viral cases, Benzodiazepines have been found to successfully control vertigo. Anti-emetics can be used for nausea and vomiting.

In patients with bacterial infections that have lead to labyrinthitis, topical antibiotics are usually prescribed except when meningitis is suspected, in which case treatment will be IV antibiotics.

In patients with autoimmune associated labyrinthitis corticosteroids can be effective.

Treatment of Meniere’s disease

Management of symptoms is the goal for therapy in Meniere’s disease as currently no cure exists. Due to the pathophysiology of Meniere’s disease – where endolymphatic
pressure is varyingly high – treatment has tended to attempt to reduce this pressure.

There is some debate as to whether this is an effective treatment option. In practice, 80% of patients find that vertigo is controlled by dietary changes and diuretics. Benzodiazepines can be helpful in some patients for the control of vertigo.

Treatment for acoustic neuromas

Treatment depends on the individual patient. Radiotherapy or surgical resection can be opted for if the tumour is large (<3cm) and growing. If it is stable and under 3 cm it may be wise to manage conservatively.

Complications of Vertigo

With many diseases causing vertigo, the common complication is falls after feeling unsteady. This can lead to trauma, especially in elderly patients.

Complications associated with BPPV

During Epley’s maneuver, a high proportion of patients will feel vertigo which may be distressing. Other complications include accidents during work or driving if patients suffer an episode of BPPV.

Complications associated with acoustic neuroma treatment

Both radiotherapy and surgery are associated with a number of risks. Risk of surgery include hearing loss, facial weakness and facial numbness. Facial nerve palsy, hearing loss and secondary malignancy can occur following radiotherapy.

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