Vertigo

Vertigo
ICD-9	438.85
eMedicine	neuro/

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

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Definition

• Illusion of movement caused by acute asymmetry in the vestibular system
• Cardinal symptom of vestibular dysfunction
• May be associated with nausea, vomiting, postural instability

Diagnosis

History and Symptoms

• Time course

  • Most helpful in determining etiology (see above)

• Brainstem symptoms

  • Diplopia
  • Facial numbness
  • Weakness
  • Hemiparesis
  • Dysphagia

• Aural fullness with deafness, tinnitus

  • Suggestive of inner ear lesion (Meniere’s, labyrinthitis)

• History of head trauma or barotrauma and symptoms triggered by straining/sneezing/coughing (perilymphatic fistula)
• Atherosclerotic risk factors or history coronary artery disease/peripheral vascular disease (CAD/PVD)

  • Increases likelihood vertebrobasilar insufficiency

• Recurrent episodes with remissions

  • Pattern suggestive of multiple sclerosis (MS), especially if other associated symptoms

• Prior history of migraines

Physical Examination

• Vestibular exam

  • Nystagmus

    • Peripheral lesions:

      • Horizontal +/- torsional component, never vertical
      • Fast phase toward the normal ear
      • Never reverses direction
      • Suppressed by visual fixation
      • (Prevent fixation via Frenzel lenses -> increased nystagmus)

    • Central lesions

      • Can be in any direction
      • May reverse direction when patient looks in direction of slow phase
      • Not suppressed by visual fixation

  • Provocative maneuvers

    • Dix-Hallpike (Baranay): Patient sitting on exam table

      • Lies down with head extending over table edge, 45° to one side
      • Position change can occur slowly; should be held for > 30 sec
      • Repeat with head turned 45° to opposite side, then without turning head
      • Peripheral lesion:

        • 2-20 sec latency before onset of nystagmus
        • Duration of nystagmus < 1 minute
        • Fatigues with repetition of maneuver
        • One type nystagmus (upbeat and torsional)
        • Severe vertigo (spinning toward normal ear)

      • Central lesion: no latency before onset of nystagmus

        • Duration of nystagmus > 1 minute
        • No fatiguability
        • Direction may change with head position
        • Less severe, if any, vertigo

• Neurologic exam

  • Cranial nerves
  • Motor/sensory deficits,
  • Deep tendon reflexes (DTRs)
  • Cerebellar signs?
  • Central lesion

• Romberg

  • Unilateral peripheral lesion -> patient leans/falls to side of lesion, but able to walk
  • Acute cerebellar lesion -> patient unable to walk without falling; variable direction of fall

• Hearing

  • Test gross hearing with whisper/finger tap
  • If asymmetric hearing loss:
  • Rinne test to confirm sensorineural (vs. conductive) loss

    • Air>bone conduction with sensorineural loss

  • Tympanum membrani (TM) exam to rule out acute or chronic otitis media as etiology
  • Speech discrimination to assess cochlear or retrocochlear

    • Identification of < 20% of 10 2-syllable words whispered into affected ear suggests retrocochlear lesion (acoustic neuroma)
    • Identification of > 70% of words = cochlear disease
    • Identification of 20-70% = indeterminate (audiology)

  • Audiometry referral to confirm hearing loss

MRI and CT

• MRI/MRA:

  • If history/physical examination suggests central cause of vertigo
  • If unable to distinguish central vs. peripheral etiology in patient with risk factors for cerebrovascular accident (CVA)
  • Sensitivity/specificity of MRA > 95% for posterior circulation lesion
  • CT less optimal for imaging cerebellum

• MRI of internal auditory canal/cerebellopontine angle

  • If acoustic neuroma suspected
  • Incidence of acoustic neuroma in patients with vertigo and no hearing loss: 1/9000
  • Incidence of acoustic neuroma in patients with dizziness and asymmetric hearing loss: 1/600

Other Diagnostic Studies

• Audiometry:

  • More sensitive detection of hearing loss at specific frequencies
  • Better test for speech discrimination (disproportionately affected in retrocochlear disease)
  • Most useful for distinguishing cochlear vs. retrocochlear causes of peripheral lesion
  • Detects sensorineural hearing loss in almost all cases acoustic neuroma

Differential Diagnosis

Distinguish cause of vertigo based on:

• Time course
• Duration
• Recurrence

• Lasting a day or longer

  • Vestibular neuronitis

    • Onset over hours, peaks in first day, improves within days
    • May recur episodically for weeks to months

  • Vertebrobasilar ischemia with labyrinth infarct

    • Abrupt onset, improves within 1 week
    • Symptomss resolve within weeks to months

  • Brain-stem stroke: usually other symptoms vertebrobasilar ischemia
  • Inferior cerebellar infarct/bleed: similar symptoms/time course to vestibular neuritis
  • Multiple sclerosis: vestibular symptoms evolve over hours to days

• Lasting minutes to hours

  • Meniere’s disease: episodic/recurrent
  • Vertebrobasilar transient ischemic attack (TIA): typically lasts < 30 minutes, may recur
  • Migraine Headache: episodic/recurrent
  • Perilymph fistula: episodic; precipitated by exertional straining or change in air pressure

• Lasting seconds

  • Benign paroxysmal positional vertigo (BPPV): usually lasts < 1 minute

Alternative anatomic classification: central vs. peripheral

• Central (20%):

  • Caused by damage to vestibular structures in brainstem or cerebellum
  • Associated with other brainstem deficits
  • Vertigo and nystagmus can be bidirectional or vertical
  • Vertebrobasilar insufficiency:

    • Accounts for ½ of central causes
    • Brainstem or cerebellar territory (anterior inferior cerebellar artery (AICA), posterior inferior cerebellar artery (PICA)) -> transient ischemic attack (TIA) or cerebrovascular accident (CVA)
    • Associated diplopia, dysarthria, dysphagia, hemiparesis, etc.
    • Cerebellar infarct may present with isolated vertigo
    • Can have pontine lacunes, labyrinthine infarcts

  • Multiple sclerosis: associated brainstem symptoms may be subtle (facial numbness)

    • Vertiginous symptoms may be sudden, transient, recurrent or persistent

  • Migraine: vertigo precedes headache and may last afterward

    • Atypical form of migraine with aura -> may respond to migraine therapy

  • Drugs

    • Sedatives, anticonvulsants may cause central vertigo in high/excess doses
    • Anticonvulsants in prescription doses may cause nystagmus (phenytoin, carbamazepine)

• Peripheral (80%):

  • Caused by damage to vestibular labyrinth, vestibular nerve
  • Associated tinnitus, hearing loss if auditory component of CN VIII affected
  • Vertigo and nystagmus are unidirectional, and not vertical
  • BPPV

    • Accounts for more than ½ of cases peripheral vestibular dysfunction
    • Common in the elderly (patients usually > 60)
    • Episodes of sudden onset, short duration -> condition often remits in 6 months
    • Mechanism = stimulation of labyrinth by debris in posterior semicircular canal

  • Vestibular neuronitis

    • Accounts for ¼ of cases peripheral vestibular dysfunction
    • Isolated vertigo due to viral infection involving labyrinth (after URI)

  • Acute labyrinthitis

    • Viral involvement of cochlea and labyrinth after upper respiratory infection (URI)
    • Vertigo associated with tinnitus and hearing loss
    • symtpoms resolve completely within 3-6 weeks

  • Meniere’s disease

    • Idiopathic endolymphatic hydrops -> damage to hair cells
    • Tinnitus, ear pressure and hearing loss associated with vertigo
    • Paroxysmal episodes lasting minutes to hours
    • Frequency of episodes waxes and wanes over time
    • Hearing loss can become permanent

  • Acoustic neuroma

    • Benign tumor, but can cause brainstem compression if unprescribed
    • Retrocochlear hearing loss, tinnitus, vague dizziness
    • Very gradual symptom onset with progressive asymmetric hearing loss
    • Vertigo not prominent because gradual time course allows central nervous system adaptation

  • Ototoxins: hearing impairment usually >> vestibular symptoms

    • Gentamicin, streptamicin most injurious to vestibular portion of CN VIII

Treatment

• Central disorders

  • Treat underlying disease
  • Vertebrobasilar ischemia

    • Vertigo usually resolves on its own
    • Risk factor modification to decrease recurrence
    • +/- Revascularization or anticoagulation

  • Migraine: adequate treatment of headache improves vertigo in 90%
  • Multiple sclerosis (MS): Therapy for MS alleviates vertiginous symptoms as well
  • Drugs: discontinue offending agents

• Peripheral disorders

  • General management
  • Physical therapy

    • Beneficial in patients with permanent peripheral vestibular dysfunction
    • Unknown benefit in patients with central disorders
    • Vestibular rehabilitation

      • Activity enables CNS adaptation to loss of vestibular input
      • Visual compensation during head motion
      • Balance shown to improve in randomized controlled trials of vestibular exercises
      • Unclear if long-term benefits or if decreased fall risk

  • Avoidance of inactivity

    • • Avoid deconditioning and loss of postural reflexes

Acute Pharmacotherapies

• Peripheral disorders

Specific management

• • BPPV

    • Epley maneuver --> in a randomized controlled trial, symptoms resolved in 50% vs. 19% sham therapy by mean 10 days
    • Meclizine (12.5-50 mg every 6 hours as often as necessary) or promethazine (25 mg every 6 hours as often as necessary) for severe symptoms

  • Meniere’s disease: low-salt diet and diuretics to reduce endolymph production

• Peripheral disorders

  • General management
  • Pharmacologic therapy

    • For acute episodes
    • Avoid long-term therapy if symptoms last > few days (will reduce CNS adaptation)
    • Anticholinergics

      • Scopolamine

        • Side effect urinary retention, dry mouth

    • Antihistamines

      • Meclizine, dimenhydrinate, diphenhydramine (anti-Ach effects)

        • Meclizine is drug of choice in pregnancy
        • Side effect sedation

    • Phenothiazines

      • prochlorperazine, promethazine (anti-Ach effects)

        • More sedating, but also have antiemetic effects
        • Risk extrapyramidal side effect (second-line)

    • Benzodiazepines

      • Diazepam, lorazepam, clonazepam (GABA-ergic effects)

        • For patients with contraindications to anti-Ach prescription (benign prostatic hypertrophy)

Surgery and Device Based Therapy

• Perilymphatic fistula

  • Bed rest, head elevation, avoidance of straining
  • Surgical patch if no resolution after several weeks

• Acoustic neuroma: surgical therapy

Additional Resources

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2. Dix MR, Hallpike CS. The pathology, symptomatology and diagnosis of certain common disorders of the vestibular system. Proc R Soc Med 1952;45:341-54.

3. Furman JM, Cass SP. Benign paroxysmal positional vertigo. N Engl J Med 1999;341:1590-6.

4. Disorders of equilibrium. In: Greenberg DA, Aminoff MJ, Simon RP. Clinical neurology. 5th ed. New York: McGraw-Hill, 2002:95-126.

5. Hasso AN, Drayer BP, Anderson RE, Braffman B, Davis PC, Deck MD, et al. Vertigo and hearing loss. American College of Radiology. ACR Appropriateness Criteria. Radiology 2000;215(suppl):471-8.

6. Hain TC, Uddin M. Pharmacological treatment of vertigo. CNS Drugs 2003;17:85-100.

7. Baloh RW. Vestibular neuritis. N Engl J Med 2003;348:1027-32.

8. Quigley EM, Hasler WL, Parkman HP. AGA technical review on nausea and vomiting. Gastroenterology 2001;120:263-86.

9. Fife TD. Episodic vertigo. In: Rakel RE, ed. Conn's Current therapy, 1999: latest approved methods of treatment for the practicing physician. 51st ed. Philadelphia: Saunders, 1999:923-30.

10. Baloh RW. Vertigo in older people. Curr Treat Options Neurol 2000;2:81-9.

11. Yardley L, Beech S, Zander L, Evans T, Weinman J. A randomized controlled trial of exercise therapy for dizziness and vertigo in primary care. Br J Gen Pract 1998;48:1136-40.

12. Cohen HS, Kimball KT. Increased independence and decreased vertigo after vestibular rehabilitation. Otolaryngol Head Neck Surg 2003;128:60-70.

13. Wrisley DM, Whitney SL, Furman JM. Vestibular rehabilitation outcomes in patients with a history of migraine. Otol Neurotol 2002;23:483-7.

14. Strupp M, Arbusow V, Maag KP, Gall C, Brandt T. Vestibular exercises improve central vestibulospinal compensation after vestibular neuritis. Neurology 1998;51:838-44.

15. Epley JM. The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 1992;107:399-404.

16. Radtke A, Neuhauser H, von Brevern M, Lempert T. A modified Epley's procedure for self-treatment of benign paroxysmal positional vertigo. Neurology 1999;53:1358-60.

17. Humphriss RL, Baguley DM, Sparkes V, Peerman SE, Moffat DA. Contraindications to the Dix-Hallpike manoeuvre: a multidisciplinary review. Int J Audiol 2003;42:166-73.

18. Lynn S, Pool A, Rose D, Brey R, Suman V. Randomized trial of the canalith repositioning procedure. Otolaryngol Head Neck Surg 1995;113:712-20.

19. Froehling DA, Bowen JM, Mohr DN, Brey RH, Beatty CW, Wollan PC, et al. The canalith repositioning procedure for the treatment of benign paroxysmal positional vertigo: a randomized controlled trial. Mayo Clin Proc 2000;75:695-700.

20. Hilton M, Pinder D. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database Syst Rev 2004;(3):CD003162.

21. Nunez RA, Cass SP, Furman JM. Short- and long-term outcomes of canalith repositioning for benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 2000;122:647-52.

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23. Van Deelen GW, Huizing EH. Use of a diuretic (Dyazide) in the treatment of Meniere's disease. A double-blind cross-over placebo-controlled study. ORL J Otorhinolaryngol Relat Spec 1986;48:287-92.

24. Santos PM, Hall RA, Snyder JM, Hughes LF, Dobie RA. Diuretic and diet effect on Meniere's disease evaluated by the 1985 Committee on Hearing and Equilibrium guidelines. Otolaryngol Head Neck Surg 1993;109:680-9.

25. James A, Thorp M. Meniere's disease. Clin Evid 2003;(9):565-73.

26. Blakley BW. Update on intratympanic gentamicin for Meniere's disease. Laryngoscope 2000;110(2 pt 1):236-40.

27. Levy EI, Hanel RA, Bendok BR, Boulos AS, Hartney ML, Guterman LR, et al. Staged stent-assisted angioplasty for symptomatic intracranial vertebrobasilar artery stenosis. J Neurosurg 2002;97:1294-301.

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29. Neuhauser H, Leopold M, von Brevern M, Arnold G, Lempert T. The interrelations of migraine, vertigo, and migrainous vertigo. Neurology 2001;56:436-41.

30. Johnson GD. Medical management of migraine-related dizziness and vertigo. Laryngoscope 1998;108(1 pt 2):1-28.

31. Reploeg MD, Goebel JA. Migraine-associated dizziness: patient characteristics and management options. Otol Neurotol 2002;23:364-71.

32. Bikhazi P, Jackson C, Ruckenstein MJ. Efficacy of antimigrainous therapy in the treatment of migraine-associated dizziness. Am J Otol 1997;18:350-4.

33. Jacob RG, Furman JM, Durrant JD, Turner SM. Panic, agoraphobia, and vestibular dysfunction. Am J Psychiatry 1996;153:503-12.

34. Staab JP, Ruckenstein MJ, Solomon D, Shepard NT. Serotonin reuptake inhibitors for dizziness with psychiatric symptoms. Arch Otolaryngol Head Neck Surg 2002;128:554-60.

35. Johansson M, Akerlund D, Larsen HC, Andersson G. Randomized controlled trial of vestibular rehabilitation combined with cognitive-behavioral therapy for dizziness in older people. Otolaryngol Head Neck Surg 2001;125:151-6.

36. Flake ZA, Scalley RD, Bailey AG. Practical selection of antiemetics. Am Fam Physician 2004;69:1169-74.

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