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| __NOTOC__ | | __NOTOC__ |
| {{Vertigo}} | | {{Vertigo}} |
| {{CMG}} | | {{SI}} |
| | {{CMG}}; {{AE}} {{ZMalik}} |
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| ==Overview== | | ==Overview== |
| Vertigo is typically classified into one of two categories depending on the location of the damaged vestibular pathway. These are peripheral or central vertigo. Each category has a distinct set of characteristics and associated findings. Vertigo can also occur after long flights or boat journeys where the mind gets used to turbulence, resulting in a person feeling as if they are moving up and down. This usually subsides after a few days. | | Vertigo is typically classified into one of two categories depending on the location of the damaged [[Vestibular system|vestibular pathway]]. These are peripheral or central vertigo. It can also be classified into 3 sub groups based on duration of vertigo. Each category has a distinct set of characteristics and associated findings. |
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| ==Classification== | | ==Classification== |
| ===Distinguish Cause of Vertigo Based on:===
| | Vertigo may be classified according to location of dysfunction into 2 subtypes and according to time course/duration into 3 subtypes:{{familytree/start |summary=Sample 1}} |
| # Time course
| | {{familytree | | | | | | | | A01 |A01=Classification of Vertigo<ref name="Dieterich2007">{{cite journal|last1=Dieterich|first1=Marianne|title=Central vestibular disorders|journal=Journal of Neurology|volume=254|issue=5|year=2007|pages=559–568|issn=0340-5354|doi=10.1007/s00415-006-0340-7}}</ref><ref name="Karatas2008">{{cite journal|last1=Karatas|first1=Mehmet|title=Central Vertigo and Dizziness|journal=The Neurologist|volume=14|issue=6|year=2008|pages=355–364|issn=1074-7931|doi=10.1097/NRL.0b013e31817533a3}}</ref><ref name="Guerraz2001">{{cite journal|last1=Guerraz|first1=M.|title=Visual vertigo: symptom assessment, spatial orientation and postural control|journal=Brain|volume=124|issue=8|year=2001|pages=1646–1656|issn=14602156|doi=10.1093/brain/124.8.1646}}</ref>}} |
| # Duration
| | {{familytree | | | | |,|-|-|-|^|-|-|-|-|.| | | }} |
| # Recurrence
| | {{familytree | | | B01 | | | | | | | | B02 | | |B01=Based on Location of Dysfunction|B02=Time Course/Duration}} |
| ====Lasting a Day or Longer====
| | {{familytree | |,|-|^|-|.| | | |,|-|-|-|+|-|-|-|.| }} |
| * Vestibular neuronitis
| | {{familytree | C01 | | C02 | | C03 | | C04 | | C05 |C01=Peripheral|C02=Central|C03=Lasting a Day or Longer|C04=Lasting Minutes to Hours|C05=Lasting Seconds}} |
| # Onset over hours, peaks in first day, improves within days
| | {{familytree | |!| | | |!| | | |!| | | |!| | | |!|}} |
| # May recur episodically for weeks to months
| | {{familytree | D01 | | D02 | | |!| | | |!| | | |!| |D01=Lesion in inner ear or vestibulocochlear nerve|D02=Lesion in brainstem or cerebellum}} |
| * Vertebrobasilar ischemia with labyrinth infarct
| | {{familytree | |!| | | |!| | | |!| | | |!| | | |!| }} |
| # Abrupt onset, improves within 1 week
| | {{familytree | E01 | | E02 | | E03 | | E04 | | E05 |E01=[[Ménière’s disease]]<br>[[Benign positional paroxysmal vertigo]]<br>[[Acute]] [[labyrinthitis]]<br>[[Acute]] [[vestibular neuronitis]]<br>[[Cholesteatoma]]<br>[[Otosclerosis]]<br>[[Perilymphatic fistula]]<br>[[Acoustic Neuroma]]|E02=[[Brainstem]] [[Stroke]]<br>Vestibular [[Migraine]]<br>[[Multiple Sclerosis]]<br>Cerebellar [[ischemia]] or [[hemorrhage]]<br>[[Cerebellar]] [[tumors]]<br>[[Lateral medullary syndrome]]<br>[[Chiari malformation]]|E03=[[Vestibular neuronitis]]<br>Vertebrobasilar ischemia with labyrinth infarct<br> [[Brainstem]] [[stroke]]<br> Inferior cerebellar infarct/bleed|E04=[[Ménière’s disease]]<br>Vertebrobasilar [[transient ischemic attack]] (TIA)<br>[[Migraine]] [[Headache]]<br>[[Perilymph fistula]]|E05=[[Benign paroxysmal positional vertigo]]}} |
| # Symptomss resolve within weeks to months
| | {{familytree/end}} |
| * Brain-stem stroke: usually other symptoms vertebrobasilar ischemia
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| * Inferior cerebellar infarct/bleed: similar symptoms/time course to vestibular neuritis
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| * Multiple sclerosis: vestibular symptoms evolve over hours to days
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| ====Lasting Minutes to Hours====
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| * Meniere’s disease: episodic/recurrent
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| * Vertebrobasilar transient ischemic attack (TIA): typically lasts < 30 minutes, may recur
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| * Migraine Headache: episodic/recurrent
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| * Perilymph fistula: episodic; precipitated by exertional straining or change in air pressure
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| ====Lasting Seconds====
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| * Benign paroxysmal positional vertigo (BPPV): usually lasts < 1 minute
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| ===Classification Based Upon Location of Dysfunction===
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| ===Central vs. Peripheral===
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| ====Central (20%):====
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| Vertigo that arises from injury to the balance centers of the [[central nervous system]] (CNS), often from a lesion in the [[brainstem]] or [[cerebellum]] and is generally associated with less prominent movement illusion and [[nausea]] than vertigo of peripheral origin.<ref name="Dieterich (2007)">{{cite journal|last=Dieterich|first=Marianne|title=Central vestibular disorders|journal=Journal of Neurology|year=2007|volume=254|pages=559–568|doi=10.1007/s00415-006-0340-7|url=http://www.springerlink.com/content/x62437220t306gr6/}}</ref> Central vertigo has accompanying [[neurological deficit|neurologic deficits]] (such as [[slurred speech]] and [[diplopia|double vision]]), and [[pathologic nystagmus]] (which is pure vertical/torsional).<ref name="Karatas (2008)" /><ref name="Dieterich (2007)" /> Central pathology can cause [[Equilibrioception|disequilibrium]] which is the sensation of being off-balance. The [[balance disorder]] associated with central lesions causing vertigo are often so severe that many patients are unable to stand or walk.<ref name="Karatas (2008)" /> | |
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| A number of conditions that involve the [[central nervous system]] may lead to vertigo including: lesions caused by [[infarction]]s or [[hemorrhagic stroke|hemorrhage]], [[brain tumor|tumors]] present in the [[cerebellopontine angle]] such as a [[vestibular schwannoma]] or cerebellar tumors,[[epilepsy]], [[cervical spine]] disorders such as [[cervical spondylosis]], degenerative ataxia disorders, [[Migraine|migraine headaches]], [[lateral medullary syndrome]], [[Chiari malformation]],[[multiple sclerosis]], [[parkinsonism]], as well as cerebral dysfunction.<ref name="Karatas (2008)" /> Central vertigo may not improve or may do so more slowly than vertigo caused by disturbance to peripheral structures.<ref name="Karatas (2008)" />
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| * Caused by damage to vestibular structures in brainstem or cerebellum
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| * Associated with other brainstem deficits
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| * Vertigo and nystagmus can be bidirectional or vertical
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| * Vertebrobasilar insufficiency:
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| # Accounts for ½ of central causes
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| # Brainstem or cerebellar territory (anterior inferior cerebellar artery (AICA), posterior inferior cerebellar artery (PICA)) -> transient ischemic #ttack (TIA) or [[Ddx:Cerebrovascular Accident|cerebrovascular accident]] (CVA)
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| # Associated diplopia, dysarthria, dysphagia, hemiparesis, etc.
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| # Cerebellar infarct may present with isolated vertigo
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| # Can have pontine lacunes, labyrinthine infarcts
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| * Multiple sclerosis: associated brainstem symptoms may be subtle (facial numbness)
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| # Vertiginous symptoms may be sudden, transient, recurrent or persistent
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| * Migraine: vertigo precedes headache and may last afterward
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| # Atypical form of migraine with aura -> may respond to migraine therapy
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| * Drugs
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| # Sedatives, anticonvulsants may cause central vertigo in high/excess doses
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| # Anticonvulsants in prescription doses may cause nystagmus (phenytoin, carbamazepine)
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| ====Peripheral (80%):====
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| Vertigo caused by problems with the [[inner ear]] or [[vestibular system]], which is composed of the [[semicircular canal]]s, the [[vestibule of the ear|vestibule]] ([[utricle (ear)|utricle]] and [[saccule]]), and the [[vestibular nerve]] is called "peripheral", "otologic" or "vestibular" vertigo.<ref name="Karatas (2008)">{{cite journal|last=Karatas|first=M|title=Central Vertigo and Dizziness|journal=The Neurologist|year=2008|volume=14|issue=6|pages=355–364|pmid=19008741|doi=10.1097/NRL.0b013e31817533a3|url=http://www.ncbi.nlm.nih.gov/pubmed/19008741}}</ref> The most common cause is benign paroxysmal positional vertigo ([[BPPV]]), which accounts for 32% of all peripheral vertigo.<ref name="Karatas (2008)" /> Other causes include [[Ménière's disease]] (12%), [[superior canal dehiscence syndrome]], [[labyrinthitis]] and visual vertigo.<ref name="Karatas (2008)" /><ref>{{cite journal|title=Visual vertigo: symptom assessment, spatial orientation and postural control|journal=Brain|volume=124|issue=8|pages=1646–1656|year=2001|url=http://brain.oxfordjournals.org/cgi/content/full/124/8/1646|doi=10.1093/brain/124.8.1646|last1=Guerraz|first1=M.|pmid=11459755}}</ref> Any cause of inflammation such as [[common cold]], [[influenza]], and bacterial infections may cause transient vertigo if it involves the inner ear, as may chemical insults (e.g., [[aminoglycoside]]s)<ref name="aminoglycoside">{{cite journal|last1=Xie|first1=J|last2=Talaska|first2=AE|last3=Schacht|first3=J|title=New developments in aminoglycoside therapy and ototoxicity.|journal=Hearing research |year=2011|volume=281|issue=1-2|pages=28–37|pmid=21640178|doi=10.1016/j.heares.2011.05.008|pmc=3169717}}</ref> or physical trauma (e.g., skull fractures). [[Motion sickness]] is sometimes classified as a cause of peripheral vertigo.
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| Patients with peripheral vertigo typically present with mild to moderate [[balance disorder|imbalance]], [[nausea]], [[vomiting]], [[deafness|hearing loss]], [[tinnitus]], fullness, and pain in the ear.<ref name="Karatas (2008)" /> In addition, lesions of the internal auditory canal may be associated with ipsilateral facial weakness.<ref name="Karatas (2008)" /> Due to a rapid compensation process, acute vertigo as a result of a peripheral lesion tends to improve in a short period of time (days to weeks).<ref name="Karatas (2008)" />
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| * Caused by damage to vestibular labyrinth, vestibular nerve
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| * Associated tinnitus, hearing loss if auditory component of CN VIII affected
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| * Vertigo and nystagmus are unidirectional, and not vertical
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| * BPPV
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| # Accounts for more than ½ of cases peripheral vestibular dysfunction
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| # Common in the elderly (patients usually > 60)
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| # Episodes of sudden onset, short duration -> condition often remits in 6 months
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| # Mechanism = stimulation of labyrinth by debris in posterior semicircular canal
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| * Vestibular neuronitis
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| # Accounts for ¼ of cases peripheral vestibular dysfunction
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| # Isolated vertigo due to viral infection involving labyrinth (after URI)
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| * Acute labyrinthitis
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| # Viral involvement of cochlea and labyrinth after upper respiratory infection (URI)
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| # Vertigo associated with tinnitus and hearing loss
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| # Symtpoms resolve completely within 3-6 weeks
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| * Meniere’s disease
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| # Idiopathic endolymphatic hydrops -> damage to hair cells
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| # Tinnitus, ear pressure and hearing loss associated with vertigo
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| # Paroxysmal episodes lasting minutes to hours
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| # Frequency of episodes waxes and wanes over time
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| # Hearing loss can become permanent
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| * Acoustic neuroma
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| # Benign tumor, but can cause brainstem compression if unprescribed
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| # Retrocochlear hearing loss, tinnitus, vague dizziness
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| # Very gradual symptom onset with progressive asymmetric hearing loss
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| # Vertigo not prominent because gradual time course allows central nervous system adaptation
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| * Ototoxins: hearing impairment usually >> vestibular symptoms
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| # Gentamicin, streptamicin most injurious to vestibular portion of CN VIII
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| ==References== | | ==References== |
| {{Reflist|2}} | | {{Reflist|2}} |
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| [[Category:Neurology]] | | [[Category:Neurology]] |
| [[Category:Otolaryngology]] | | [[Category:Otolaryngology]] |
| [[Category:Signs and symptoms]]
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| [[Category:Primary care]]
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| {{WH}}
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| {{WS}}
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