Vertigo

1
Vertigo
The Dizzy Patient
2
Vertigo

• Latin origin vertere, to spin
• the illusion that the environment is spinning
• distinct from dizziness
• light-headed faintness
• off-balanced feeling
• feeling of floating

3
Acute Vertigo

• Determine whether it represents a peripheral or a
  central problem
• peripheral (99100) refers to the inner ear or
  vestibular nerve up to the root entry zone in the
  brain stem
• central (1100) refers to the brain, usually
  associated with focal neurologic findings, may be
  from cerebellar infarct

4
Acute Vertigo clues from history and physical

• peripheral - look for signs of ear involvement
  unilateral hearing loss, tinnitus, fullness, or
  pain
• central - most patients have vascular risk
  factors age gt60, HTN, smoking, known
  atherosclerotic cardiac or or peripheral vascular
  disease

5
Clues from History and Physicaldegree of
imbalance

• peripheral - patients prefer to lie down, they
  can get up and walk if asked but tend to veer to
  one side
• central - patients with cerebellar lesions
  usually have such severe imbalance that they
  cannot stand up

6
Clues from History and Physicalnystagmus

• Most often found in patients with peripheral
  vestibular lesions
• peripheral - always beats in one direction
  inhibited with fixation usually disappears
  within a few days
• central - typically changes direction toward the
  direction of gaze not inhibited with fixation
  last gt 1-2 days

7
Clues from History and Physicaldouble vision

• usually suggests central brainstem involvement,
  but may occur in peripheral inner-ear or
  vestibular nerve damage
• peripheral lesions
• siemicircular canal ? nystagmus
• otolith organs ? slight static eye displacement,
  use cover-uncover test

8
Acute Vestibulopathy of unknown cause

• other diagnostic labels
• vestibular neuritis
• vestibular neuronitis
• viral labyrinthitis
• viral neurolabyrinthitis
• vascular occlusion of inner ear

9
Acute Vestibulopathy treatment

• hydration and promethazine
• vestibular rehabilitation
• begin with onset of symptoms
• make head movements that provoke vertigo, walk,
  bend, straighten up
• recovery occurs as the brain compensates for loss
  of function
• meclizine - for short term use only

10
Benign Positional Vertigo

• vertigo produced by change in position
• the most common cause of vertigo after head
  trauma, or other damage to the ear, such as
  infections
• results from the free movement of dislodged
  utricle particulate debris - calcium carbonate
  crystals - in the semicircular canals

11
Benign Positional Vertigodiagnostic testing

• Dix-Hallpike test
• positional testing using the head-hanging
  technique
• patients with benign positional vertigo will show
  a burst of nystagmus after a delay of 5 to 10
  seconds, the nystagmus lasts about 30 seconds
• the test is never subtly positive

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Benign Positional Vertigotreatment

• Epley maneuverthe patients head is
  systematically rotated to move the loose
  particles out of the posterior semicircular canal
  back into the utricle (see reference)

Otolaryngol Head Neck Surg 1992107399
13
Vertigo of Central Origin

• Diagnotic clues
• risk factors, focal neurologic findings
• Diagnostic tests
• MRI brain scan
• MRI angiography
• Treatment
• aspirin 325 mg a day

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References

• Dizzy Patients The Varieties of VertigoBaloh
  RW, Baringer JR. Hosp Practice 199833(6)55-77.
• Dizziness, Hearing Loss, and TinnitusBaloh RW.
  FA Davis, Philadelphia, 1998.