Vertigo is the sensation that the environment is spinning around relative to oneself (objective vertigo) or vice versa (subjective vertigo). The term is sometimes used erroneously to mean any form of dizziness. True vertigo is described as a rotary sensation of the patient or surroundings, and is often of vestibular origin. Vertigo may result from diseases of the inner ear or disturbances of the vestibular centers or pathways in the central nervous system (e.g., Meniere disease, arteriosclerosis of cerebral vessels, brain lesion, head injury, motion sickness, or large and rapid variations in barometric pressure). Depending on the underlying cause/condition, it may be associated with nausea and vomiting, or accompanied by other symptoms and signs (e.g., headaches and visual symptoms). Most causes of vertigo are peripheral and non-life-threatening. However, those few central causes (vascular and neoplastic) are emergencies that should not be overlooked.
Can be categorized into 4 subgroups: vertigo, presyncope, disequilibrium, and lightheadedness (or nonspecific dizziness). The most common causes of dizziness in primary care settings are benign paroxysmal positional vertigo (vertigo caused by the presence of a canalith in the vestibular apparatus), Meniere disease, and acute vestibular neuronitis. These all present with vertigo symptoms.
A peripheral vestibular disorder characterized by sudden-onset, severe attacks of vertigo usually lasting <30 seconds and precipitated by specific head movements (e.g., looking up or bending down, getting up, turning the head, or rolling over to one side in bed). Diagnosis is clinical with key diagnostic factors including episodic vertigo (repeated attacks over days, weeks, or months), absence of associated symptoms, normal neurologic exam, positive Dix-Hallpike maneuver (posterior canal BPPV) or supine lateral head turn (lateral canal BPPV), and normal otologic exam.
Auditory disease characterized by an episodic, sudden onset of vertigo; hearing loss and roaring tinnitus; and a sensation of pressure or discomfort in the affected ear. Vertigo lasts minutes to hours and may be associated with nausea and vomiting. Risk factors for MD include increased age (>40 years), family history, recent viral illness, and autoimmune disorders. In patients with MD and no systemic cause, a combination of a low-salt diet and diuretics (to reduce endolymph) is thought to control vertigo in over 80% of patients. Vestibular and balance rehabilitation therapy is recommended for patients who have problems with balance. Use of the Meniett device 3 times a day to deliver intermittent pressure pulses through the ear canal may significantly reduce vertigo frequency. Intratympanic administration of corticosteroids or gentamicin is also effective.
An inflammatory condition, which affects the labyrinth in the cochlea and vestibular system of the inner ear. Viral labyrinthitis is typically associated with a preceding upper respiratory tract infection. Other etiologic viral agents include varicella zoster virus, cytomegalovirus, mumps, measles, rubella, and HIV. Bacterial labyrinthitis is associated with acute or chronic otitis media, meningitis, and cholesteatoma. Labyrinthitis may also manifest in certain autoimmune conditions (e.g., Cogan syndrome or Behcet disease). Symptoms include varying degrees of hearing loss, vertigo, and disequilibrium (problems with balance), and there may be associated tinnitus. Most acute episodes are short-lived and self-limited, and treatment is symptomatic and primarily involves the use of vestibular suppressants and antiemetics.
A common cause of vertigo and the most common cause of spontaneous episodic vertigo. It affects approximately 10% of patients with migraine. Symptoms include spontaneous and positional vertigo, head motion vertigo/dizziness and ataxia, all of variable duration, ranging from seconds to days, and independent of migraine associated headache. Photophobia, phonophobia, or aura may be diagnostic symptoms. Management is similar to the recommended treatment of migraine headaches, and includes dietary and lifestyle modifications, and prophylactic therapies (beta blockers, calcium channel blockers, and tricyclic antidepressants).
Vestibular neuritis (vestibular neuronitis) is an acute peripheral vestibulopathy due to reactivation of a viral infection, most commonly herpes simplex virus, which affects the vestibular ganglion, vestibular nerve, labyrinth, or a combination of these sites. Early diagnosis is important because there may be long-term functional impairment if untreated. Early treatment with corticosteroids has been shown to accelerate recovery of vestibular function and, if within 3 days of onset of symptoms, may shorten the attack.
Dizziness is a common presenting feature in cerebrovascular events. Cerebellar stroke (due to infarction or hemorrhage) may present in a similar fashion to peripheral causes of vertigo with sudden intense vertigo, nausea, and vomiting. Nystagmus (bilateral or vertical) may suggest a central cause of the vertigo. Other neurologic signs include limb ataxia and impaired gait. Patients with cerebellar stroke usually cannot stand without support, even with the eyes open, whereas a patient with acute vestibular neuritis or labyrinthitis is usually able to do so. Unlike peripheral causes, the head-impulse test is negative (no saccadic adjustment of the eyes on sudden head twisting). Urgent MRI should be requested in all patients with acute vertigo who have significant risk factors for a cerebellar stroke, such as hypertension, diabetes mellitus, smoking, and cardiovascular disease, since it is possible that central signs on exam may not present.
Typically, occurs as a result of blunt head trauma such as a fall, an assault, or a motor vehicle accident. Presenting symptoms may be of a traumatic perilymphatic fistula or post-traumatic Meniere disease. Patients may complain of vertigo, disequilibrium, tinnitus, pressure, headache, and diplopia. Other causes are postsurgical (middle-ear surgery, cochlear implantation) and diving. Superior semicircular canal dehiscence should be differentiated from post-traumatic vertigo; it is characterized by episodes of vertigo associated with loud sounds and/or altered middle-ear pressure.
Intracranial tumors and acoustic neuromas may present with vertigo, as well as other symptoms such as signs of intracranial pressure (e.g., headache, altered mental status, nausea, and/or vomiting) and gait abnormality. Cranial nerve deficits may also manifest. Neuroimaging with CT/MRI is essential.
BMJ Publishing Group
This overview has been compiled using the information in existing sub-topics.
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