Vertigo/Dizziness

Describe Vertigo

• Causes

• Two Classifications

Vertigo

Cause

• Acute asymmetry of the vestibular system.

  • inner ear, 

  • vestibular nerve, 

  • Nucleus w/in medulla

  • portions cerebellum

Two Classification:

• Peripheral vestibular Disease

• Central Vestibular Disease

List the causes of Peripheral and Central Vestibular Disease

Peripheral Causes 

• Benign paroxysmal positional vertigo

• Vestibular neuritis/labyrinthitis

• Herpes zoster oticus (Ramsay Hunt syndrome)

• Meniere disease

• Labyrinthine concussion

• Perilymphatic fistula

• Semicircular canal dehiscence syndrome

• Cogan’s syndrome

• Recurrent vestibulopathy

• Acoustic neuroma

• Aminolycoside toxicity

• Otits Media

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Central Causes

• Vestibular migraine

• Brainstem ischemia

• Cerebellar infarction and hemorrhage

• Chiari malformation

• Multiple Sclerosis

• Episodic ataxia

Compare Peripheral vs Central NYSTAGMUS

• Visual Fix.

• Types

• Direction

• Fatigue

• Visual Fix

  • P: suppressed

  • C: Not Affected

• Types:

  • P: Horizontal/ Vertical/ rotary/torsional 

  • C: horizontal, torsional, or vertical + many others

• Direction:

  • P: Fast phase away from affected ear

    • Intensifies when looking away from affected ear

  • C: may change directions

• Fatigue:

  • P: Eventually Fatigues

    • Always beats in same or adapt

  • C: Doesn’t Fatigues

What is the Dix-Hall-Pix Maneuver

Describe BENIGN PAROXYSMAL POSITIONAL VERTIGO

• STATs

• Clinical Presentation

• Patho

• Dx

• Rx

STATs

• Most common cause of vertigo

Clinical Presentation:

• Brief vertigo + nystagmus associated w/ position change 

  • (often rolling over in bed).

  • Vertigo lasts 10-60 secs 

• Lag (few secs) after head movement before vertigo onset 

• May even awaken from sleep

• No sustained nystagmus

---

Patho:

• Secondary to abnormal stimulation of posterior semicircular canal (93%)

Dx: 

• History and Dix-Hall-pike

Rx: 

• Epley maneuver;

• Vestibular rehab

Describe CANALITH REPOSITIONING PROCEDURE/EPLEY

Describe MENIERE’S DISEASE

• Patho

• Symptoms

• Dx

• Treatment

• Patho:

  • Secondary to increased endolymph pressure. ( abnormal fluid in inner ear).

  • “Endolymphatic hydrops”

• Symptoms:

  • Experience fullness in ear -> low frequency hearing loss

  • Tinnitus – low pitch (roaring)

  • Vertigo

• Dx: 

  • Audiometric testing (low frequency hearing loss) 

  • history

  • Nystagmus during an attack- otherwise nml exam. 

  • Consider MRI.

---

Treatment:

• Symptomatic

• Low salt diet + diuretics 

  • ( ie. Hydrochlorothiazide or triamterene or acetazolamide).

• Antiemetics 

  • (Meclizine or dimenhydrinate or prochlorperazine or promethazine).

• Surgery 

• remove bony/membranous labyrinth or vestibular neurectomy. 

• decompression or shunting of endolymphatic sac.

  • Nondestructive

Describe VESTIBULAR MIGRAINE

• Duration

• Occurrence

• Symptoms

• Duration:

  • Few hours -> days

• Occurance:

  • Precedes, simultaneous, or follows head ache

  • Rarely Chronic

• Symptoms:

  • Similar to BPPV

  • Mild-Severe

  • Associated w/ Aura

  • photophobia or phonophobia

NOTE:

• Timing and presentation similar to Meneire’s but Migraine much more common

How to do head thrust test/head impulse test

Describe VESTIBULAR NEURITIS/LABYRINTHITIS

• What is it?

• Timing?

• Symptoms?

• Why do brain imaging needed

• Clinical Presentation

• Treatments

• What is it?

  • Viral /post viral inflammatory disorder affecting CNVIII (50%)

• Timing:

  • Sudden onset

  • Lasts for several days

---

• Symptoms:

  • N/V

  • Hearing loss 

    • ***this makes it labyrinthitis***

  • Tinnitus

  • Nystagmus

• Clinical Presentation:

  • Pt initially suffer greatly for few-several days -> gradual diminution of symptoms and a return of equilibrium

---

• Brain Imaging Needed

  • b/c  clinical features of cerebellar hemorrhage/infarction = similar to vestibular neuritis

    • Need to RULE OUT

• Treatment:

  • Prednisone 

    • (corticosteroid therapy)

  • Symptomatic treatment: 

    • antiemetics, antihistamines, anticholinergics, and benzodiazepines

  • Vestibular rehabilitation

HERPES ZOSTER OTICUS/RAMSAY HUNT

Describe HERPES ZOSTER OTICUS/RAMSAY HUNT

• Patho

• Symptoms

• Rx

• Patho:

  • VZV latent react. (shingles) -> infection of geniculate ganglion

• Symptoms:

  • Acute vertigo + hearing loss, 

  • ipsilateral facial paralysis, 

  • ear pain

  • vesicles in auditory canal + auricle 

• Rx: 

  • corticosteroids 

  • acyclovir

Describe ACOUSTIC NEUROMA/ACOUSTIC SCHWANNOMAS

• STATs

• symptoms

STATs

• Third most common primary intracranial neoplasm

Symptoms:

• Imbalance or vague feeling of swaying or tilting

  •  may be only manifestations 

NOTE:

• Because it is slow growing, typically has subtle imbalances.

[COMMON SENSE]

Describe Wallenberg Syndrome:

• What is it?

• Symptoms

• Blood Supply affeced

• What is it?

  • Lateral medullary infarction

• Symptoms:

  • acute onset of vertigo and disequilibrium

  • abnormal eye movement, 

  • Ipsilateral Horner syndrome

  • ipsilateral limb ataxia 

  • dissociated sensory loss

  • Hoarseness and dysphagia

• Blood Supply Affected

  • posterior inferior cerebellar artery

Describe STROKE

• What is it

• Symptoms

STROKE

What is it?

• Cerebellar infarction/hemorrhage

Symptoms:

• Sudden vertigo + N/V

• LImb Ataxia

NOTE:

• Older patients with risk factors

Describe Rotational vertebral artery syndrome 

• AKA

• Patho

• Dx

Rotational vertebral artery syndrome 

• AKA:

  • Vertebrobasilar Insufficiency

• Patho:

  • symptomatic vertebral artery compression by bony elements of spine 

    • (usually at C1-C2)

  • Causes vertigo or nonspecific dizziness w/ head turning

• Dx

  • Vascular imaging

    • In Neutral/Symptomatic position

List the tumors that can cause vertigo

TUMORS Causing Vertigo

• Tumors of internal auditory canal and cerebellopontine angle

  • Schwannomas – involve eighth crainal nerve

  • Meningioma

  • Epidermoid cysts

  • Cholesterol granulomas

  • Mets

• Brain tumors

  • Brainstem

  • 4th ventricle

  • Cerebellum

Describe Craniocervical junction disorders

• Patho

• clinical Presentation

• Treatment

Craniocervical junction disorders

Patho:

• Chiari I malformation: congenital anomaly ->  cerebellar tonsils extend below foramen magnum

Clinical Presentation:

• Vertigo is positionally induced – neck extension

• Downbeating nystagmus

Treatment:

• surgical decompression

Describe DISEMBARKMENT SYNDROME

• AKA

• What is it?

• Treatment

• AKA:

  • (MAL DE DEBARQUEMENT) Syndrome

• What is it?

  • perception of self-motion + imbalance  following exposure to passive motion. 

    • Water travel = most usual trigger, 

    • others (air or land travel, flight simulators, water beds) 

• Treatment:

  • Scopolamine

  • Promethazine

  • Anti-histamine

    • ( dimenhydrinate, Diphendryamine)