Vertigo

Vertigo Differential Diagnosis & Treatment

Symptomatic Medications for Vertigo (General):

• Dimenhydrinate: 50 mg IV stat, then 50 mg every 4 hours; OR 50 mg orally 3 times daily (with meals) OR 50-100 mg orally every 4-6 hours as needed
• Cinnarizine HCl: 25 mg orally 3 times daily (with meals)
• Flunarizine: 5-10 mg orally at bedtime
• Metoclopramide (Antiemetic): 10 mg IV stat, then 10 mg IV every 6 hours

Important Notes:

• This table is intended for informational purposes only and should not be used as a substitute for professional medical advice, diagnosis, or treatment.
• Treatment plans should always be individualized based on the underlying cause, patient history, and clinical judgment.
• Always consult with a qualified healthcare professional for any health concerns or before making any decisions related to your health or treatment.

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Understanding Vertigo: Beyond Spinning

Vertigo, the illusion of movement, arises from dysfunction within the vestibular system, a complex network encompassing the inner ear, vestibular nerve (CN VIII), brainstem, cerebellum, and cortical areas. It's crucial to differentiate true vertigo from other forms of dizziness:

• True Vertigo: Characterized by a distinct sensation of spinning, tilting, or swaying, often accompanied by nausea, vomiting, and imbalance.
• Dizziness: A broader term encompassing lightheadedness, unsteadiness, and disorientation, not necessarily implying vestibular dysfunction.

Differentiating the Culprit: Central Vertigo vs. Peripheral Vertigo

The distinction between central and peripheral vertigo hinges on the location of the underlying pathology:

1. Peripheral Vertigo:

• Origin: Vestibular apparatus (inner ear) or vestibular nerve (CN VIII).
• Causes:
  • Benign Paroxysmal Positional Vertigo (BPPV): Most common, caused by dislodged otoliths within the semicircular canals.
  • Vestibular Neuritis/Labyrinthitis: Inflammation of the vestibular nerve or labyrinth, often viral in origin.
  • Meniere's Disease: Characterized by episodic vertigo, fluctuating hearing loss, tinnitus, and aural fullness, thought to be caused by endolymphatic hydrops.
  • Acoustic Neuroma: Benign tumor of the vestibulocochlear nerve (CN VIII).
• Clinical Features:
  • Vertigo: Typically severe, episodic, and rotational, often triggered by head movements.
  • Auditory Symptoms: Hearing loss, tinnitus, and aural fullness may be present.
  • Nystagmus: Unidirectional, horizontal or torsional, suppressed by visual fixation.
  • Neurological Deficits: Absent.

2. Central Vertigo:

• Origin: Brainstem, cerebellum, or cerebral cortex.
• Causes:
  • Stroke: Involving the posterior circulation (e.g., cerebellar stroke, brainstem infarction).
  • Multiple Sclerosis: Demyelinating disease affecting the central nervous system.
  • Migraine: Vestibular migraine can present with vertigo, headache, and other neurological symptoms.
  • Tumors: Affecting the brainstem or cerebellum.
• Clinical Features:
  • Vertigo: Typically milder, continuous, and less clearly rotational.
  • Auditory Symptoms: Usually absent.
  • Nystagmus: Multidirectional, vertical, or purely torsional, not suppressed by visual fixation.
  • Neurological Deficits: Often present, such as ataxia, dysarthria, diplopia, or sensory disturbances.

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Diagnostic Approach: Unveiling the Underlying Cause

1. History:

• Characterize Vertigo: Onset (acute vs. gradual), duration (seconds, minutes, hours), triggers (head movements, positions), associated symptoms.
  • Onset:
    • Acute: Did the vertigo start suddenly or gradually?
    • Gradual: Did it develop over time?
  • Duration:
    • Seconds: Brief episodes suggest conditions like Benign Paroxysmal Positional Vertigo (BPPV).
    • Minutes to hours: Could indicate Meniere’s disease or vestibular migraine.
    • Hours to days: Consider vestibular neuritis or central causes.
  • Triggers:
    • Head Movements: Does changing the position of the head trigger the vertigo? (Common in BPPV)
    • Positional: Does lying down or turning over in bed affect the vertigo?
  • Associated Symptoms:
    • Nausea/Vomiting: Common in both peripheral and central vertigo.
    • Hearing Loss: Suggests peripheral causes like Meniere’s disease.
    • Tinnitus (Ringing in the ears): Often associated with Meniere’s disease.
    • Fullness in the ear: Indicative of Meniere’s disease.
    • Neurological Symptoms: Numbness, weakness, difficulty speaking (suggest central causes like stroke).
• Past Medical History: Migraines, stroke risk factors, recent infections, head trauma, medications.
  • Migraines: History of migraines can suggest vestibular migraine.
  • Stroke Risk Factors: Including hypertension, diabetes, hyperlipidemia, smoking, and atrial fibrillation.
  • Recent Infections: Upper respiratory infections or ear infections can precede vestibular neuritis.
  • Head Trauma: Recent head injuries can cause labyrinthine concussion or benign paroxysmal positional vertigo (BPPV).
  • Medications: List all current medications, focusing on those that might cause dizziness (e.g., antihypertensives, antibiotics, diuretics).
• Specific Questions to Ask
  • Character of Vertigo:
  • Describe the sensation. Is it spinning (vertigo), lightheadedness, or imbalance?
  • When did it start? How long does it last? How often does it occur?
  • Triggers and Relieving Factors:
    • What were you doing when it started?
    • Does any specific movement make it worse or better?
    • Do symptoms improve with closing your eyes or lying still?
  • Hearing and Ear Symptoms:
    • Have you noticed any hearing loss, ringing in the ears, or ear fullness?
    • Any history of ear infections?
  • Neurological Symptoms:
    • Any weakness in the arms or legs?
    • Any difficulty speaking, swallowing, or changes in vision?
  • Systemic Symptoms:
    • Any recent infections, fever, or weight loss?
    • Any history of fainting or blackouts?

2. Physical Examination:

• Vital Signs: Check blood pressure (supine and standing) for orthostatic hypotension.
• Neurological Exam: Cranial nerves, motor strength, sensory function, coordination (finger-to-nose, heel-to-shin), gait, Romberg test.
• Otoscopic Examination: Visualize the tympanic membrane for signs of middle ear pathology.
• Vestibular Testing:
  • Dix-Hallpike Maneuver: Provokes characteristic nystagmus in BPPV.
  • Head Impulse Test: Assesses the vestibulo-ocular reflex, abnormal (catch-up saccades) in peripheral lesions.
  • Caloric Testing: Evaluates each labyrinth's function by inducing temperature-dependent endolymph flow.

3. Imaging Studies:

• MRI (with contrast): Indicated for suspected central causes, acoustic neuroma, or when the diagnosis is unclear.
• CT Scan: May be used if MRI is contraindicated or unavailable.

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Step-by-Step Guide to Vertigo Tests and Maneuvers

This guide breaks down key procedures used to diagnose and treat vertigo, providing clear instructions for ENT residents:

1. Dix-Hallpike Maneuver (Diagnosing BPPV)

Purpose: Provoke characteristic nystagmus to diagnose Benign Paroxysmal Positional Vertigo (BPPV), typically affecting the posterior semicircular canal.

Steps:

• Explain the procedure to the patient, including the potential for brief vertigo.
• Position: Patient sits upright on the exam table with legs extended.
• Head Turn: Turn the patient's head 45 degrees towards the side being tested.
• Lie Down Quickly: While supporting the head and neck, rapidly guide the patient backward, ending with their head hanging slightly off the table, still turned 45 degrees, and extended 20 degrees backward.
• Observe: Closely observe the patient's eyes for nystagmus (type, direction, duration) and ask about any vertigo. Maintain this position for 30-60 seconds.
• Return Upright: Gently bring the patient back to the seated position.
• Repeat: Repeat on the other side after any dizziness subsides.

Interpretation:

• Positive: Vertigo and torsional, upbeating nystagmus with a latency of a few seconds, fatiguing after repeated maneuvers. The direction of the top pole of the eye beating indicates the affected ear (e.g., right-beating nystagmus suggests right posterior canal BPPV).
• Negative: No nystagmus or vertigo.

2. Head Impulse Test (HIT) (Assessing Vestibulo-Ocular Reflex)

Purpose: Evaluate the vestibulo-ocular reflex (VOR), which stabilizes gaze during head movements.

Steps:

• Explain: Explain the test to the patient.
• Position: The patient sits upright, focusing on a target straight ahead (your nose or a distant object).
• Head Hold: Gently cup the patient's head with both hands.
• Quick Head Turn: Instruct the patient to maintain focus on the target. Quickly and unexpectedly rotate the head horizontally about 15-20 degrees to one side.
• Observe: Observe the eyes for corrective saccades (catch-up movements).
• Repeat: Repeat on the other side.

Interpretation:

• Normal: Eyes maintain fixation on the target throughout the head movement.
• Abnormal (Positive): Eyes move with the head and then make a corrective saccade back to the target. Indicates a peripheral vestibular lesion on the side to which the head was turned.

3. Caloric Testing (Evaluating Individual Labyrinth Function)

Purpose: Assesses the function of each inner ear (labyrinth) separately by stimulating the horizontal semicircular canal with temperature changes.

Steps:

• Explain: Explain the procedure thoroughly, including possible discomfort (mild vertigo, nausea).
• Position: Patient lies supine with head elevated 30 degrees.
• Warm Irrigation (One Ear): Irrigate the external auditory canal with warm water (44°C or 111.2°F) for 30 seconds. Observe for nystagmus. The expected response is slow phase eye movement opposite to the side of irrigation, followed by a quick phase (nystagmus) toward the side of irrigation.
• Cold Irrigation (Same Ear): After nystagmus from warm irrigation subsides, irrigate the same ear with cold water (30°C or 86°F) for 30 seconds. Observe for nystagmus (slow phase towards, fast phase away from the irrigated ear).
• Repeat: Repeat steps 3 and 4 on the opposite ear after a rest period.

Interpretation:

• Normal: Nystagmus occurs in the expected directions (warm-same side, cold-opposite side) with roughly equal intensity for both ears.
• Abnormal: Reduced or absent nystagmus suggests a vestibular deficit on the side of the affected ear.

4. Epley's Maneuver (Canalith Repositioning for BPPV)

Purpose: Repositions displaced otoconia (canaliths) from the posterior semicircular canal back into the utricle, resolving BPPV.

Steps:

• Explain: Explain the procedure to the patient.
• Start: Patient sits upright on the exam table.
• Head Turn (45 degrees): Turn the head 45 degrees toward the affected side.
• Lie Down Rapidly: Quickly guide the patient backward until lying down with head hanging slightly off the table, still turned 45 degrees. Maintain this position for 1-2 minutes.
• Head Rotation (90 degrees): Without lifting the head, rotate it 90 degrees towards the unaffected side. Hold for 1-2 minutes.
• Body Roll (90 degrees): Turn the patient's head and body another 90 degrees in the same direction (now lying on their side aka. unaffected side). Hold for 1-2 minutes.
• Sit Up Slowly: Slowly assist the patient into an upright seated position, keeping their head turned to the side.
• Rest: Advise the patient to rest for a few minutes.

Post-Procedure Instructions:

• Avoid lying flat or tilting the head back for the rest of the day.
• Sleep with the head elevated for a few nights.

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Management of Vertigo: Targeted Treatment Strategies

1. Peripheral Vertigo:

• BPPV: Canalith repositioning maneuvers (Epley, Semont) are highly effective.
• Vestibular Neuritis/Labyrinthitis: Corticosteroids (e.g., prednisone) to reduce inflammation, vestibular suppressants (e.g., meclizine, dimenhydrinate) for symptom relief.
• Meniere's Disease: Low-salt diet, diuretics (e.g., hydrochlorothiazide), vestibular suppressants, intratympanic steroid injections, or surgical interventions in severe cases.
• Acoustic Neuroma: Treatment depends on tumor size and growth rate, ranging from observation to surgery or radiation therapy.

2. Central Vertigo:

• Stroke: Requires urgent neuroimaging and management in a stroke unit, including thrombolysis or thrombectomy if indicated.
• Multiple Sclerosis: Disease-modifying therapies, corticosteroids during exacerbations, symptomatic treatment for vertigo.
• Migraine: Triptans, antiemetics, migraine prophylaxis medications (e.g., beta-blockers, anticonvulsants).
• Tumors: Treatment depends on tumor type and location, may involve surgery, radiation, or chemotherapy.

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Beyond Treatment: Vestibular Rehabilitation

Vestibular rehabilitation therapy (VRT) is crucial for both central and peripheral causes to promote central nervous system compensation, improve balance, and reduce dizziness.

Special Considerations:

• Nystagmus Interpretation: Direction, duration, and response to visual fixation provide valuable clues to the underlying pathology.
• Red Flags: Sudden onset, persistent neurological deficits, headache, fever, or neck stiffness warrant urgent investigation for serious conditions like stroke or meningitis.
• Patient Education: Reassurance, explanation of the diagnosis and treatment plan, and lifestyle modifications are essential for optimal outcomes.

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Conclusion

Effective management of vertigo necessitates a systematic approach encompassing a detailed history, thorough physical examination, targeted investigations, and individualized treatment strategies. Differentiating between central and peripheral causes is paramount to guide appropriate interventions and ensure the best possible patient care. This comprehensive guide equips ENT residents with the essential knowledge and clinical skills to confidently diagnose and manage patients presenting with vertigo.