VERTIGO. AYESHA SHAIKH PGY2 EMORY FAMILY MEDICINE 09.17.2008. CASE. 31,female doctor, otherwise healthy, post partum week 5. First episode, sudden feeling of room spinning, while entering patient data in computer, during Family Medicine Clinic… One fine day last year same time! .
EMORY FAMILY MEDICINE
1- CENTERAL VESTIBULAR CAUSES
(Brain stem or cerebellum)
2- PERIPHERAL VESTIBULAR CAUSES
( Labyrinth or vestibular nerve)
( Slowly progressive Unilateral/Bilateral)
Q: When you have dizzy spells , do you feel lightheaded or do you see the world spin around you?
Q: Duration of Vertigo and associated symptoms?
( differentiate peripheral vs central causes)
Duration of episode Suggested diagnosis
A few seconds Peripheral cause: unilateral loss of vestibular function; late stages of
acute vestibular neuronitis; late stages of Ménière's disease
to a few minutes Benign paroxysmal positional vertigo; perilymphatic fistula
to one hour Posterior transient ischemic attack; perilymphatic fistula
Hours Ménière's disease; perilymphatic fistula from trauma or surgery;
migraine; acoustic neuroma
Days Early acute vestibular neuronitis*; stroke; migraine; multiple sclerosis
Weeks Psychogenic (constant vertigo lasting weeks without improvement)
*-Vertigo with early acute vestibular neuritis can last as briefly as two days or as long as one week or more.
Information from references 3, 6, and 12.
Symptom Suggested diagnosis
Aural fullness Acoustic neuroma; Ménière's disease
Ear or mastoid pain Acoustic neuroma; acute middle ear disease (e.g., otitis media, herpes zoster oticus)
Facial weakness Acoustic neuroma; herpes zoster oticus
Focal neurologic Cerebellopontine angle tumor; cerebrovascular disease;
findings) multiple sclerosis (especially findings not explained by single neurologic lesion
Headache Acoustic neuroma; migraine
Hearing loss Ménière's disease; perilymphatic fistula; acoustic neuroma; cholesteatoma;
otosclerosis; transient ischemic attack or stroke involving anterior inferior cerebellar
artery,herpes zoster oticus
Imbalance Acute vestibular neuronitis (usually moderate); cerebellopontine angle tumor
Nystagmus Peripheral or central vertigo
Phonophobia, photophobia Migraine
Tinnitus Acute labyrinthitis; acoustic neuroma; Ménière's disease
Information from references 1, 6, and 12 through 14.
Causes of Vertigo Associated with Hearing Loss
Diagnosis Characteristics of hearing loss
Acoustic neuroma Progressive, unilateral, sensorineural
Cholesteatoma Progressive, unilateral, conductive
Herpes zoster oticus
(i.e., Ramsay Hun
syndrome) Subacute to acute onset, unilateral
Ménière's diseases Sensorineural, initially fluctuating, initially affecting lower frequencies;
later in course: progressive, affecting higher frequencies
Otosclerosis Progressive, conductive
Perilymphatic fistula Progressive, unilateral
Transient ischemic attack or
stroke involving anterior inferior cerebellar
artery or internal auditory artery Sudden onset, unilateral
Information from references 9, 12, and 13.
Distinguishing Characteristics of Peripheral vs. Central Causes of Vertigo
Feature Peripheral vertigo Central vertigo
Nystagmus Combined horizontal and torsional; Purely vertical, horizontal, or torsional
inhibited by fixation of eyes onto object; ; not inhibited by fixation of eyes onto object;
fades after a few days; does not change may last weeks to months
direction with gaze to either side ; may change direction with gaze
Imbalance Mild to moderate; able to walk Severe; unable to stand still or walk
Nausea May be severe Varies
tinnitus Common Rare
Nonauditory Rare Common
diagnostic Longer (up to 20 seconds) Shorter (up to 5 seconds)
Information from references 14 and 15.
Clues Peripheral vertigo Central vertigo
Findings on Latency of symptoms None
Dix-Hallpike and nystagmus 2 to 40 seconds
Severity of vertigo Severe Mild
Duration of nystagmus Usually< 1 minute Usually>1 minute
Fatigability* Yes No
Habituation† Yes No
Postural instability Able to walk; Falls while walking;
unidirectional instability severe instability
or tinnitus Can be present Usually absent
Symptoms Absent Usually present
*-Response remits spontaneously as position is maintained.
†-Attenuation of response as position repeatedly is assumed.
Information from references 3 and 4.
No LAB testing!
Brain imaging : MRI with contrast for acute vertigo and Sensorineural hearing loss, MRA for vertebrobasilar circulation
5 to 10 mg by slow IV every 6 hours
25 mg rectally every 12 hours
5 to 10 mg by slow IV over 2 minutes
(Usually posterior canal Calcium Debris)
Contraindication: Severe carotid stenosis, unstable heart disease, severe neck disease
Success rate: 80 % after one treatment, 100% with repeated treatments.
Recurrence rates: 15% /year, 20% @ 20 months, and 37% @ 60 months.
2- Vestibular Neuronitis
( Acute Prolonged Vertigo)
(Distension of Endolymphatic compartment due to impaired endolymphatic filtration and excretion)
(Sudden onset of vertigo with additional symptoms eg
diplopia, ataxia, dysphagia, dysarthria)
Reduce or eliminate Aspartame, chocolate, caffeine and alcohol, Lifestyle changes, Vestibular rehabilitation exercises.
Meds: BDZ, TCA, BB, SSRI, CCB, Antiemetics.
( Anxiety , Panic disorders more common than depression; Hyperventilation is the cause.)