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Vertigo causes, ddx, Clinical approach of diagnosis and treatment

Definition: Vertigo is a sensation of being off balance, whn you feel like you are spinning or as if the world is spinning around you.

Causes of vertigo:

  • Height vertigo 
  • Motion Sickness
  • Peripheral: Labyrinthine and vestibular nerve disorders.
  • Central: Vestibular disorders involving vestibular nuclei and their connections in the brainstem and cerebellar .

I. Peripheral

1-Benign paroxysmal positional vertigo (BPPV):
  • Very common.
  • May occur after head trauma, infection or spontaneous.
  • Recurrent attacks of severe vertigo provoked by change in head position, no deafness.
  • Due to presence of stray otoconia in the SSC.
  • A Dix-Hallpike manoever is diagnostic…..transient vertigo and nystagmus.
  • Treated by Epley manoever.
  • In resistant cases singular nerve section (the nerve supplying post. SCC).

3-Secondary endolymphatic hydrops e.g. due to Otosclerosis
5-Autoimmune inner ear disorder
6-Vascular Infarction
7-Traumatic Temporal bone fracture
  • Labyrinthine concussion 
  • Perilymphatic fistula (PLF)
-Acoustic neuroma (vestibular schwanoma) - Meningioma
  • Post-ear surgery 
  • Trans tympanic gentamycin ttt.

II. Peripheral and/or central

  • 1) Basilar migraine.
  • 2) Benign paroxysmal vertigo of childhood.
  • 3) Vestibular paroxysmia (Neuro-vascular cross-compression; disabling positional vertigo): pressure-induced dysfunction of the eighth nerve by direct pulsatile compression by arteries or rarely veins in the cerebellar pontine angle.
  • 4) Vertebro-basilar ischemia 
  • 5) AICA ischemia.

III. Central

  • 6) Vestibular epilepsy
  • 7) Paroxysmal ataxia/dysarthria (MS)
  • 8) Familial episodic ataxia
  • 9) Paroxysmal ocular tilt reaction

N.B. Some central and peripheral vestibular disorders are associated with auditory dysfunction

 Clinical approach of diagnosis and treatment of Vertigo

a. History taking

This allows differentiation of the patient’s complaint into:

  • Dizziness and light-headedness: a sensation of spatial disorientation.
  • Vertigo: abnormal sense of rotation either of the patient or the surrounding or it is a hallucination of movement.
  • Disequilibrium: off-balance, imbalance or giddiness, walking on uneven surfaces.
  • Oscillopsia: difficulty walking, riding, or reading, unable to focus on objects with movement (apparent motion of the visual scene).

Important points about history

  1. Make sure that the patient is actually describing vertigo (sense of rotation).
  2. Timing of vertigo; occurs in attacks or persistent.
  3. It should be determined whether vertigo is provoked by certain positions, as in benign positional vertigo.
  4. Associated symptoms of nausea, vomiting and diarrhea indicating the severity of vertigo.
  5. Loss of consciousness should raise the possibility of epilepsy.
  6. Symptoms of ear disease: deafness, tinnitus, earache, and discharge.
  7. Neurological symptoms: Headache, weakness, parasthesia, diplopia, ataxia and in coordination, may suggest a central cause.

b. Bedside Examination of a Dizzy Patient (clinical testing):

1. General examination: pulse B.P. for atherosclerosis, pallor for anemia.
2. Full neurological examination: including coordination, motor power, superficial and deep sensations, reflexes of UL and LL.
3. Cranial nerves examination
4. Vestibular examination:
  • Head Posture and Ocular Alignment.
  • Neurological examination: including cranial nerve testing, coordination, motor power, superficial and deep sensations, reflexes of UL and LL.
  • Balance:
Romberg test: the patient is asked to stand with the feet close together with the eyes open, and then to close the eyes. The test result is positive when the patient is stable with the eyes open but loses balance with the eyes closed.
Gait assessment (eg. Ataxic?)
Stepping test (Fukuda)

Causes of Dizziness and light-headedness (Differential diagnosis):

1-Pre-syncopal dizziness (cardiac and non-cardiac):
  • a. Orthostatic hypotension 
  • b. Cardiac arrhythmias.
2-Psychosomatic dizziness
  • a. Panic attacks 
  • b. Hyperventilation syndrome.
3-Metabolic hypoglycemia.
4-Alcohol and drug intoxication.


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