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.

Vertigo is one of the common symptoms in primary care and emergency departments in hospitals, but a distinction must be made between vertigo, dizziness and pre-fainting symptoms, and this is what will be explained in this report.

Causes of vertigo:

Vertigo mostly occurs due to a disturbance in the vestibular system in the inner ear or in the nervous system (the brain stem in particular), but there are physiological (unsatisfactory) causes of vertigo as well, and the reasons are detailed as follows:

Physiological causes

  • Sea sickness
  • Hight vertigo

Pathological causes

  • Peripheral causes: disorders of the vestibule (inner ear) and vestibular nerve
  • Central causes: diseases and disorders of the brain stem that affect the nuclei of the vestibular and auditory nerves

a. Peripheral pathology

Most of the causes of  vertigo are mainly peripheral causes resulting from disorders of the vestibular system, which is part of the inner ear, and peripheral causes include the following:

1. Benign paroxysmal positional vertigo (BPPV)

  • Very common
  • It can occur after an injury or wound to the head or after infection in the vicinity of the skull and its components, or it occurs spontaneously
  • Recent research suggests that this type is caused by excess calcium or debris being deposited in the posterior semicircular canal (part of the balance system in the inner ear).
  • Recurrent episodes of vertigo and loss of balance that occur as a result of moving the head and there is no hearing loss with it and the attack lasts only for a few minutes
  • The Dix-Hall Pike test confirms the diagnosis with 100% accuracy, the doctor quickly lowers patients to a lying position with the head below the level of the body at an angle of 30 degrees, causing dizziness immediately
  • It is treated using the "Epili" method

In difficult cases that do not respond to the previous method, surgery is used to remove part of the nerve.

Vertigo in cases of Meniere's disease is characterized by diminished hearing or hearing loss, tinnitus and a feeling of fullness in the ears.

Symptoms of Meniere's disease occur as a result of an increase in the volume of endolymph in the posterior semicircular duct.

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

What are the symptoms of Vertigo?

Dizziness is one of the most common symptoms associated with vertigo, and it gets worse if the patient moves his head in any direction, and the patient describes the condition as spinning around himself and feeling that things around him are moving with him.

Other symptoms associated with vertigo include:
  • increased sweating
  • feeling nauseous
  • vomiting
  • headache
  • Ringing or buzzing in the ear
  • Hearing impairment or deafness (in the case of Meniere's disease)
  • loss of balance

 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.

Notes about Vertigo management

Treatment of vertigo depends on the cause. If we eliminate the cause of the vertigo, the symptoms will disappear.

Medications can be helpful in relieving acute symptoms that last from a few hours to a few days.

The most important medications used in the treatment of acute motor vertigo include:
  • Antihistamines, especially meclizine, are safe during pregnancy
  • Hypnotics and sedatives from the "benzodiazepine" group
  • antiemetics
Non-pharmacological treatment of motion sickness includes:

For patients with permanent vestibular dysfunction (either unilateral or bilateral): undergoing physiotherapy and vestibular rehabilitation. Rehabilitation exercises train the brain through alternate and assimilated visual clues to maintain balance. 

Numerous studies have demonstrated the effectiveness of "rehabilitation" in reducing vertigo symptoms and improving the patient's ability to perform normal functions.

For patients with eighth nerve: the best treatment is a combination of medications (cortisone) and rehabilitation exercises.

For Meniere's disease: Combine medication and rehabilitation, as well as instructions for lifestyle changes. More details on the treatment of Meniere's disease can be found here.

Patients with benign paroxysmal positional vertigo (BPPV) benefit from treatment with medications (eg Betaserc) as well as head rotation exercises that help move calcium deposits in the back of the vestibular system via the techniques described above.
Vertigo causes, ddx, Clinical approach of diagnosis and treatment
Dr.Tamer Mobarak


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