What is vertigo? Someone may refer vertigo as benign paroxysmal vertigo, positional vertigo, labyrinthitis or acute vestibular neuritis. Vertigo is thought as a sensation of movement when the movement is not actually occurring. The patient may complain of illusions of movement in which he feels that the surrounding is revolving around him ( objective vertigo) or he feel that he is spinning around/ revolving around in space ( subjective vertigo). As a conclusion vertigo is divided into objective vertigo and subjective vertigo. Sometimes patient may also complain of being pulled by a magnet sideways.
It is very easy to confuse vertigo with dizziness. Dizziness is a sensation which is non – specific and characterizes as light headiness and imbalance. Dizziness is not accompanied by hearing loss, tinnitus, nystagmus, nausea and vomiting. These symptoms are more common with vertiginous gait. The vertigo is worse with movement and relieve with lying down. Vertigo begins abruptly. The vertigo may be permanent or temporary and mild or severe.
Patient with vertigo should remain precautious at all time to avoid any injuries (fall) as a result from imbalance. Pre- treatment with scopolamine which is an anticholinergic drug is useful if vertigo is associated with motion sickness.
The risk factors for developing vertigo may include exposure to the toxins, history of migraine, history of cerebrovascular accident , any postural changes, trauma such as barotrauma, depression, psychological stress, heavy weight bearing, perilymphatic fistula and ototoxic medication.
In terms of epidemiology, patient with risk factors for cerebrovascular accident, elderly or woman are particularly more prone to suffer from vertigo. The woman also is more prone to develop vertiginous migraine. 54% cases of dizziness may associate with vertigo and more than 90% of these cases are associated with benign paroxysmal positional vertigo. In terms of prevalence, vertigo account for 5%- 10% of the general population.
In terms of pathophysiology, vertigo is caused by dysfunction or impairment of the rotational velocity sensor that present on the inner ears. This will result in asymmetrical central processing. Vertigo is also associated with a combination of malfunction of the central vestibular apparatus and sensory disturbance of the component of the motion.
There are plenty causes of vertigo which include, herpes zoster, osteosclerosis, benign paroxysmal positional vertigo ( BPPV), acute labyrinthitis, oticus cholesteatoma, acute vestibular neuronitis and Meniere disease, migraine, cerebrovascular accident, multiple sclerosis and cerebellar tumour ( Central cause of vertigo). Drugs that may cause vertigo may include anxiolytic agents, antidepressant agents, antipsychotic agents, mood stabiliser and anticonvulsant. Other drugs may include amiodarone, furosemide, aminoglycosides and aspirin. Psychological factors may also associate with vertigo as well as heavy alcohol intake/ alcohol intoxication and hyperventilation.
Recent studies indicate that any disturbance of the equilibratory apparatus by otology, cranial and neurological disorders may predispose that individual to vertigo. What is equilibratory apparatus? Equilibratory apparatus consists of eight cranial nerves, vestibule semi-circular canals, and vestibular nuclei in the brainstem and the connection of the temporal lobe and eyes.
The most common symptoms and signs of vertigo may include pain, diaphoresis, hearing loss, nausea and vomiting, nystagmus, rotatory illusions and dizziness as well as other neurological symptoms such as ataxia.
One of the most important steps in confirming the presence of vertigo is to perform a proper history and examination of the patient. One of the main aim in history taking is to determine the presence of true vertigo or other causes related to dizziness ( such as feeling light headiness) It is also vital to distinguish between the peripheral and central causes of vertigo. Vertigo, which last from second to minutes indicates a vertigo which is peripheral related (peripheral causes – such as BPPV, acute labyrinthitis, vestibular neuritis, cholestoma). Vertigo, which last for minutes or hours or days indicates the peripheral and central causes (central causes may include cerebellopontine angle tumour, cerebrovascular disease, migraine and multiple sclerosis). Vertigo, which last for weeks indicates a central or psychological cause.
Vertigo which is associated with head position is thought to be central or peripheral in nature. The vertigo that is accompanied by upper viral respiratory tract infection is thought to be peripheral in origin. The vertigo that is provoked by stress is more psychological or peripheral in nature. The vertigo that is associated with changes in ear pressure or immunosuppression is peripheral in origin.
Patient with vertigo may also complain of other associated symptoms, such as nausea and vomiting with rotatory illusion (peripheral cause vertigo), horizontal, rotational and vertical nystagmus ( central cause vertigo) rotation and horizontal nystagmus ( peripheral cause vertigo) hearing loss ( peripheral cause vertigo) and the presence of other neurological symptoms (central cause vertigo).
Other questions that are worth asking include the duration and onset of vertigo. Is it worth asking does the patient feel that the surrounding area is moving or the patient is moving? How often does the patient suffer from vertigo? Do the episodes of vertigo come abruptly? Is it predictable? It is also important to ask the patient if he or she able to walk while having a vertigo attack or lean to one side. Any evidence of alcohol or drug abusers (caffeine, nicotine, ) or intake or ototoxic drug should also be noted. Patient‘s past medical history such as cerebrovascular accident and sexual history is also well mentioning.
The physical examination will focus on neurology, head and neck and cardiovascular examination. The neurological examination will focus on identifying any nystagmus or cranial nerve palsies. Any disorders or disability in maintaining a balance is indicated of peripheral related vertigo especially if it is mild to moderate and the patient is able to walk again. In central cause of vertigo, the balance is severely affected and the patient cannot walk.
The Dix - Hallpike manoeuvre is useful in detecting vertigo. A repeated manoeuvre that causes the induced symptom to be subsides is related to peripheral cause of vertigo while central cause of vertigo is associated with the inability of the manoeuvre to subsides the induce symptoms. A patient who suffers from vertigo may also suffer from sensorineural hearing loss based on the auditory diagnostic test.
Head and neck examination may include focus examination of the tympanic membrane. We need to rule out any cholesteatoma or the presence of any vesicles (herpes zoster osticus). Any orthostatic changes in blood pressure should also be noted. The patient may also be dehydrated and present with autonomic dysfunction.
The common differential diagnosis of vertigo is seizures, multiple sclerosis, Meniere’s disease, labyrinthitis, herpes zoster, head trauma, brain stem ischemia, benign positional vertigo and acoustic neuroma.
Vertigo is associated with temporal lobe seizures. Besides that, vertigo may also be associated with other symptoms of partial complex seizures. Besides suffering from paraesthesia, blurred vision, diplopia, ataxia, intention tremor, hypereflexia, spasticity, paralysis, weakness of the muscle, constipation and nystagmus, the multiple sclerosis sufferer may also complain vertigo.
Meniere’s disease is associated with dysfunction of the labyrinthine. Dysfunction of the labyrinthine may causes vertigo of abrupt onset that last for a few minutes, hours or even days. The patient may fall due to the unpredictable episodes of vertigo and unsteadiness. During the sudden attack of vertigo (sudden head or eye movement) patient may suffer from nausea and vomiting. The onset of vertigo will follow by head trauma or middle ear infection (in unilateral case). Hearing loss and tinnitus may also associate with vertigo.
Labrynthitis is associated with inner ear infection. Abruptly, severe vertigo will occur. Vertigo is presented as single episodes or recurs after months or years later. Besides vertigo, a patient may also complain of nystagmus, nausea, vomiting and progressive sensorineural hearing loss.
Herpes zoster or infection of the eight cranial nerve may also cause vertigo which is accompanied by hearing loss in the affected ear , facial palsy and herpetic vesicular lesion which present in the region of the auditory canal.
Head trauma may also associate with vertigo (positional vertigo) which present with positional or spontaneous nystagmus at the same times as the hearing loss if the temporal bone is affected or fractured. Other findings of head trauma include loss of consciousness, headache, nausea, vomiting, sensory or motor deficit , seizures, visual blurring, diplopia and signs of increase intracranial pressure.
Brain stem ischemia may also cause vertigo. The vertigo is initially presented as sudden and severe vertigo. Then, the vertigo will be episodic and persistent in later stage. Other findings are hemiparesis, nystgamus, and tachycardia, lateral deviation of the eye towards the site of lesion, hypertension, nausea and vomiting as well as ataxia.
Vertigo may also occur when the patient moves his head. The onset of vertigo is associated with the presence of debris in the semicircular canal. The condition is known as benign positional vertigo. The benign positional vertigo is temporary in nature and treat effectively with positive manoeuvres.
The eight cranial nerve tumour or acoustic neuroma may cause intermittent, mild vertigo with unilateral sensorineural hearing loss. Other findings are sub occipital or post auricular pain, tinnitus and facial paralysis as a result of compression of the cranial nerve.
Other differential diagnoses are anxiety disorder, cerebellar haemorrhage, tumour, degeneration, multiple sclerosis, perilymphatic fistula, vascular ischemia, syphilis, vertiginous migraine and ototoxicity or vestibular neuritis.
Investigation requires may include full blood count and biochemistry profile. Diagnostic testing such as caloric testing is performed. Caloric testing involved irrigation of the ears with cold or warm water to induce vertigo. Another test may include electronystagmography. MRI is considered if the patient present with progressive unilateral hearing loss, present with risk factors for cerebrovascular accident or prominent neurological symptoms. Audiometry is performed if Meniere’s disease or acoustic neuroma is suspected.
The treatment of vertigo may include general approach and a special therapy. A general approach may include an explanation as well as assurance to prevent any anxiety that may worsen the vertigo. Other treatment may include performing modified Epley manoeuvre or just Epley manoeuvre for benign paroxysmal positional vertigo or vestibular exercise rehabilitation or vestibular suppressant medication in vertigo that is associated with labrynthitis or vestibular neuritis. The intake of diuretics such as hydrochlorothiazide and low salt diet (1-2g/day) is beneficial if vertigo is associated with Meniere’s disease.
What is Epley manoeuvre? Epley manoeuvre or modified Epley manoeuvre is performed to displace the deposition of calcium at the semi-circular canal in patient with benign paroxysmal positional vertigo. The manoeuvre is contraindicated in severe neck disease, unstable cardiac disease and cardiac stenosis. Epley manoeuvre is effective to provide symptomatic relief and converting the patient from positive sign for the negative sign of Dix – Hallpike Manoeuvre.
Future episodes of vertigo are prevented in patients with vascular ischaemia by antiplatelet or anticoagulation therapies, smoking cessation and lipid lowering drugs as well as reduction of the blood pressure. Vertiginous migraine is treated with lifestyle and dietary modification, prophylactic medication, migraine abortive medication and vestibular rehabilitation exercise. Any drugs which cause vertigo also needs to be discontinued. Selective serotonin reuptake inhibitor (SSRI) is useful in treating psychological causes of vertigo. Dietary modification and restricting salt intake is useful for vertiginous migraine and Meniere’s disease.
The physical therapy is also known as vestibular rehabilitation exercise which include walking turns, tightrope, thumb tracking, target change, lying to standing and ball- toss.
The first line of drug in treating vertigo may include meclizine (Antivert) and dimenhydrinate ( Dramamine) . The adverse effect of this drug may include xerostomia and sedation. This drug may also interact with central nervous system depressant.
Other first line of drug may include prochlorperazine (Compazine) which is contraindicated in patient age less than 2 years, blood dyscrasias and severe hypotension. Extra care /precaution should be taken in prostatic hyperplasia, pregnancy, impairment of cardiovascular function, history of breast cancer, glaucoma or children with acute illness. The adverse effect may include xerostomia, sedation, hypotension and extrapyramidal effect. The drug will interact with tricyclic antidepressant and phenothiazine.
Metoclopramide (Reglan) is another drug. It is contraindicated in patient with seizures or the use of drugs with extrapyramidal side effects. Metoclopramide will interact with levodopa, digoxin, cyclosporine and linezolid. Precaution is taken in hypertension, Parkinson’s disease and depression. The side effects may include constipation, fluid retention and sedation.
Benzodiazepine drugs such as lorazepam or diazepam is also useful in treating vertigo. Benzodiazepine is contraindicated in a patient who is less than 6 months age and glaucoma. Precaution is taken in pregnancy, hepatic insufficiency and concomitant use of antidepressants. Benzodiazepines will interact with other central nervous system depressant. The side effects are hypotension, respiratory depression and sedation.
In elderly, vestibular suppressant medication should be used with care due to increased risk of urinary retention and fall.
Patient with vertigo usually refers to an ENT specialist, otolaryngologist or neurologist for further care if required. Prognosis depends on response to treatment and diagnosis. The complication may include disability, depression and anxiety. The patient is typically assessed after 1-2 weeks for symptoms of recurrence, adverse effect of medication new onset of symptoms and relief from the vestibular rehabilitation exercise.
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