Vertigo

VERTIGO AND ITS TYPES
  • Vertigo is defined as subjective sense of imbalance
  • . Vertigo is classified into either peripheral or central depending on the location of the dysfunction of the vestibular pathway
Peripheral:
  • Vertigo caused by problems with the inner ear or vestibular system is called "peripheral", "otologic" or "vestibular".
  • The most common cause is benign paroxysmal positional vertigo (BPPV) but other causes include Meniere's disease, superior canal dehiscence syndrome, labyrinthitis and visual vertigo. Any cause of inflammation such as common cold, influenza, and bacterial infections may cause transient vertigo if they involve the inner ear, as may chemical insults (e.g., aminoglycosides) or physical trauma (e.g., skull fractures).
  • Motion sickness is sometimes classified as a cause of peripheral vertigo.
Central:
  • If vertigo arises from the balance centers of the brain, it is usually milder, and has accompanying neurologic deficits, such as slurred speech, double vision or pathologic nystagmus. Causes like Brain stem tumor and vertebrobasilar TIA

Charactersitic Central Vertigo Peripheral Vertigo
Severity Mild Severe
Onset Gradual Sudden
Duration Weeks / Months Seconds / minutes
Positional NO Yes
Fatigable No Yes
Associted symptoms
Assocaited
Nystagmus
Nerologic / Visual
Vertical
Auditory
Horizontal

CAUSES OF VERTIGO IN DIFFERENT SITUATIONS
  1. Vertigo precipitated by the movement of head in a specific direction: Benign positional vertigo.
  2. Intermittent brief vertigo with occasional drop attacks, ataxia, visual loss, double vision and confusion: Vertebrobasilar insufficiency.
  3. Episodic recurrent vertigo, with auditory symptoms, headache, photophobia and aura: Migraine.
  4. Vertigo with sensorineural hearing loss, facial weakness,appearance of vesicles on the canal and pinna and loss of taste sensation: Ramsay hunt syndrome.
  5. Triad of episodic vertigo, tinnitus and progressive deafness: Meniere's disease.
  6. Triad of tinnitus, progressive deafness and vertigo along with facial weakness may be seen in Acoustic Neuroma.
  7. Weakness, vertigo and convulsions in a patient on Total Parenteral Nutrition may be seen in Hypomagnesemia.
  8. Vertigo, tinnitus, headache and visual disturbances due to hyperviscosity,Systolic hypertension,Aquagenic pruritus:Polycythemia rubra vera.
  9. Post traumatic vertigo is due to Perilymphatic fistula,Secondary endolymphatic hydrops.
  10. Ocular features like Chronic granulomatous anterior uveitis, posterior uveitis ,etc,Neurological lesions like meningism, encephalopathy, tinnitis, vertigo and deafness and Cutaneous lesions likealopecia, poliosis and vitiligo may be present in Vogt-Koyanagi ­Harada syndrome.
  11. Tullio phenomenon is a condition where the subject gets attack of vertigo/dizziness by loud sounds.
  12. lt is seen in labyrinthine fistula and after fenestration surgery.
BASILAR MIGRAINE
  • Basilar type migraine describes recurrent attacks of migraine with aura in which symptoms suggest a brainstem origin (including vertigo & ataxia)
  • The onset of Basilar type migraine is typically before 30 years of age and peaks during adolescence.
  • Headache which is intermittent in episode and associated with tinnitus, vertigo and hearing loss
  • There is a distinct female preponderance with girls more frequently affected than boys in a ratio of 3:1 (majority of sufferers are girls )
  • Family history of migraine is frequent
  • Unlike other types of migraine headache may be occipital in origin.
BENIGN PAROXYSMAL POSITIONAL VERTIGO
  • Vertigo when the head is placed in a certain critical position
  • No hearing loss or other neurological symptoms
  • It can be precipitated by head injury
  • It generally abates after weeks to months.
  • On exam, patients display nystagmus and the symptoms can be reproduced by head movement.
  • In addition, the symptoms show latency, fatigability and habituation.
  • Occurs due to stimulation of posterior semicircular canal
  • Otoconial debris, consisting of crystals of calcium carbonate, is released from the degenerating macula of the utricle and floats freely in the endolymph of posterior semicircular canal.
  • Diagnosed by: Hallpike manoeuvre
  • The condition can be treated by performing Vestibular exercise-Epley's manoeuvre.
  • The principle of this manoeuvre is to reposition the otoconial debris from the posterior semicircular canal back into the utricle.
MANAGEMENT OF VERTIGO
  1. Labyrinthine suppressants: suppress end organ receptors or inhibit central cholinergic pathway:
  2. Antihistaminics (with anticholinergic action as well) - cinnarizine, cyclizine, dimenhydrinate, diphenhydramine, promethazine.
  3. Anticholinergics-atropine, hyoscine.
  4. Antiemetic phenothiazines-prochlorperazine.
  • Vasodilators: improve blood flow to labyrinth and brain stem-betahistine, codergocrine, nicotinic acid, naftidrofuryl.
  • Diuretics: decrease labyrinthine fluid pressure -acetazolamide, thiazides, furosemide.
  • Anxiolytics,antidepressants: modify the sensation of vertigo-diazepam, amitriptyline.
  • Corticosteroids: suppress intralabyrinthine edema due to viral infection or other causes.
  • Parenteral prochlorperazine is the most effective drug for controlling violent vertigo and vomiting.
Exam Question
  • Intermittent brief vertigo with occasional drop attacks, ataxia, visual loss, double vision and confusion: Vertebrobasilar insufficiency.
  • Vertigo is defined as subjective sense of imbalance
  • Epley's Maneuvre is used in the treatment of BPPV.
  • Most likely diagnosis in an adolescent female with a positive family history having occipital headache which is intermittent in episode and associated with tinnitus, vertigo,ataxia and hearing loss is Basilar Migraine.
  • Vertigo with sensorineural hearing loss, facial weakness,appearance of vesicles on the canal and pinna and loss of taste sensation:Ramsay hunt syndrome.
  • Vertigo, tinnitus, headache and visual disturbances due to hyperviscosity,Systolic hypertension,Aquagenic pruritus:Polycythemia rubra vera.
  • Most possible diagnosis in a patient on total parenteral nutrition for 20 days presenting with weakness, vertigo and convulsions is Hypomagnesemia.
  • Postitional vertigo is due to stimulation of Posterior Semicircular Canal.
  • Vestibular Exercises is the treatment for Benign Positional vertigo
  • In BPPV,patients display nystagmus and the symptoms that can be reproduced by head movement.
  • In addition, the symptoms show latency, fatigability and habituation.
  • Ocular features like Chronic granulomatous anterior uveitis, posterior uveitis ,etc,Neurological lesions like meningism, encephalopathy, tinnitis, vertigo and deafness and Cutaneous lesions likealopecia, poliosis and vitiligo may be present in Vogt-Koyanagi ­Harada syndrome.
  • Antiemetic Phenothiazine with labrynthine suppressant activity used for vertigo is Prochlorperazine.
  • Tullio phenomenon is a condition where the subject gets attack of vertigo/dizziness by loud sounds.
  • Mnemonics
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