VERTIGO

INTRODUCTION
  • Sensation of movement when no movement is actually occurring. Results from peripheral or central causes or, in some instances, may be induced by medications or anxiety disorders.
  • System Affected: Nervous
  • Synonym: Dizziness; Acute vestibular neuronitis; Labyrinthitis; Benign paroxysmal positional vertigo (BPPV)
  • Precautions to avoid injuries from falls that may occur secondary to imbalance
  • If due to motion sickness, pretreatment with anticholinergics such as scopolamine
  • Women are more likely to experience central causes, particularly vertiginous migraine.
  • Patients who are elderly and have risk factors for cerebrovascular disease (CVD) are more likely to experience central causes.
RISK FACTORS
  • History of migraines
  • History of CVD or risk factors for CVD
  • Use of ototoxic medications
  • Trauma or barotrauma
  • Perilymphatic fistula
  • Heavy weightbearing
  • Psychosocial stressExposure to toxins
  • Family history of CVD or migraines may indicate higher risk of central causes.
PATHOPHYSIOLOGY
Caused by dysfunction of the rotational velocity sensors of the inner ear. Results in asymmetrical central processing. Related to the combination of sensory disturbance of motion and the malfunction of the central vestibular apparatus.

ETIOLOGY
Peripheral causes
  - Acute labyrinthitis, acute vestibular neuronitis, BPPV, cholesteatoma, herpes zoster oticus, Meniere disease, otosclerosis
· Central causes
  - Cerebellar tumor, CVD, migraine, multiple sclerosis
· Other causes
  - Cervical, drug-induced, psychological

DIAGNOSIS

SIGNS AND SYMPTOMS
  • Dizziness
  • Rotary illusions
  • Nystagmus
  • Nausea and vomiting
  • Hearing loss
  • Pallor
  • Diaphoresis
  • PainNeurologic symptoms (i.e., ataxia)
History
· Determine if true vertigo exists versus other causes of dizziness by asking the patient if they feel lightheaded or if they see the world spinning around them during a dizzy spell.
  - Affirmative answer to spinning is indicative of true vertigo
· Distinguish between peripheral and central causes.
  Timing and duration
  1.      Seconds to minutes: Peripheral
  2.      Minutes to hours: Peripheral or central
  3.      Days: Peripheral or central
  4.      Weeks: Central or psychological
  - Provoking factors
  1.      Changes in head position: Peripheral or central
  2.      Spontaneous episodes: Peripheral or central
  3.      Recent upper viral respiratory infection: Peripheral
  4.      Stress: Central or psychological
  5.      Immunosuppression: Peripheral
  6.      Changes in ear pressure: Peripheral
  Associated symptoms
  1.      Rotary illusions with nausea and vomiting: Peripheral
  2.      Horizontal and rotational nystagmus: Peripheral
  3.      Horizontal, vertical, or rotational nystagmus: Central
  4.      Hearing loss: Peripheral
  5.      Neurologic symptoms: Central
Medical and medication history
  - Recent use of ototoxic medications
  - History of CVD or risk factors for CVD

Physical Exam
Neurologic
  - Cranial nerves for signs of palsies, nystagmus
  - Balance
  •      Peripheral: Mild to moderate, able to walk
  •      Central: Severe, unable to walk
  - Dix-Hallpike maneuver (PPV = 83%, NPV = 52%)
  •      If induced symptoms subside after repeated maneuvers, consider peripheral causes.
  •      If induced symptoms do not subside, consider central causes.
 Head and neck
  - Tympanic membranes
  •      Vesicles: Herpes zoster oticus
  •      Cholesteatoma
Cardiovascular
  - Orthostatic changes in BP: Dehydration or autonomic dysfunction

TESTS

Lab
Audiometry if acoustic neuroma or Meniere disease is suspected

Imaging
Consider MRI in the presence of neurologic symptoms, risk factors for CVD, or progressive unilateral hearing loss.

TREATMENT

  • Epley maneuver for BPPV
  • Modified Epley maneuver for BPPV
  • Vestibular exercises for acute vestibular neuronitis
  • Low-salt diet and diuretics for Meniere disease
  • Migraine prophylaxis, migraine abortive medications, and vestibular exercises for vertiginous migraines
  • Selective serotonin reuptake inhibitors (SSRIs) when associated with anxiety disorders
  • Vestibular suppressant medications for symptom relief in acute vestibular neuronitis
GENERAL MEASURES
Avoid anxiety that may exacerbate vertigo.
Treatments depend on cause
  - BPPV: Epley maneuver or modified Epley maneuver
  - Vestibular neuronitis and labyrinthitis
  •      Vestibular suppressant
  •      Vestibular rehabilitation
  - Meniere disease:
  •      Low-salt diet (<1-2 g/d)
  •      Diuretics such as hydrochlorothiazide
  - Vascular ischemia
    Prevention of future events through blood pressure reduction, lipid lowering, smoking cessation, antiplatelet therapy, and anticoagulation if necessary
  - Vertiginous migraines
     Dietary and lifestyle modifications, vestibular rehabilitation exercises, prophylactic and migraine abortive medications
  - Drug-induced vertigo
     Discontinue causative agent
  - Psychological
     SSRIs

Diet
· Restricted salt intake for Meniere disease
· Dietary modifications for vertiginous migraine

SPECIAL THERAPY
Epley maneuver or modified Epley maneuver for BPPV to displace calcium deposits in the semicircular canals.
· Improves symptoms and converts patient from positive to negative Dix-Hallpike maneuver
· Contraindications: Carotid stenosis, unstable cardiac disease, severe neck disease

Physical Therapy
Vestibular rehabilitation exercises
  •  Ball toss
  •  Lying-to-standing
  •  Target-change
  •  Thumb-tracking
  •  Tightrope Walking turns
MEDICATION (DRUGS)

First Line
Meclizine : 12.5-50 mg PO q4-8h
Dimenhydrinate (Dramamine): 25-100 mg PO, IM, or IV q4-8h
  - Precautions: Concomitant use of CNS depressants, prostatic hyperplasia, glaucoma
  - Adverse effects: Sedation, xerostomia
  - Interactions: CNS depressants
Prochlorperazine (Compazine): 5-10 mg PO or IM q6-8h; 25 mg rectally q12h; 5-10 mg by slow IV over 2 minutes
  - Contraindications: Blood dyscrasias, age <2 years, severe hypotension
  - Precautions: Children with acute illness; glaucoma, history of breast cancer, impaired cardiovascular function, pregnancy, prostatic hyperplasia
  - Adverse effects: Sedation, xerostomia, hypotension, extrapyramidal effects
  - Interactions: Phenothiazines, tricyclic antidepressants
Metoclopramide (Reglan): 5-10 mg PO q6h, 5-10 mg slow IV q6h
  - Contraindications: Concomitant use of drugs with extrapyramidal effects, seizure disorders
  - Precautions: History of depression, Parkinson disease, hypertension
  - Adverse effects: Sedation, fluid retention, constipation
  - Interactions: Linezolid, cyclosporine, digoxin, levodopa
Benzodiazepines
  - Diazepam (Valium): 2-10 mg PO or IV q4-8h
  - Lorazepam (Ativan): 0.5-2 mg PO, IM, or IV q4-8h
     Contraindications: Glaucoma, age <6 months
     Precautions: Concomitant use of CNS depressants, hepatic insufficiency, pregnancy
     Adverse effects: Sedation, respiratory depression, hypotension
     Interactions: CNS depressants

COMPLICATIONS
  • Anxiety
  • Depression
  • Disability
  • Injuries from falls

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