Vertigo

Be sure you’re interested in Vertigo, not the “dizziness” we call Lightheadedness

• Vertigo — room or person spinning or being thrust, in just one direction
• Lightheadedness  —  a vague sense of being woozy, wobbly, unsteady, fuzzy, tipsy, etc., in any or all directions

The following represents the clinician’s condensed thought-process when face-to-face with a patient. For more in-depth discussion & explanations, see Vertigo — Full Text.

Causes of Vertigo

xxxxxPeripheral (Inner- or Middle-Ear)   • Benign Paroxysmal Positional Vertigo xxxx(BPPV) [this is the most common cause] • Acute Labyrinthitis [also fairly common] • Herpes Zoster • Meniere’s Disease • Labyrinthine Concussion • Perilymphatic Fistula • Semicircular Canal Dehiscence Syndrome • Otitis Media (middle ear infection) • Impacted Ear Wax

xxxxxxxxCentral (Brain)   • Stroke / TIA • Cervical Artery Dissection (tear) • Multiple Sclerosis (M.S.) • Migrainous Vertigo x x x x x

1.  BPPV is far-&-away the most common & likely —  Symptoms occur with change of head position, last <1 min. (usually just seconds).  To be sure, we also:

• Make sure no double vision, slurred speech, swallowing difficulty (may be a Stroke ?)
• Examine Ears & Perform a Neurological Exam —  should be normal
• Perform an Epley Maneuver (includes Dix-Hallpike) to confirm BPPV & serve as treatment
• If negative, still likely BPPV. Can try in other direction. Have patient perform regularly at home
• Still doesn’t work?  If symptoms are truly <1 min duration, & only occur with head movement, we reassure patient they’ll recover, & encourage the Epley anyway.

2.  If Vertigo is new & acute, never happened before, is unrelated to head movement, & is ongoing non-stop through the day, we either:

1. Diagnose Acute Labyrinthitis; OR
2. Send to an E.R. to rule out Stroke or Cervical Artery Tear (in a neck artery)

We send a vertigo patient to the E.R. if any positives within the following table:

When We Worry that a Stroke may be causing Vertigo

xxxxxxxStroke Risk Factors   • Age >60 • Hypertension • Diabetes • Some auto-immune diseases (Lupus, etc.) • Certain heart diseases (atrial fibrillation, metal heart valves, etc.) xxxxCertain Stroke Symptoms   • Double vision • Slurred speech • Significant swallowing difficultyx

xxxxSuggestion of Cervical Artery Tear   • Severe head or neck pain • Recent trauma (including vigorous exercise; see link in Table)   xxxSigns of Stroke on Physical Exam   • Cranial nerve abnormalities • Coordination abnormalities • Special Maneuvers most Clinicians don’t know See also Stroke as a Cause of Vertigo

We must send possible stroke to a Stroke Center Hospital, not just any E.R.

If the only positives above are the first three “Stroke Risk Factors,” we may not send to an ER if we find any reason to diagnose Herpes Zoster Oticus (Shingles, but without blistering rash):

• One-sided ear pain, hearing loss, tinnitus (ringing)
• Facial droop (“Bell’s Palsy“)
• Blisters on ear or in ear canal [often absent]

Of course, if there’s ear pain and we see an Ear Infection (Otitis Media), or Impacted Ear Wax, we’ve got a diagnosis.

3.  Recurrent Vertigo (similar episodes have happened before), we consider:

** Meniere’s Disease

• Onset 20-40 y.o.
• Attacks last 20 minutes to 24 hrs.
• Diagnosis:  Vertigo + Neurologic Hearing Loss + Tinnitus
• Requires formal hearing exam & referral to Ear specialist (ENT)

**  Labyrinthine Concussion  —  Vertigo episodes beginning right after head injury

• If suspicious, we send to ENT for diagnosis & treatment

**  Perilymphatic Fistula  —  Vertigo caused by previous barotrauma (from pressure)

• May be severe, or just come & go
• Suspect if vertigo is provoked by straining, sneezing, coughing, even loud noises
• If sounds possible by patient’s history, we send to ENT for diagnosis & treatment

** Superior Semicircular Canal Dehiscence Syndrome (SSCDS / SCDS) — probably rare

• Loud Noise induces vertigo & tremulous eyes (Tullio phenomenon)
• Pressure on opening to canal causes vertigo & tremulous eyes (Hennebert sign)
• Weird symptoms, e.g. “I hear my eyes moving;” constant pulsating tinnitus (ringing in ear)

**  Multiple Sclerosis (MS)  —  We ask about previous typical MS symptoms, that lasted ≥24 hrs.:

• Tingling, numbness, loss of sensation
• Electric shocks down body when bending neck (Lhermitte’s Sign)
• Visual disturbances, esp. Double vision
• Weakness of just one part of body; disturbed gait
• Urinary or Stool Incontinence (exaggerated occurrances, not just drops of urine or stains of stool), or Urinary Retention (bladder makes you want to pee, but you can’t)
• Uhthoff Phenomenon: above symptoms worsen with heat (fever, hot showers)

We send to a Neurologist if suspicious symptoms, or Neurological abnormalities on exam, esp.:

• Eyes (“optic atrophy”, “afferent pupillary defect“)
• Complete loss of sensation by Pinprick Testing (can’t feel it) on areas of sensory symptoms
• Decreased strength in just one part of body, on our physical exam

**  Migrainous Vertigo  —  Recurrent vertigo, moderate-severe.

• Vertigo provoked by loud noises (phonophobia) & bright light (photophobia )
• Vertigo w/ aura (various weird sensations just before the vertigo)
• Vertigo in migraine sufferer
• We’d let a Neurologist make this diagnosis & treat it
• Uncertain if this condition truly exists, but it’s diagnosed fairly often

**  Stroke ???

• maybe past episodes were TIAs, & today is the big one
• See #2 above, and #4 below

4.  Vertigo now Resolved (maybe it was present when they called for appointment)

We consider the same diseases as in #1 and #3 above.  But we especially consider a Transient Ischemic Attack (TIA) and obtain an MRI (of brain) & MR-Angiogram (of head & neck) for anyone with:

• History of Stroke Symptoms during the vertigo (see #2 above)
• Maybe if significant Stroke Risk Factors (see #2 above)
• But NOT if prominent Ear Symptoms along with the vertigo

If Vertigo recurs, and is not bursts of seconds-long attacks (BPPV), we send to a Neurologist.

See also Vertigo — Full Text for more in-depth explanations and discussions.