Vertigo

Question 1

What is vertigo?

Answer 1

• Dizziness/sensation of motion with central (brain) or peripheral (inner ear) origins
• Either self-motion or motion of environment

Question 2

S/s of vertigo?

Answer 2

• N/V
• Postural instability and gait
  ~ More often in vertigo of central origin (lesion in cerebellar region)
• Pallor, sweating
• Tinnitus, deafness
• Headache
• Photophobia
  ~ When associated with migraine
• Nystagmus
  ~ Horizontal, vertical, rotary

Question 3

What is the pathophysiology of vertigo?

Answer 3

• CNS receives signals from both left and right labyrinths
  ~ Compares the signals with one another
  ~ When still, signals are balanced
  ~ When in motion, r/l labyrinths are alternately excited and inhibited

Question 4

What are the vestibular labyrinths?

Answer 4

• Relays information to CN 8 from brainstem -> cerebellum -> ocular motor nuclei and spinal cord
• Vestibuloocular connections: coordinated eye movements
• Vestibulospinal pathways: Upright posture
• Cerebellar connections: Modulates ^^ activities
• Semicircular canals: sense angular motion
• Otolith organs: sense linear motion
• Vertigo suggests abnormality of semicircular canals or CNS structures

Question 4

How do you diagnose vertigo?

Answer 4

• History taking (single/recurrent episodes, duration)
• Aggravating and provoking factors
• PmHx
  ~ Hx of migraine attacks
  ~ Stroke risk factors
  ~ Family history
  ~ Medication (aminoglycosides, phenytoin) toxcity
• Physical examination
  ~ Central vs peripheral causes of vertigo
  ~ Types of nystagmus
  ~ Abnormal balance and gait
  ~ Neurologic examination
  ~ Hearing tests (to rule out deafness)
  ~ Caloric tests
• Diagnostic tests
  ~ MRI (suspected of central)
  ~ CT scan not really used as it is less sensitive
  ~ Electronystagmography (ENG) (electrodes to record eye movements)
  ~ Videonystagmography (VNG) (video camera to ^^)
  ~ Audiometry (to detect hearing loss)

Question 5

What are the types of hearing tests?

Answer 5

• Rinne
• Weber

Question 6

Clinical features of central vs peripheral vertigo?

Answer 6

1) Nystagmus
- (P) Unidirectional and fast towards normal ear
- (P) Horizontal vs (C) Any direction
- (P) Suppressed
- (P) Absence of other neurologic signs
- (P) Unidirectional instability but walking is preserved vs (C) Severe instability and falls
- (P) Deafness or tinnitus may be present

Question 7

What are the peripheral causes of vertigo?

Answer 7

1) Benign Paroxysmal Positional Vertigo
2) Vestibular neuritis
3) Meniere’s disease
4) Herpes zoster
5) Labyrinthitis

Question 8

What is benign paroxysmal positional vertigo?

Answer 8

• Most common
• Spinning sensation when tilting the head upwards, or tuning in beds
• Occurs very briefly
• Due to calcium debris within the posterior semicircular canal
  ~ Upset balance stimulates nerve cells in the canals

Question 9

What is vestibular neuritis?

Answer 9

• Viral or postviral inflammatory disorder
• Affects 8th cranial nerve (vestibulocochlear)
• Severe with rapid onset

Question 10

What is Meniere’s disease?

Answer 10

• Excess endolymphatic fluid pressure in ear causes dysfunction
  ~ Severe vertigo
  ~ Tinnitus
  ~ Ear fullness
• Often associated with N/V and disabling imbalance
• Spontaneous episodes can lasts mins-hours

Question 11

How does herpes zoster cause vertigo?

Answer 11

• Activates latent herpes zoster
• Hearing loss, ipsilateral facial paralysis and ear pain
  ~ Dermatological rash and neuritis with vesicular regions

Question 12

What is labyrinthitis?

Answer 12

• Inflammation of the inner ear labyrinth
• Due to infx, drug toxicity, trauma, tumor

Question 13

What are the causes of central vertigo?

Answer 13

1) Brainstem ischemia
2) Cerebellar infarction and hemorrhage
3) Multiple sclerosis
4) Epileptic vertigo
5) Vestibular migraine

Question 14

What is brainstem ischemia?

Answer 14

• Due to the occlusions in vertebrobasilar arterial system
• May be caused by TIA

Question 15

How does cerebellar infarction and hemorrhage cause vertigo?

Answer 15

• Sudden and intense vertigo w/ N/V
• More likely to occur in patients >60 y/o

Question 16

How does Multiple Sclerosis cause vertigo?

Answer 16

• Demyelination of brain and spinal cord with plaques near vestibular nuclei and root entry zone of CN 8

Question 17

What is epileptic vertigo?

Answer 17

• Vertigo may be a manifestation of focal epilepsy
• Motor and sensory changes may accompany

Question 18

What is vestibular migraine?

Answer 18

• Recurrent vertigo due to migraine attacks
• Variability in vertigo severity

Question 19

Management of migraine?

Answer 19

• Disease-specific management
• Symptom-specific treatment
  ~ Anti-histamines
  ~ Anti-emetics
  ~ BZP
• Vestibular rehabilitation for chronic vertigo
  ~ Therapist helps px to improve balance and reduce problems related to dizziness