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Vertigo                                             (Related links at the bottom of the page)

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General Considerations

    • Patient’s definition of dizziness may not match with that of the examiner, defining the patient’s thoughts and feelings is important.
    • Dizziness: Any discomfort other than pain, related to the head. The etiology could be visual, cerebral, vestibular or gastrointestinal.
    • Vertigo: Actual sensation of motion, often rotatory, in which either the patient or the environment is moving.
    • Unsteadiness: is a loss of equilibrium in relationship to one’s environment. Often described as ‘bumping into things’, or ‘almost falling’. The etiology could be cerebellar, cerebral, posterior column or vestibular. A pure labyrinthine etiology rarely gives rise to unsteadiness without vertigo.
    • Lightheadedness: is described by the patient as a feeling of ‘ going to faint’.

History And Examination

    • Determine the duration, frequency, of each episode, and whether it is constant, episodic, or related to position or other activity.
    • Past medical history of dizziness, fainting, collapse, fits, etc. should be taken into consideration when arriving at a diagnosis.
    • General medical history of diabetes, cardiovascular disorders, neurological dsiorders and drugs should always be obtained.
    • A complete ENT and neurological examination which includes observation of nystagmus in three directions of gaze is a requisite.
    • Audiometric tests, radiology for posterior fossa and IAM, caloric tests or ENG can be obtained if needed.
    • Positional testing is performed if the symptoms are induced when the patient assumes a particular position.

Note: Sudden change of position may aggravate the symptoms of any type of dizziness without necessarily implying a disease of labyrinthine origin or positional vertigo.

Clinical Features

Certain clinical presentations, although they result from a diverse group of etiologies manifest the same clinical picture, they are discussed here rather than individually.

Sudden Unilateral Vestibular Loss

    • Causes:
    1. Blunt or sharp trauma
    2. Surgical ablation of labyrinth
    3. Suppurative or viral labyrinthitis
    • The sudden loss of vestibular function with normal function in the opposite labyrinth evoke certain symptoms. They are;
    • Severe whirling vertigo, with nausea, vomiting, pallor and sweating.
    • Intensity is maximum at one hour, and remain at the same intensity for 12 to 36 hours.
    • Vertigo gradually resolves, but reappears with sudden head movements. There are problems with gait, picking objects from the floor, reading and driving.
    • Patients develop adaptation by 2-3 months.

Gradual Unilateral Vestibular Loss

    • Causes:
    1. Space occupying lesions of the IAM or vestibular nerve.
    • The process takes place over months.
    • No vertigo is perceived. Symptoms are related to gait and station instability, worsened by fatigue and darkness when compensatory mechanisms fail.

Gradual Symmetric Vestibular Loss

    • Causes:
    1. Vestibulotoxic drugs.
    • Symptoms are related to gait and station problems. Gait becomes staggering and broad based.
Differential Diagnosis

When evaluating a patient with vertigo, one should try to differentiate between vertigo of peripheral and that of central origin.

Peripheral
Central
1. A definite sensation of movement is present.

2. Severe and paroxysmal.

3. Attacks last from minutes to days, often accompanied by nystagmus and autonomic symptoms.

4. Patient never loses consciousness.

1. The vertigo is mild and more like a sensation of unsteadiness.

2. Vague and with no specific onset or termination.

3. The attacks lasts for weeks, often without nystagmus.

Vestibular neuronitis (Vestibular paralysis)
    • Usually follows an upper respiratory infection.
    • Patient experiences sudden attack of vertigo with nausea, vomiting, sensation of blacking out and unsteadiness. This is aggravated by sudden movements.
    • Can last for days to weeks.
    • Cochlear symptoms (Deafness and tinnitus) are absent.
    • No neurologic deficit.
    • When seen initially there is spontaneous nystagmus towards the contralateral side.
    • A caloric test shows marked hypofunction or no response..
    • Audiometry and radiology of IAM is normal.
    • After the subsidence of the acute attack, the patient may continue to experience unsteadiness for or lightheadedness for several weeks.
    • Some patient experience a relapse in 3 to 6 months.
    • The acute episode may be followed by BPPV.

Benign Paroxysmal Positional Vertigo (Cupulolithiasis)

    • Also called positional vertigo.
    • Etiology: Degenerative changes, otitis media, concussion, ear surgery, and occlusion of anterior vestibular artery.
    • Histology has demonstrated otoconia on the cupula of the posterior semicircular canal.
    • Patient presents with sudden attacks of vertigo precipitated by certain head positions.
    • Vertigo is always of short duration.
    • Diagnosis is confirmed by positional testing.
    • There are no cochlear symptoms.

Vertigo Due to Whiplash Injury

    • Patients often complain of dizziness following whiplash I injury.
    • Onset of dizziness is usually after 7-10 days of injury particularly on head movements to the side of injury.
    • Symptoms may last for months or years after the accident.
    • Otological examination is normal.
    • Vestibular examination can reveal spontaneous or positional nystagmus with the head turned in the direction of whiplash.
    • Electronystagmography is essential in evaluating these patients.

Cervical Vertigo

    • It can caused by cervical spondylosis and other etiologies.
    • There are several theories about the causation of vertigo due to cervical spondylosis;
    • Osteophytes cause irritation of the vertebral sympathetic plexus, which is in close proximity to the vertebral artery. Spasm causes temporary ischemia leading to vertigo.
    • Loss of proprioception in the neck causes vertigo.
    • Subclavian steal syndrome may also cause cervical vertigo.

S/S:

Headache, vertigo, syncope, nausea and vomiting (Vagal),visual symptoms such as flashing lights due to ischemia of the occipital lobe caused by involvement of the posterior cerebral artery, a branch of the basilar artery.

All above symptoms occur when the head and neck are in certain positions.

Treatment:

    • Avoidance of critical neck positions.
    • Neck exercises.
    • Cervical traction.
    • Cervical collar.

Migraine

    • Vertebro-basilar migraine is due to impairment of circulation to brainstem.
    • Symptoms include vertigo, dysarthria, ataxia, paraesthesia, diplopia, scintillating scotomas, and homonymous hemianopia.
    • The initial phase of vasoconstriction is followed by vasodilatation leading to throbbing headache.
    • A positive family history may be obtained.

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