Vertigo

Vertigo is an illusion of movement (usually rotatory) due to an acute imbalance of tonic vestibular activity. Symptoms of vertigo are nonspecific and occur when there is a disturbance anywhere in the peripheral or central vestibular system. Determining the site of the lesion is important, as central causes can be life threatening and require immediate intervention. Vertigo should be differentiated from other causes of dizziness such as disequilibrium, presyncope, and anxiety.

Differential Diagnosis

• Benign paroxysmal positional vertigo (BPPV)
  –Each episode lasts seconds to minutes
• Vestibular neuritis
  –Viral infection of the vestibular nerve
• Otitis media
• Migraine
  –Vertigo may precede, follow, or present with the headache and aura
• Acute labyrinthitis
  –Acute onset with nausea and vomiting
  –Lasts for days and slowly resolves
  –45% cluster with viral infections
• Posttraumatic
  –Perilymphatic fistula
  –Labyrinthine concussion
  –Associated with postconcussive syndrome
  –Worsened by change in head position, cough, sneeze, swallow, straining, and airplane travel
• Cerebellar tumors
  –Tumors may be associated with tinnitus, facial weakness, and nystagmus
• Toxins/drugs: Antibiotics (aminoglycosides), salicylates, alcohol, phenytoin, quinine, arsenic, tricyclic antidepressants
• Autoimmune: Collagen vascular disease, Wegener granulomatosis
• Posterior circulation dissection
  –Often associated with a history of neck extension or rotational injury
• Cerebellar hemorrhage: Acute onset of vertigo, headache, nausea, and vomiting
• Multiple sclerosis
  –Vertigo is the presenting symptom in 5%
  –Hearing loss rare
  –Most common in young women
• Temporal lobe or complex partial seizures
• Ménière disease
• Familial periodic ataxia syndromes
  –Recurrent bouts of vertigo brought on by emotional stress or physical exertion
• CNS infection: Syphilis, Lyme disease
• Motion sickness
• Vertigo mimics: Presyncope, disequilibrium from decreased vision or proprioception
• Psychogenic
  –Panic or anxiety disorder

Workup and Diagnosis

• History
  –Duration, headache, nausea, vomiting, worsening with activity or movement (postural hypotension, hyperventilation)
  –Nausea and vomiting are classically more prominent with peripheral vertigo
  –Associated neurologic deficits (extremity weakness, numbness, incoordination, dysarthria, diplopia, tinnitus, hearing loss, loss of consciousness)
  –Facial numbness/weakness
  –History of autoimmune disease, hyperlipidemia, stroke, migraine, seizure, cancer, prior ear surgery

• Physical exam may be normal in asymptomatic periods
• Cardiac and peripheral vascular examination for murmurs, arrhythmias, orthostatic changes in pulse and blood pressure (±ECG, Holter, Echo, Doppler)
• Nystagmus, truncal ataxia, and limb incoordination are sometimes found in cerebellar infarction or neoplasm
• Vertigo of a panic attack can sometimes be elicited by having the patient hyperventilate
• Dix-Hallpike maneuver: Rapidly lay the patient down from sitting allowing the head to hang over the side of the bed while turning to the left or right; positive test shows vertigo with rotatory nystagmus within 30 seconds; if the etiology is peripheral, the nystagmus shows extinction with positioning maneuvers
• MRI and MRA can help evaluate the posterior circulation

Treatment

• If the vertigo is accompanied by nausea and vomiting, supportive care with fluid and electrolyte replacement
• Migraine aura associated vertigo: Analgesics and vestibular suppressants such as sumatriptan, propranolol, amitriptyline, diazepam; avoid triggers
• Acute viral labyrinthitis: Bedrest, antiemetics, IV fluids, diazepam, antihistamines
• Control of hypertension, diabetes, cardiac arrhythmia
• Cerebellopontine angle tumors: Surgical resection
• BPPV/ Ménière disease: Positioning procedure; brief treatment with diazepam, meclizine, or dimenhydrinate
• Perilymph fistula: Pneumatic otoscopy reproduces symptoms; often heals spontaneously
• Vertebrobasilar stroke: Neurology consultation
• Cerebellar hemorrhage: Emergent neurosurgical consult for question of posterior fossa decompression

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

Other Book Chapters Related to Coordination problems

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Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

More About Causes of Coordination problems

• Back to symptom: Coordination problems: Introduction (review 353 causes)
• Next Book Extract About Coordination problems: Vertigo (Handbook of Signs & Symptoms (Third Edition))
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More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9

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