Peripheral Vertigo


Article Author:
Brett Baumgartner


Article Editor:
Roger Taylor


Editors In Chief:
Casey Ciresi


Managing Editors:
Avais Raja
Orawan Chaigasame
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Abdul Waheed
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Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
6/3/2019 9:13:11 PM

Introduction

It is important to remember vertigo is a symptom, not a diagnosis. Most of us have experienced some vertigo in our lives. However, this can be difficult for an individual to describe, so often, vertigo is described in various ways. One of the simplest forms of vertigo which many have experienced is the transient feeling of dizziness and perception of ourselves or the environment spinning around us after rapidly turning in circles. Often, nausea and vomiting will accompany these symptoms.[1]

Etiology

The etiology of vertigo is typically due to a disturbance of the vestibular system, semicircular canals, or cranial nerve 8. This disturbance could be related to damage of one of these organs or simply confused neuronal input. It is important to remember that the central nervous system receives inputs bilaterally from these structures/systems, assembles the input and then, forms a response. The central nervous system (CNS) also coordinates these bilateral inputs with our visual and sensory inputs creating an overall picture of whether we are moving in space/time or if the environment around us is moving. Suffice it to say that conflicting inputs from these various symptoms overwhelm the central nervous system causing “dizziness,” nausea, and the perception of movement.

The following are the various causes of vertigo:

Peripheral Vertigo

Benign paroxysmal positional vertigo (BPPV), Meniere's disease, vestibular neuritis, labyrinthitis, herpes zoster, acoustic neuroma, otitis media, perilymphatic fistula, aminoglycoside toxicity, viral infections, and Cogan syndrome.

Central Vertigo

Brainstem ischemia/infarction, vertebrobasilar insufficiency, space-occupying lesions, demyelination syndromes, vestibular migraine, and Chiari malformation.

Benign Paroxysmal Positional Vertigo

Benign paroxysmal positional vertigo is classically described as a sudden onset of spinning brought on by a rapid head movement or a quick turn in bed before getting up. There is no associated ear pain, tinnitus or hearing loss. The pathophysiology behind this is usually displacement of otolith or calcium debris located in the posterior semicircle canal. This type of vertigo classically can be made worse with the Dix Hallpike maneuver and subsequently fixed with the Epley maneuver by relocating these otoliths. Other less commonly used maneuvers include Semont, Lempert, and Hamid.

Peripheral Vertigo Causes

  • Vestibular neuritis is usually a post-viral inflammatory syndrome. Patients typically develop rapid, severe nausea, vomiting, vertigo, and gait instability. Despite gait instability patients are still able to ambulate. They display the typical peripheral vertigo physical findings discussed below. If there is an associated unilateral hearing loss, it is then called labyrinthitis. Often, due to the severity of the symptoms, this can be confused with a central process. Consequently, magnetic resonance imaging is performed if clinician suspicion is high to aid in the diagnosis.
  • Meniere's disease: Excess endolymphatic fluid causes Meniere's disease. The excess pressure causes an inner ear dysfunction. Patients present with episodic unilateral tinnitus, hearing loss, nausea, vomiting, gate instability, and vertigo. Audiometry testing demonstrating a low sensorineural hearing loss can aid in diagnosis.
  • Cogan syndrome is an autoimmune process which presents with symptoms similar to those of Meniere’s disease, so it seems relevant to mention (even though not one of the more common causes). Caloric testing usually demonstrates absent vestibular function.

Epidemiology

Approximately 80% of vertigo is peripheral whereas approximate 20% is central in origin. Of this 80%, benign paroxysmal positional vertigo (BPPV) is by far the most common cause of peripheral vertigo.[2]

Pathophysiology

A disturbance of the vestibular system, semicircular canals, or cranial nerve 8 is the underlying issue. This disturbance could be related to damage of one of these organs or simply confused neuronal input. It is important to remember that the central nervous system receives inputs bilaterally from these structures/systems, assembles the input and then, forms a response. The CNS also coordinates these bilateral inputs with our visual and sensory inputs creating an overall picture of whether we are moving in space/time or if the environment around us is moving. Suffice it to say that conflicting inputs from these various symptoms overwhelm the central nervous system causing dizziness, nausea, and the perception of movement.[3][4]

Vertigo is broken down into two types: peripheral and central. As the main focus of this chapter is on peripheral vertigo, we will only touch slightly on central vertigo to help distinguish between the two.

Usually, peripheral vertigo is, although not always, due to a benign process whereas central vertigo often indicates a more serious pathology.

History and Physical

Peripheral vertigo is described as dizziness or a spinning sensation. Other symptoms associated with peripheral vertigo include:

  • Loss of hearing in one ear
  • Ringing in one or both ears
  • Difficulty focusing vision
  • Loss of balance

Evaluation

The diagnosis and workup consist of taking a very accurate and detailed history along with symptomatic/physical findings. Peripheral vertigo is typically episodic and acute/severe. Alternatively, central vertigo typically is over a longer duration of time and “most” of the time, less severe symptoms occur. Peripheral vertigo usually can be made worse with head movements and typically has been associated with horizontal/rotary nystagmus which is fatigable and unidirectional.

Central vertigo can have nystagmus in any direction is not fatigable and typically multi-directional. 

The Dix Hallpike test can be used to aid in the diagnosis of peripheral vertigo typically making symptoms worse and nystagmus more obvious.

Other specialized tests include:

  • Electro/videonystagmography (ENG)
  • The rotating-chair test also referred to as sinusoidal harmonic acceleration (SHA)
  • Computerized dynamic posturography (CDP)
  • Vestibular evoked myogenic potentials

Treatment / Management

Treatment usually involves giving the body time to heal and treatment of the underlying process. There is some data to suggest, antihistamines, benzodiazepines, corticosteroids, antiemetics, and anticholinergic’s may be of use depending on the etiology of peripheral vertigo. Vestibular rehabilitation therapy (VRT) may also offer relief to some patients. Vestibular rehabilitation therapy is a form of physical therapy which takes advantage of the plasticity of the brain using specialized exercises and head movements to help gaze and gait stabilization.[5][6]

Differential Diagnosis

The differential diagnosis of peripheral vertigo can be vast and will not be discussed in depth here however it is important to always consider stroke, infection and other potentially treatable etiologies.

Prognosis

The prognosis for peripheral vertigo is typically quite favorable.  It may lead to some morbidity however once the etiology is correctly identified symptoms can usually be quite tolerable if not completely resolved.

Enhancing Healthcare Team Outcomes

The management of peripheral vertigo is best done with a multidisciplinary team including nurses and pharmacists. Many treatments exist for peripheral vertigo but none is reliably effective. In many cases, a trial of one agent is performed and if it does not work, another remedy is tried. The quality of life of most patients with peripheral vertigo is poor. Drugs like antihistamines are often not well tolerated and corticosteroids have serious adverse effects.


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Peripheral Vertigo - Questions

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How should the Dix-Hallpike test for dizziness be performed?



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Which of the following is NOT characteristic of a classically positive Dix-Hallpike test result?



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A 65-year-old patient presents with a history of whirling vertigo when rolling over in bed. Which clinical test should be ordered or performed during the first office visit?



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Assuming that the patient is in the supine position, which of the following clinical findings confirms the diagnosis of classic right-sided benign paroxysmal positional vertigo (BPPV)?



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Which of the following about benign positional vertigo is true?



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Which is least consistent with the diagnosis of peripheral vertigo?



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Which is consistent with a diagnosis of peripheral vertigo?



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The patient is complaining of vertigo. The provider performs the Hallpike test in order to evaluate for which condition?



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A patient has benign paroxysmal positional vertigo. Which of the following interventions is employed to cure BPPV?



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How does benign paroxysmal positional vertigo generally present?



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Migraines are most associated with which of the following vestibular disorders?



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Select the correct statement about benign paroxysmal positional vertigo (BPPV).



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A patient with benign paroxysmal positional vertigo becomes dizzy and nauseated while receiving physical therapy for canalith repositioning. What should be done?



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A patient presents with several months of vertigo and has been diagnosed with benign paroxysmal positional vertigo. He reports increased symptoms with head movements to the right. The exam is only remarkable for provocation of the symptoms with the Dix-Hallpike maneuver. This consists of recumbence and turning the head to the side. Select the finding that would support the diagnosis of central positional vertigo.



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Which is typical in benign positional vertigo?



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Which semicircular canal is commonly affected in benign paroxysmal positional vertigo (BPPV)?



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A patient with vertigo undergoes a diagnostic evaluation. His symptoms are reproduced for about 15 seconds after he suddenly assumes the supine position with his head turned to the right or left. Sitting the patient up reverses the direction of vertigo. What diagnosis does this suggest?



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The Dix-Hallpike test elicits a transient upbeating positional nystagmus (UPN) with left torsion. What is most likely the location and mechanism of benign paroxysmal positional vertigo?



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Peripheral Vertigo - References

References

Wang X,Strobl R,Holle R,Seidl H,Peters A,Grill E, Vertigo and dizziness cause considerable more health care resource use and costs: results from the KORA FF4 study. Journal of neurology. 2019 May 22;     [PubMed]
Jahn K,Lopez C,Zwergal A,Zur O,Cakrt O,Kellerer S,Kerkeni H,Tjernström F,Meldrum D, Vestibular rehabilitation therapy in Europe: chances and challenges. Journal of neurology. 2019 May 17;     [PubMed]
Rivera M,Porras-Segovia A,Rovira P,Molina E,Gutiérrez B,Cervilla J, Associations of major depressive disorder with chronic physical conditions, obesity and medication use: Results from the PISMA-ep study. European psychiatry : the journal of the Association of European Psychiatrists. 2019 May 14;     [PubMed]
Mathkour M,Helbig B,McCormack E,Amenta PS, Acute Presentation of Vestibular Schwannoma Secondary to Intratumoral Hemorrhage: A Case Report and Literature Review. World neurosurgery. 2019 May 16;     [PubMed]
Becares-Martinez C,Lopez-Llames A,Arroyo-Domingo MM,Marco-Algarra J,Morales Suarez-Varela MM, [What do MRI and CT scan provide us in patients with vertigo and dizziness? A cost-utility analysis]. Revista de neurologia. 2019 Apr 16;     [PubMed]
Huppert D,Straube A,Albers L,von Kries R,Obermeier V, Risk of traffic accidents after onset of vestibular disease assessed with a surrogate marker. Journal of neurology. 2019 Apr 9;     [PubMed]

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