INTRODUCTION AND EPIDEMIOLOGY
Vertigo is defined as the sensation of self-motion when no motion is occurring. Vestibular disorders are conditions that affect the vestibular sensory organs in the inner ear or the cerebellum and brainstem and the connections between them.
Some patients have difficulty describing the sensation of vertigo.1 Dizziness is a nonspecific word patients use quite often to describe the vertigo they experience when suffering from a vestibular disorder. Although asking about the quality of dizziness that the patient is experiencing may be helpful in many cases, overreliance on the description may lead to misdiagnosis.
To add to the confusion, dizziness is also used by some patients to describe the symptoms of presyncope, imbalance, light-headedness, and other sensations. In the initial evaluation of a patient presenting with dizziness, the clinician must keep this broader differential diagnosis in mind. Fortunately, the nonvestibular causes of dizziness can be suspected and appropriate investigations selected based on the context of the patient’s presentation.
Vertigo can be a diagnostic challenge for emergency physicians. One reason is because it has many potential causes (Table 170-1).
TABLE 170-1Peripheral and Central Causes of Vertigo |Favorite Table|Download (.pdf) TABLE 170-1 Peripheral and Central Causes of Vertigo
|Peripheral Causes ||Relative Frequency of Presentation to the ED ||Key Points ||Clinical Course |
|Benign paroxysmal positional vertigo ||The most common cause of vertigo ||Less than 2-minute episodes of vertigo, initiated by head movement. Dix-Hallpike test shows vertical upward and rotatory nystagmus. ||Benign, particle repositioning maneuvers is first-line treatment. Medications rarely indicated. |
|Vestibular neuritis ||Common ||Hours/days of continuous, constant vertigo. Use HINTS plus exam if nystagmus present. ||Spontaneous improvement over days/weeks. |
|Labyrinthitis ||Less common ||Ear pain, tinnitus, and hearing loss onset 1 or more days before vertigo; otherwise similar to vestibular neuritis. ||A complication of otitis media. Serious if bacterial (rare). |
|Ménière’s disease ||Less common ||Recurrent episodes of vertigo, hearing loss, tinnitus, and ear fullness. ||Slowly progressive; can lead to profound hearing loss. |
|Perilymph fistula ||Rare ||Vertigo and hearing loss after head trauma or pressure changes to middle ear (flying/diving/nose blowing). ||Can benefit from surgical correction. |
|Superior canal dehiscence ||Rare ||Vertigo brought on by loud sounds, coughing, and straining. ||Surgery for severe cases. |
|Vestibular schwannoma ||Rare ||Slow onset of hearing loss, tinnitus, and less commonly, vertigo. ||Slowly growing; amenable to surgery if growing and symptomatic. |
|Central Causes || || || |
|Vestibular migraine ||Most common central cause of vertigo, but much underdiagnosed. ||Recurrent attacks in patients with migraine, including episodes of isolated vertigo. At least half the episodes have migrainous features. ||Most experts recommend treatment as per migraine headache. |
|Cerebellar/brainstem stroke ||Common || |
Often presents with other neurologic signs or symptoms, but can present with symptoms similar to vestibular neuritis; use HINTS plus exam if nystagmus is present.
Hearing loss can occur at onset of stroke.
|Admit to hospital, as patients can develop edema and/or hydrocephalus, leading ...|