Vertigo

Vertigo is a type of dizziness and refers to a false sensation that oneself or the surroundings are moving or spinning (usually accompanied by nausea and loss of balance) that is a result of a mismatch between vestibular, visual, and somatosensory systems.

Types

• Central (cerebral cortex, cerebellum, brainstem) – eg, cerebrovascular disease, migraine, multiple sclerosis, acoustic neuroma, diplopia, alcohol intoxication.
• Peripheral (vestibular labyrinth, semicircular canals or vestibular nerve) – eg, viral labyrinthitis, vestibular neuritis, benign paroxysmal positional vertigo (BPPV), Ménière’s disease, motion sickness, ototoxicity (eg, gentamicin), herpes zoster (Ramsay Hunt syndrome).

Causes

Causes of vertigo may include:

• Viral labyrinthitis.
• Vestibular neuritis (often misdiagnosed as labyrinthitis).
• Benign paroxysmal positional vertigo.
• Vertebrobasilar ischaemia
• Eustachian tube dysfunction (causes mild vertigo).
• Ménière’s disease
• Chronic otitis media.
• Drugs: salicylates, quinine, aminoglycosides.
• Vestibularmigraine.
• Epilepsy the likely diagnosis if vertigo is associated with loss of consciousness.
• Acoustic neuroma may cause mild vertigo, but associated with unilateral sensorineuraldeafness and tinnitus.
• Nasopharyngeal carcinoma
• Neurological:brain stem cerebrovascular accident,multiple sclerosis,syringobulbia,cerebellar tumours
• Following head injury

Assessment

Complaints of dizzy spells are very common and are used by patients to describe many different sensations. The key to making a diagnosis is to find out exactly what the patient means by dizzy and then decide whether or not this represents vertigo. With a clear description of vertigo, the precipitants and time course (onset, frequency, and duration of attacks) are often diagnostic.

Assess the nature of the dizziness

• Assess whether the person has vertigo rather than presyncope, disequilibrium (imbalance), or light-headedness. Vertigo usually causes rotatory or spinning symptoms.

Assess any associated symptoms

• Ear symptoms – eg, hearing loss, ear discharge, tinnitus.
• Neurological symptoms – eg, headache, diplopia, visual disturbance, dysarthria or dysphagia, paraesthesia, muscle weakness or ataxia.
• Autonomic symptoms – eg, nausea and vomiting, sweating or palpitations.
• Symptoms suggesting migraine aura – eg, visual or olfactory symptoms.

Assess any relevant medical history

• Recent upper respiratory tract infection or ear infection (may suggest a diagnosis of vestibular neuronitis or labyrinthitis).
• History of migraine.
• Head trauma or recent labyrinthitis suggests BPPV.
• Direct trauma to the ear, which may indicate possible perilymph fistula.
• Both anxiety or depression can aggravate dizziness or vertigo.
• Cardiovascular risk factors increase the likelihood that stroke may be the cause of vertigo.
• Some drugs (eg, aminoglycosides, furosemide, antidepressants, antipsychotics, anticonvulsants) may cause vertigo.
• Acute intoxication with alcohol may cause vertigo.

Examination

• Neurological examination including gait and their ability to stand unaided, cranial nerves, cerebellar function, signs of peripheral neuropathy and any indication of a cerebrovascular event.
• Ear examination including signs of infection, discharge and cholesteatoma.
• Eye examination: nystagmus (common in acute vertigo), fundoscopy.

Investigations

• No investigations are likely to be performed in primary care.
• Secondary care investigations include:
  • Audiometry for cochlear function.
  • Vestibular function: electronystagmography, calorimetry and brain stem-evoked responses.
  • Possible neurological cause: CT or MRI.
  • Electroencephalography (EEG): epilepsy.
  • Lumbar puncture: possible multiple sclerosis.
  • Syphilis serology.

Management

Explanation and reassurance are important as anxiety exacerbates vertigo. Persistent disequilibrium should be overcome by central adaptation, but anxiety may prevent this.

General advice

• Advise the person not to drive when they are dizzy, or if they are likely to experience an episode of vertigo while driving.
• The person should inform their employer if their vertigo poses a risk in the workplace, eg using ladders, operating heavy machinery or driving.
• Discuss the risk of falling in the home during an episode of vertigo and suggest measures

Drug treatment

Consider offering symptomatic drug treatment with prochlorperazine, cinnarizine, cyclizine or promethazine (antihistamines) for no longer than one week. It is important that the person should stop symptomatic treatment 48 hours before seeing a specialist.

Rehabilitation programmes

• There is evidence to support the efficacy of vestibular rehabilitation programmes for unilateral peripheral vestibular disorder; a simple programme including patient education and home-based exercises can be sufficient.
• Booklet based vestibular rehabilitation for chronic dizziness has been shown to be a simple and cost effective means of improving patient reported outcomes in primary care.
• Balance rehabilitation is important and beneficial in elderly people, in whom dizziness is invariably multifactorial.
• A recent Cochrane review confirmed the efficacy of Epley’s manoeuvre and then a period of post-Epley postural restriction (eg, upright head posture for 48 hours) in treating BPPV.

Surgery

Surgical options for Ménière’s disease include endolymphatic sac surgery, vestibular nerve section, micropressure therapy and labyrinthectomy.

Complications

• Increased risk of falls, especially in the elderly.
• Vertigo may confine people to their homes, making them fearful or depressed.

Prognosis

• Follow-up studies have shown BPPV rates of 50% at five years and a persistence of dizziness related to anxiety in almost a third of patients one year after vestibular neuritis