8/14/2019 Vertigo Overview http://slidepdf.com/reader/full/vertigo-overview 1/10 Vertigo Overview Vertigo is the feeling that you or your environment is moving or spinning. It differs from dizziness in that vertigo describes an illusion of movement. When you feel as if you yourself are moving, it's called subjective vertigo, and the perception that your surroundings are moving is called objective vertigo. Unlike nonspecific lightheadedness or dizziness, vertigo has relatively few causes. Vertigo Causes Vertigo can be caused by problems in the brain or the inner ear. • Benign paroxysmal positional vertigo (BPPV) is the most common form of vertigo and is characterized by the sensation of motion initiated by sudden head movements or moving the head in a certain direction. This type of vertigo is rarely serious and can be treated. • Vertigo may also be caused by inflammation within the inner ear (labyrinthitis), which is characterized by the sudden onset of vertigo and may be associated with hearing loss. The most common cause of labyrinthitis is a viral or bacterial infection.
The evaluation of vertigo consists primarily of a medical history and physical exam.
The history is comprised of four basic areas.
1. The doctor may want to know if the patient feels any sensation of motion, which mayindicate that true vertigo exists. Report any nausea, vomiting, sweating, and abnormal eye
movements.
2. The doctor may ask how long the patient has symptoms and whether they are constant or
come and go. Do the symptoms occur when moving or changing positions? Is the patientcurrently taking any new medications? Has there been any recent head trauma or
whiplash injury?
3. Are there any other hearing symptoms? Specifically, report any ringing in the ears or
hearing loss.
4. Does the patient have weakness, visual disturbances, altered level of consciousness,
difficulty walking, abnormal eye movements, or difficulty speaking?
The doctor may perform tests such as a CT scan if a brain injury is suspected to be the cause of vertigo.
Blood tests to check blood sugar levels and the use of an electrocardiogram (ECG) to look at
heart rhythm may also be helpful.
Medical Treatment
The choice of treatment will depend on the diagnosis.
• Vertigo can be treated with medicine taken by mouth, through medicine placed on the
skin (a patch), or drugs given through an IV.
• Specific types of vertigo may require additional treatment and referral:
o Bacterial infection of the middle ear requires antibiotics.
o For Meniere's disease, in addition to symptomatic treatment, people might be
placed on a low salt diet and may require medication used to increase urine
output.
o A hole in the inner ear causing recurrent infection may require referral to an ear,
• In addition to the drugs used for benign paroxysmal positional vertigo, several physical
maneuvers can be used to treat the condition.
o Vestibular rehabilitation exercises consist of having the patient sit on the edge of a
table and lie down to one side until the vertigo resolves followed by sitting up and
lying down on the other side, again until the vertigo ceases. This is repeated untilthe vertigo no longer occurs.
o Particle repositioning maneuver is a treatment based on the idea that the condition
is caused by displacement of small stones in the balance center (vestibular system) of the inner ear. The head is repositioned to move the stones to their
normal position. This maneuver is repeated until the abnormal eye movements are
no longer visible.
Medications
Commonly prescribed medications for vertigo include the following:
• meclizine hydrochloride (Antivert)
• diphenhydramine (Benadryl)
• scopolamine transdermal patch (Transderm-Scop)
• promethazine hydrochloride (Phenergan)
• diazepam (Valium)
These medications should be taken only as directed and under the supervision of a doctor.
Next Steps
Follow-up
Anyone with a new diagnosis of vertigo should follow-up with his or her doctor or be referred
directly to a neurologist or ENT specialist.
Prevention
• People whose balance is affected by vertigo should take precautions to prevent injuries
from falls.
• Those with risk factors for stroke should control their high blood pressure and high
• Patient's with Meniere's disease should limit salt in their diet.
Outlook
The prognosis depends on the source of the vertigo.
• Vertigo caused by problems in the inner ear, while usually self-limited, in some cases can
become completely incapacitating. The use of drugs and rehabilitation exercise is
mainstay of treatment. Most commonly this will make the symptoms completely go away
or make the condition tolerable.
• The prognosis of vertigo from a brain lesion depends on the amount of damage done to
the central nervous system. Vertigo caused by a brain lesion may need emergency
evaluation by a neurologist and neurosurgeon.
Other Vertigo Symptoms
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Peripheral vestibular disorders also may cause the following symptoms:
• Blurred vision
• Fatigue and reduced stamina
•
Headache• Heart palpitations (rapid fluttering of the heart)
• Imbalance
• Inability to concentrate
• Increased risk for motion sickness
• Muscle ache (especially of the neck and back)
• Nausea and vomiting
• Reduced cognitive function (i.e., thinking and memory)
• Sensitivity to bright lights and noise
• Sweating
Vertigo caused by a central vestibular disorder usually develops gradually. In addition tovertigo, central vestibular disorders (e.g., stroke [brain attack], migraine) may cause thefollowing symptoms:
Vertigo, or dizziness, usually results from a disorder in the peripheral vestibular system (i.e.,
structures of the inner ear). Dizziness also may occur as a result of a disorder in the centralvestibular system (i.e., vestibular nerve, brainstem, and cerebellum). In some cases, the cause of
vertigo is unknown.
Peripheral vestibular disorders include the following:
• Benign paroxysmal positional vertigo (BPPV; most common peripheral disorder; may be
accompanied by hearing loss, reduced cognitive function, and facial muscle weakness)
• Cogan's syndrome (inflammation of connective tissue in the cornea; results in vertigo,
ringing in the ears [tinnitus], and loss of hearing)• Ménière disease (fluctuating pressure of inner ear fluid [endolymph]; results in severe
vertigo, ringing in the ears [tinnitus], and progressive hearing loss)• Ototoxicity (i.e., ear poisoning)
• Vestibular neuritis (inflammation of vestibular nerve cells; may be caused by viral
infection)
Benign paroxysmal positional vertigo (BPPV) usually affects one of the sensing tubes in the
inner ear called the posterior semicircular canal. BPPV occurs when debris made up of calciumcarbonate and protein (called otoliths or ear crystals) builds up in and moves around in the
posterior semicircular canal. BPPV also can affect the anterior canal or the horizontal canal.
When the head is moved in certain ways (e.g., turning in bed, looking up, bending over), the
calcium crystals move around and trigger inner ear sensors, causing a brief sensation of spinning.Inner ear degeneration (usually occurs in elderly patients), head trauma, and inner ear infection
(e.g., otitis media, labyrinthitis) can cause BPPV.
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Some medications and environmental chemicals (e.g., lead, mercury, tin) can cause ototoxicity
(i.e., ear poisoning), which may result in damage to the inner ear or the 8th cranial nerve
(acoustic nerve) and cause vertigo. The damage can be permanent or temporary.
Long-term use or high doses of certain antibiotics (e.g., aminoglycosides [streptomycin,
gentamicin]) and antineoplastics (e.g., cisplatin, carboplatin) can cause permanent ototoxicity.
Medications that may cause temporary ototoxicity include the following:
• Prescription and over-the-counter cold medicines
• Quinine (e.g., chloroquine, quinidine)
Alcohol, even in small amounts, can cause temporary vertigo in some people.
•
• Headache (may be severe)
• Impaired consciousness
• Inability to speak due to muscle impairment (dysarthria)
• Lack of coordination
• Nausea and vomiting
• Weakness
Complications
Severe vertigo can be disabling and may result in complications such as irritability, loss of self-esteem, depression, and injuries from falls. Falls are the leading cause of serious injury in people
over the age of 65.
Vertigo Diagnosis
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It is important to diagnose the cause of vertigo, or dizziness, as quickly as possible to rule outserious conditions such as cardiovascular disease, stroke, hemorrhage, or tumor. Diagnosis
includes clinical history, physical and neurological examination, blood tests, and imaging tests(e.g., CT scan, MRI scan).
Important considerations include the following:
• What triggers the vertigo?
• What other symptoms occur?
• How long does the dizziness last?
• What improves or worsens symptoms?
Physical examination includes measuring blood pressure and heart rate. Neurological
examination includes testing facial and vestibular nerves and muscles, strength, coordination,
balance, and walking (gait).
The positional vertigo test is used to help distinguish peripheral from central vestibular disorders. In this test, the patient sits on a table with the head turned to the side. The physician
then supports the head and lowers it gently below the table while the patient lies back. The
patient reports symptoms of vertigo while the physician looks for circular movement of the eyes
(called nystagmus).
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A delay between the onset of nystagmus and the sensation of vertigo usually indicates a
peripheral vestibular disorder. Lack of a delay may indicate a central vestibular disorder. The testis repeated with the head turned in the opposite direction.
Electronystagmography (ENG) is a neurological test used to evaluate the vestibular system. It
involves testing hearing in both ears (audiometry tests), testing eye movements, and evaluating
responses to changes in posture and position.
Blood tests include a complete blood count (CBC) and kidney and thyroid panels to rule out
systemic diseases (e.g., kidney disease, hypothyroidism). If the patient is taking medication, druglevels are obtained.
Imaging tests may be used to detect brain abnormalities (e.g., stroke, tumor). Computed
tomography (CT scan) produces x-ray images of the brain and magnetic resonance imaging(MRI scan) uses a magnetic field to produce detailed images of brain tissue and arteries in the
neck and brain
Vertigo Treatment
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Treatment for vertigo, or dizziness, depends on identifying and eliminating the underlying cause.If a particular medication is responsible for the condition, lowering the dosage or discontinuing
the drug may eliminate vertigo.
Vestibular Rehabilitation Therapy
Vestibular rehabilitation therapy (VRT) is a type of physical therapy used to treat vertigo. The
goal of treatment is to minimize dizziness, improve balance, and prevent falls by restoring
normal function of the vestibular system.
In VRT, the patient performs exercises designed to allow the brain to adapt to and compensate
for whatever is causing the vertigo. The success of this treatment depends on several factorsincluding the following:
• Age of the patient
• Cognitive function (e.g., memory, ability to follow directions in order)
• Coordination and motor skills
• Overall health of the patient (including the central nervous system)
Vestibular rehabilitation therapy is designed by a physical therapist under the direction of a
physician. In most cases, patients visit the therapist on a limited basis and perform custom-designed exercises at home, several times a day. As the patient progresses, difficulty of the
exercises increases until the highest level of balance is attained during head movement, eyemovement (i.e., tracking with the eyes), and walking.
According to the American Academy of Neurology, the most effective treatment for benign
paroxysmal positional vertigo (BPPV) caused by ear crystals in the posterior semicircular canal,
is a technique called the canalith repositioning procedure, or the Epley maneuver.
In this procedure, a physician or physical therapist assists the patient in performing a series of
head and body movements, which move the calcium crystals out from the posterior semicircular
canal and into another inner ear canal, where it is absorbed by the body. Another technique(called the Semont maneuver) also may be effective, but additional studies are needed
Vertigo Medication
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Ear infections (e.g., otitis media, labyrinthitis) caused by bacteria may be treated using
antibiotics (e.g., amoxicillin, ceftriaxone). Myringotomy is a surgical procedure that may beused to treat chronic ear infections. In this procedure, which is performed under anesthesia, an
incision is made in the eardrum and a small tube is placed in the opening to prevent fluid and
bacteria from building up inside the ear.
BPPV that does not respond to canalith repositioning may be treated with meclizine (Antivert®),an oral antiemetic that can be taken up to 3 times a day, or only as needed. Meclizine may cause
drowsiness, dry mouth, and blurred vision.
If meclizine is ineffective, benzodiazepines such as clonazepam (Klonopin®) or antihistamines
such as promethazine (Phenergan®) may be prescribed. Side effects of clonazepam includedrowsiness, lack of coordination (ataxia), and confusion. Promethazine may cause drowsiness,
fatigue, insomnia, and tremors.
Ménière disease may be treated by reducing sodium (salt) intake and with diuretic medications.A short, tapered course of corticosteroids (e.g., prednisone) may be prescribed early in thedisease to reduce inflammation and stabilize hearing. Antibiotics (e.g., gentamicin) may be
administered into the middle ear (called intratympanic perfusion) to treat severe vertigo caused
by Ménière disease.
Vertigo caused by migraine can often be treated with medication.
Cerebrovascular disease (stroke), tumors, and multiple sclerosis may require treatment with
medication, radiation, or surgery.
Questions to Ask Your Doctor about Vertigo
•
What do you suspect is causing my vertigo? Why do you suspect this cause?• What kinds of activities may trigger or worsen my vertigo symptoms? Is there anything I
should do or avoid doing to help reduce the severity and frequency of symptoms?
• What types of examinations, evaluations, and/or diagnostic tests will be performed to
determine if an underlying condition is causing my dizziness?• How do I prepare for these exams and tests?
• Do you recommend that I see a specialist or visit a hospital or medical center that
specializes in vertigo for my condition? Why or why not?
• What is the usual prognosis for people with this type of vertigo? In addition to dizziness,
what other symptoms and complications related to this type of vertigo may develop?
• What should I do if I experience new symptoms or serious complications? Telephone
number to call:
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• Can the underlying cause for my vertigo usually be successfully treated? If so, do you
expect treatment to resolve my dizziness and other vertigo symptoms?
• What is the recommended treatment for my vertigo? Why do you recommend this
treatment?
• If this treatment is unsuccessful, what other treatment options might you recommend?
• Will I undergo vestibular rehabilitation therapy to treat my vertigo? If so, how often will I
have therapy and how long will therapy last?
• What is the canalith repositioning procedure, also called the Epley maneuver? Might thistechnique be used to treat my vertigo?
• Will medication(s) be used to treat my vertigo? If so, which medications?
• What are the most common side effects of the medication(s)?
• What types of severe side effects may occur? What should I do if I experience severe side
effects? Telephone number to call:
• Might surgery be required to treat my condition? Why or why not?
• If I do require surgery, what type of surgery may be performed and how do I prepare for
the procedure?
• What can I expect following surgery to treat vertigo?
• What should I do if I experience complications after surgery? Telephone number to call:
• Do you recommend that I participate in a vertigo clinical trial or explore newer treatmentoptions?
• Can you recommend a local or online support group for patients with vertigo?
