Vertigo and Dizziness Ch. 231 Tintinalli

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Vertigo and DizzinessCh. 231 Tintinalli
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• Vertigo- the perception of movement
• Syncope- transient LOC, loss of postural tone,
  with spontaneous recovery.
• Near-Syncope- light-headedness, signaling an
  impending LOC
• Disequilibrium- unsteadiness, imbalance, or a
  sensation of floating while walking.

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Pathophysiology

• CNS integrates sensory input from- visual,
  vestibular, and proprioceptive system. Vertigo
  occurs when a mismatch of the 3 systems occur.
• Visual inputs provide spatial orientation while
  the vestibular system helps with body orientation
  is respect to gravity.

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• Three semicircular canals sense orientation to
  movement of the head. Filled with endolymph, the
  movement of fluid moves hair cells causing
  vestibular impulses to fire through the nucleus
  of the 8th cranial nerve.
• Asymmetrical input from the vestibular apparatus
  may result in vertigo. Symmetrical bilateral
  deficiencies cause truncal or gait instability.

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• Nystagmus- clinically associated with vertigo is
  the rhythmic movement of eyes.
• Fast and Slow Component
• Direction named by fast component
• With horizontal nystagmus, slow component points
  to affected side
• Vertical nystagmus can signify brainstem
  abnormality

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• Vertigo and dizziness occurs mostly in elderly
  due to decrease in visual acuity, proprioception
  and vestibular input.
• Near syncope increases with age d/t dysrhythmias,
  orthostatic hypotension, and autonomic
  dysfunction.
• Medication use can lead to all the above.

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• Peripheral vertigo caused by disorders affecting
  the vestibular apparatus and the 8th cranial
  nerve. Sudden onset, spinning, intermittent, CNS
  signs absent. Increases with removal of visual
  fixation.
• Central vertigo caused by brainstem and
  cerebellum disorders. Variable onset, constant,
  vertical nystagmus, usually seen with CNS signs.
  Decreases with visual fixation.

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• On PE in pts with vertigo, the EAC and TM should
  be examined. Hearing should be tested, Webber
  and Rhine testing should be performed.
• If central vertigo is considered, test corneal
  reflex, facial paresis, difficulty swallowing,
  dysphonia, and depressed gag reflex. Tandem
  gait, Romberg, proprioception and vibration
  testing should be done.

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• Diagnosis of BPPV can be aided with the Dix
  Hallpike position test.
• Pts with near syncope should be tested for
  orthostatic hypotension as well as cardiac
  testing performed.

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• Vertigo associated with closed head injury needs
  a CT or MRI
• In central vertigo, if hemorrhage, infarction or
  tumor is suspected get a CT or MRI immediately.
  If suspect vertebral art. disscection, get an MRA

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• Peripheral vertigo is treated with short term
  pharmacotherapy with drugs with anticholinergic
  effects such as scopolamine.
• H1 antihistamines are effective against vertigo
  but H2 are not.
• Calcium channel blockers are a second line
  treatment.

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Other causes of peripheral vertigo

• Menieres disease-increase of endolymph.
  Difficulty regulating the volume, flow, and
  composition of endolymph. Associated with
  roaring tinnitus, hearing loss, and ear fullness.
• Treated with antihistamines and diuretics
  triamterene and HCTZ.

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• Labyrinthitis- infection of the labyrinth assoc.
  with hearing loss. May be assoc. with
  mumps/measles. Infection can develop from otitis
  media or cholesteatoma.
• Hallmarks are sudden onset of vertigo, hearing
  loss, and middle ear findings.
• Need antibiotics, ENT, and possible drainage.

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• Ototoxicity caused by aminoglycosides leads to
  hearing loss and peripheral vestibular
  dysfunction. Damage is irreversible and is
  dose/duration dependent.
• Can also be seen with the use of vinblastine,
  cisplastin, chloroquine, and mefloquine.

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• Reversible causes of vestibular damage and
  ototoxicity include, NSAIDS, salicylates,
  minocycline, erythromycin, and fluoroquinolones.
• Central vestibular syndrome can be caused by
  anticonvulsants, TCA, neuroleptics, opiates and
  alcohol.
• Irreversible cerebellar toxicity can be caused by
  phenytoin and toluene and well as chemotheraeutic
  drugs.

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• Cerebellopontine angle tumors such as acoustic
  neuromas, meningiomas, and dermoids. Present with
  ipsilateral facial weakness, loss of corneal
  reflex, and cerebellar signs.

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• Post-traumatic vertigo can be caused by a blow to
  the labyrinthine membranes resolves in several
  weeks.
• Onset is immediate with N/V.
• May be associated with temporal bone fracture.
• Get a CT

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Disorders causing central vertigo

• Central vertigo caused by disorders affecting the
  cerebellum and brainstem. Gradual onset, mild
  intensity, not provoked by changes in position.
  Vertical nystagmus is more likely.
• Cerebellar hemorrhage usually causes acute
  vertigo and ataxia. Vertigo may not be intense
  and may have truncal ataxia.

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• Wallenberg Syndrome is a lateral meduallary
  infarction of the brainstem. Classic ipsilateral
  findings such as facial numbness, loss of corneal
  reflex, Horner syndrome, and paralysis or paresis
  of the soft palate, pharynx and larynx.
• Contralateral loss of pain and temp. sensation in
  the trunk and limbs.

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• Vertebrobasilar insufficiency can cause TIAs of
  the brainstem and produce vertigo. Last less
  than 24 hrs. VBI may be provoked by position.
• Vertebral Artery Dissection can cause strokes of
  the post. Circulation. S/S include HA, vertigo
  and unilateral Horner. Caused by sudden rotation
  or extension of the neck.

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• Multiple Sclerosis may cause vertigo that can
  last days to weeks and is not usually intense.
• Neoplasms of the fourth ventricle can cause
  brainstem S/S and vertigo.
• Vertigo can be assoc. with and aura of migraine

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• Disequilibrium of aging is assoc. with loss of
  hearing, balance, proprioceptive input, and
  vision as well as decline in central integration
  and motor responses.
• Near syncope is a feeling of light-headedness
  that include vasovagal, situational, orthostatic,
  drug induced, and cardiac causes.

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• Pts with peripheral vertigo may be discharged
  from the ED once symptoms are controlled.
• Refer 1st time vertigo pts to PCP for neuro
  follow up.
• Suspected central causes need ED neuro cosult

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