This is a short video on causes of peripheral vertigo.
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ADDITIONAL TAGS:
Central vertigo:
Stroke
Multiple sclerosis
Migrainous vertigo (vestibular migraine)
Posterior fossa lesion
Benign paroxysmal positional vertigo
Ménière's
disease
Labyrinthitis (vestibular neuritis)
Herpes zoster oticus (Ramsay Hunt syndrome)
Perilymphatic fistula
Others
Peripheral vertigo
First, what is dizziness?
Vertigo (~50%): spinning sensation, false sense of motion
Disequilibrium (~15%): off-balance
Presyncope (~15%): blacking out, feel like going to pass out (lose consciousness)
Lightheadedness (~10%): vague, disconnection from surroundings
Benign paroxysmal positional vertigo
Pathophys: Crystalline deposits (canaliths) in semicircular canals → disrupt normal vestibular fluid flow → contradictory signals from either side interpreted as spinning/vertigo
Sx: Brief, reproducible episodes of vertigo, rotary nystagmus, nausea; triggered by head movement; lasting seconds to ~1 min
Dx: Clinical; Dix-Hallpike (patient in supine with head rotated 45 deg) triggers nystagmus
Tx: Canalith repositioning maneuver (Epley maneuver); antihistamine (Meclizine); otherwise BPPV resolves spontaneously in most cases but can recur months/years later
Ménière's disease
Pathophys: increased volume and/or pressure of endolymph (endolymphatic hydrops)
Sx: Episodes of vertigo, sensorineural hearing loss, tinnitus; lasting 20 min to 24 hrs. SNHL starts unilateral, at low frequencies, progresses to all frequencies
Dx: Clinical. Weber/Rinne to confirm SNHL; audiometry to monitor it.
Tx: Lifestyle changes (restrict sodium nicotine, caffeine, alcohol) +/- diuretics → antihistamines, benzos, antiemetics for acute symptoms → endolymphatic shunt placement if severe, intractable.
viral or post-viral inflammation of vestibular nerve
Sx: Acute episode of vertigo, n/v, hearing loss, gait instability; lasting up to several days. Onset ~4 weeks after URI.
Dx: Abnormal head thrust test. Diagnosis of exclusion. Brain imaging to r/o pontine stroke/tumors, cerebellar hemorrhage/infarction
Tx: Steroids within 72 hours. Will eventually resolve but balance and hearing can be compromised. Meclizine for vertigo.
Labyrinthitis (vestibular neuritis)
Benign paroxysmal positional vertigo
Ménière's
disease
Labyrinthitis (vestibular neuritis)
Herpes zoster oticus (Ramsay Hunt syndrome)
Perilymphatic fistula
Others
Pathophys: reactivation of latent herpes zoster (VZV) from geniculate ganglion; disrupts facial nerve function
Sx: Ipsilateral ear pain, facial paralysis, and dermatomal vesicular rash in EAC. Additional auditory (tinnitus, hyperacusis) and vestibular (vertigo, n/v) problems if spread to CN VIII. Systemic symptoms are rare ( 20%).
Dx: Clinical
Tx: Steroids, acyclovir within 3 days, speeds resolution, limits adverse outcomes (residual facial weakness). Protect eye (artificial tears) on weak side of face.
Pathophys: trauma → break in the otic capsule (often at oval or round windows) → fistula, leakage of perilymph, transfer of pressure
Sx: Progressive SNHL; Episodic vertigo with nystagmus triggered by pressure changes (Valsalva, elevation, sneeze, cough, strain); loud clap/noise induces nystagmus (Tullio phenom.)
Dx: Clinical; CT might show fluid around round window
Tx: Bed rest, head elevation; limit activities that increase inner ear pressure (avoid straining) → surgical patch if refractory
Cogan syndrome:
Pathophys: Uncertain; possibly autoimmune inflammation of eye.
Sx: Episodes of hearing loss, vertigo, n/v, ataxia, vision changes.
Dx: slit-lamp exam, inflammatory markers. MRI
Tx: immunosuppressants (eg, steroids).
Vestibular schwannoma (acoustic neuroma): peripheral or central vertigo?
Pathophys: Schwann cell-derived tumors of vestibular part of CN VIII.
Sx: Unilateral hearing loss, tinnitus (CN VIII). Slow growing tumor usually allows for vestibular compensation. +/- Unilateral facial numbness (CN V) and weakness (CN VII).
Bilateral is associated with neurofibromatosis type II.
Dx: Clinical, audiometry, MRI
Tx: Surgical resection or radiation
Aminoglycoside toxicity:
Pathophys: Gentamicin is vestibulotoxic → bilateral vestibular damage
Sx: Disequilibrium; oscillopsia. No right/left imbalance of vestibular input = no vertigo.
Dx: Clinical: abnormal horizontal head impulse; reduced visual acuity during head shake
Oscillopsia is an illusion of an unstable visual world.