Vertigo

1. Epidemiology
   1. Most common cause of Dizziness (54% of cases)
      1. Kroenke (1992) Ann Intern Med 117:898-904
2. Pathophysiology
   1. Sensation of spatial disorientation
   2. Stimuli Mismatch: vestibular, visual, somatosensory
3. Symptoms
   1. Vertigo pattern
      1. Sensation of movement (usually spinning)
         1. Room is spinning around patient
      2. Episodic (Discrete attacks)
         1. Onset: Sudden
         2. Duration: several hours
         3. May experience residual queasy feeling for days
      3. Provocative: Change in head position
      4. Palliative: Rest
   2. Associated Symptoms
      1. Nausea or Vomiting
      2. Hearing Loss
      3. Tinnitus
   3. Symptoms suggesting other cause Dizziness (not Vertigo)
      1. Patient senses spinning on the inside
      2. Constant unremitting Dizziness
      3. No Nystagmus present
4. Signs
   1. Vital Signs
      1. Orthostatic Blood Pressure and Pulse
   2. Complete Head and Neck Exam
      1. Nystagmus
         1. Spontaneous Nystagmus (Check with non-fixated gaze)
            1. Frenzel Lenses
            2. Occlusive Ophthalmoscopy
               1. Cover one of patients eye
               2. Use ophthalmoscope to focus on the optic disk
               3. Note Nystagmus movements
         2. Head impulse test
            1. Grasp head with both hands
            2. Rapidly rotate head 10-15 degrees
            3. Abnormal if one eye lags in response to maintain forward gaze
               1. Makes quick saccade movement to catch-up or correct
         3. Alternate eye Cover Testing
            1. Cover and uncover each eye to see response
            2. Identifies skew deviation where one eye corrects by looking up and the other by looking down
            3. Associated with a Head Tilt
            4. May be associated with Horner's Syndrome
      2. Provocative Testing
         1. Dix-Hallpike Maneuver
      3. Ear Exam
         1. Tuning Fork Tests
            1. Weber Test and Rinne Test
            2. See Hearing Loss
         2. Middle Ear Anatomy
            1. Tympanic Membrane Perforation or erythema
            2. Tympanic Membrane vessicles: Herpes Zoster Oticus
            3. Cholesteatoma (Posterior superior aspect of TM)
   3. Neurologic Exam
      1. Cranial Nerves
      2. Cerebellar tests
         1. Rapid alternating movements
         2. Balance (Romberg and Gait)
      3. Carotid Bruits
      4. Do not perform Carotid Sinus Massage
5. Precautions: Red Flags (Brainstem or cerebellar cause)
   1. Vertical Nystagmus (or change in direction)
   2. Skew deviation
   3. Normal head impulse test
   4. Severe imbalance
   5. Associated neurologic findings
6. Labs
   1. See Vertigo Labs
7. Diagnostics and Imaging
   1. See Vertigo Diagnostic Testing
8. Differential Diagnosis: Dizziness
   1. Vertigo Causes
      1. Peripheral Causes of Vertigo
      2. Central Causes of Vertigo
      3. Miscellaneous Causes
         1. Motion Sickness
         2. Vertigo Caused by Medication
         3. Psychological cause
   2. Dysequilibrium
   3. Syncope
   4. Light Headedness
9. Management
   1. See Vertigo Management
10. References
    1. Baloh (1999) Postgrad Med 105(2):161-72
    2. Knox (1997) Am Fam Physician 55(4):1185-90
    3. Labuguen (2006) Am Fam Physician 73:244-51
    4. Tusa (2005) Neurol Clin 23:655-673
    5. Tusa (2003) Med Clin N Am 87:609-41