Peripheral vertigo

This is a short video on causes of peripheral vertigo. This presentation was created with Google Slides. Images and figures have Creative Commons license. 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.