Vertigo overview: Difference between revisions
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==Pathophysiology== | ==Pathophysiology== | ||
Disruption in the [[vestibular system]] results in vertigo. The region of disruption could be peripheral ([[labyrinth]], [[vestibular]] [[nerve]]) or central ([[brainstem]], [[cerebellum]]). [[Vestibulo-ocular reflex]] is responsible for stabilizing [[gaze]] during head movement, it is controlled by six [[neurotransmitters]], which are [[glutamate]], [[acetylcholine]], [[GABA]], [[dopamine]], [[histamine]] and [[norepinephrine]]. | |||
==Causes== | ==Causes== | ||
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==Epidemiology and Demographics== | ==Epidemiology and Demographics== | ||
Among the patient who presents with [[dizziness]] in the primary care setting, fifty-four percent have vertigo upon investigation. [[Benign paroxysmal positional vertigo]], [[acute vestibular neuronitis]], and [[Ménière’s disease]] account for ninety-three percent of patients diagnosed with true vertigo in a primary care setting. | |||
==Risk Factors== | ==Risk Factors== | ||
There are no established risk factors for vertigo, as it is a symptom of an underlying disease. However, vertigo can be prevented in some cases by controlling risk factors for the underlying cause. | |||
==Screening== | ==Screening== | ||
There is insufficient evidence to recommend routine [[screening]] for vertigo. | |||
==Diagnostic Study of Choice== | |||
There are no established criteria for the diagnosis of vertigo. The best approach to diagnose vertigo [[etiology]] is to obtain a complete history paired with a focal examination. | |||
==History and Symptoms== | |||
It is important to differentiate between other causes of [[dizziness]] before evaluating the cause of vertigo. True vertigo is described as the room spinning around the patient. Once true vertigo is established next step is to identify if the origin of [[dysfunction]] is central or peripheral. Detailed investigation of the time course of vertigo and associated signs and [[symptoms]] aid in identifying the cause of vertigo. | |||
==Physical Examination | ==Physical Examination | ||
Physical examination of patients experiencing vertigo should include assessment of cranial nerves, nystagmus, sensorineural hearing loss (Rinne or Webers test), otoscopic exam of the ear canal and tympanic membrane, HINTS (cover/uncover test), Dix-Hallpike maneuver, and/or Hennebert’s sign. | |||
==Laboratory Findings== | ==Laboratory Findings== | ||
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There are no ECG findings associated with vertigo. [[ECG]] monitoring may be indicated if the cause of [[dizziness]] is uncertain. | There are no ECG findings associated with vertigo. [[ECG]] monitoring may be indicated if the cause of [[dizziness]] is uncertain. | ||
==X-ray== | ==X-ray== | ||
There are no [[x-ray]] findings associated with vertigo. | |||
==Echocardiography or Ultrasound== | ==Echocardiography or Ultrasound== | ||
There are no [[echocardiography]]/[[ultrasound]] findings associated with vertigo. | |||
==CT scan== | ==CT scan== | ||
[[CT]] scan is not the first-line imaging preferred to determine the underlying cause of central vertigo. If [[MRI]] is contraindicated then a thin cut [[CT]] scan can be used. | |||
==MRI== | ==MRI== | ||
An [[MRI]] is the first-line imaging if the cause of vertigo is suspected to be central in origin. [[MRI]] is superior to a [[CT]] scan due to its ability to visualize the [[posterior fossa]]. | |||
==Other Imaging Findings== | ==Other Imaging Findings== | ||
There are no other [[imaging]] findings associated with vertigo. However, some underlying cause may benefit from [[electronystagmography]] or [[electroencephalogram]]. Further [[imaging]] should be conducted according to the diagnostic requirements of the [[etiology]] behind the [[symptom]] of vertigo. | |||
==Other Diagnostic Studies== | ==Other Diagnostic Studies== | ||
There are no other [[Diagnosis|diagnostic studies]] associated with vertigo. However, the causes of vertigo should be evaluated further according to its [[diagnostic]] [[protocol]]. | |||
== | ==Medical Therapy== | ||
[[Acute]]/severe attacks of vertigo may subside in a day or two after brainstem compensation. Supportive therapy includes bed rest, [[antihistamine]], [[antiemetic]] ([[prochlorperazine]], [[metoclopramide]]) to relief the [[symptom]]. [[Antihistamine]] ([[meclizine]],[[betahistine]],[[dimenhydrinate]]), [[antiemetic]], [[anticholinergic]] ([[scopolamine]]) and [[benzodiazepines]] ([[diazepam]],[[lorazepam]]) are the common medications used to treat vertigo as a [[symptom]]. These drugs should not be used for a long period of time as it may delay the compensatory mechanism in the [[brainstem]] and result in the prolongation of vertigo [[symptom]]. Some patients may be a candidate for [[vestibular]] [[rehabilitation]]. Treating the underlying cause is the definitive treatment of vertigo | |||
==Surgery== | ==Surgery== | ||
For the majority of underlying causes of vertigo, the mainstay of treatment is medical therapy. Surgery is usually reserved for patients with either [[tumor]]-associated vertigo, [[cholesteatoma]], and/or when it does not respond to multiple medical therapies. | |||
==Primary Prevention== | ==Primary Prevention== | ||
Revision as of 19:05, 12 January 2021
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Vertigo overview On the Web |
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American Roentgen Ray Society Images of Vertigo overview |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Zehra Malik, M.B.B.S[2]
Overview
Vertigo is identified as 'room spinning around'. It is a type of dizziness. Presyncope, lightheadedness and disequilibrium are other types of dizziness and should be ruled out. The cause of vertigo can be peripheral or central in origin. In peripheral vertigo, dysfunction is in the vestibular system which includes the vestibule (utricle and saccule), semicircular canals, and the vestibular nerve. Central etiologies of vertigo usually originates from the brainstem or cerebellum. Most common causes of vertigo to appear in primary-care are benign paroxysmal positional vertigo, acute vestibular neuronitis, and Ménière’s disease. Best approach to diagnose vertigo etiology is to obtain a complete history paired with a focal examination including assessment of cranial nerves, nystagmus, sensorineural hearing loss (Rinne or Webers test), otoscopic exam of ear canal and tympanic membrane, HINTS (cover/uncover test), Dix-Hallpike maneuver and/or Hennebert’s sign. Acute/severe attacks of vertigo may subside in a day or two after brainstem compensation. Supportive therapy includes bed rest, antihistamine, antiemetic (prochlorperazine, metoclopramide) to relief the symptom. These drugs should not be used for a long period of time as it may delay the compensatory mechanism in the brainstem and result in the prolongation of vertigo symptom.Treating the underlying cause is the definitive treatment of vertigo.
Historical Perspective
Vertigo is derived from the Latin words vertigin and vertere which means "a whirling or spinning movement," and "to turn", respectively.
Classification
Vertigo is classified on the basis of the location of dysfunction into:
- Peripheral: Lesion in the inner ear or vestibulocochlear nerve.
- Central: Lesion in brainstem or cerebellum.
- It can also be classified on the basis of its time course or duration:
- Lasting a day or longer
- Lasting minutes to hours
- Lasting seconds
Pathophysiology
Disruption in the vestibular system results in vertigo. The region of disruption could be peripheral (labyrinth, vestibular nerve) or central (brainstem, cerebellum). Vestibulo-ocular reflex is responsible for stabilizing gaze during head movement, it is controlled by six neurotransmitters, which are glutamate, acetylcholine, GABA, dopamine, histamine and norepinephrine.
Causes
- Common causes of vertigo:
- Peripheral: Benign paroxysmal positional vertigo (BPPV), Ménière's disease, acute labyrinthitis, vestibular neuritis, Herpes zoster oticus(Ramsay Hunt syndrome).
- Central: Ischemic/hemorrhagic stroke in the cerebellum or brainstem, tumor in cerebellopontine angle, vestibular migraine.
- Drug induced
- Psychological Vertigo
Differentiating Vertigo from other Diseases
- Vertigo is one of the four type of dizziness, therefore it must be differentiated from other forms of dizziness, presyncope, lightheadedness and disequilibrium.
Epidemiology and Demographics
Among the patient who presents with dizziness in the primary care setting, fifty-four percent have vertigo upon investigation. Benign paroxysmal positional vertigo, acute vestibular neuronitis, and Ménière’s disease account for ninety-three percent of patients diagnosed with true vertigo in a primary care setting.
Risk Factors
There are no established risk factors for vertigo, as it is a symptom of an underlying disease. However, vertigo can be prevented in some cases by controlling risk factors for the underlying cause.
Screening
There is insufficient evidence to recommend routine screening for vertigo.
Diagnostic Study of Choice
There are no established criteria for the diagnosis of vertigo. The best approach to diagnose vertigo etiology is to obtain a complete history paired with a focal examination.
History and Symptoms
It is important to differentiate between other causes of dizziness before evaluating the cause of vertigo. True vertigo is described as the room spinning around the patient. Once true vertigo is established next step is to identify if the origin of dysfunction is central or peripheral. Detailed investigation of the time course of vertigo and associated signs and symptoms aid in identifying the cause of vertigo. ==Physical Examination Physical examination of patients experiencing vertigo should include assessment of cranial nerves, nystagmus, sensorineural hearing loss (Rinne or Webers test), otoscopic exam of the ear canal and tympanic membrane, HINTS (cover/uncover test), Dix-Hallpike maneuver, and/or Hennebert’s sign.
Laboratory Findings
There are no diagnostic laboratory findings associated with vertigo.
Electrocardiogram
There are no ECG findings associated with vertigo. ECG monitoring may be indicated if the cause of dizziness is uncertain.
X-ray
There are no x-ray findings associated with vertigo.
Echocardiography or Ultrasound
There are no echocardiography/ultrasound findings associated with vertigo.
CT scan
CT scan is not the first-line imaging preferred to determine the underlying cause of central vertigo. If MRI is contraindicated then a thin cut CT scan can be used.
MRI
An MRI is the first-line imaging if the cause of vertigo is suspected to be central in origin. MRI is superior to a CT scan due to its ability to visualize the posterior fossa.
Other Imaging Findings
There are no other imaging findings associated with vertigo. However, some underlying cause may benefit from electronystagmography or electroencephalogram. Further imaging should be conducted according to the diagnostic requirements of the etiology behind the symptom of vertigo.
Other Diagnostic Studies
There are no other diagnostic studies associated with vertigo. However, the causes of vertigo should be evaluated further according to its diagnostic protocol.
Medical Therapy
Acute/severe attacks of vertigo may subside in a day or two after brainstem compensation. Supportive therapy includes bed rest, antihistamine, antiemetic (prochlorperazine, metoclopramide) to relief the symptom. Antihistamine (meclizine,betahistine,dimenhydrinate), antiemetic, anticholinergic (scopolamine) and benzodiazepines (diazepam,lorazepam) are the common medications used to treat vertigo as a symptom. These drugs should not be used for a long period of time as it may delay the compensatory mechanism in the brainstem and result in the prolongation of vertigo symptom. Some patients may be a candidate for vestibular rehabilitation. Treating the underlying cause is the definitive treatment of vertigo
Surgery
For the majority of underlying causes of vertigo, the mainstay of treatment is medical therapy. Surgery is usually reserved for patients with either tumor-associated vertigo, cholesteatoma, and/or when it does not respond to multiple medical therapies.
Primary Prevention
There are no established measures for the primary prevention of vertigo, as it occurs as a symptom of underlying pathology. In some diseases controlling risk factors or triggering, factors can prevent the disease hence preventing the symptoms.
Secondary Prevention
Effective measures for the secondary prevention of vertigo include optimal treatment of the underlying etiology.