Sandbox:ZMalik

Pathophysiology of Common Causes of Vertigo
Ménière’s disease	Increased endolymph volume in semicircular canals.
Benign paroxysmal positional vertigo	Dislodged otoliths stimulate vestibular sense organ.
Acute labyrinthitis	Inflammation of labyrinth/ viral or bacterial.
Acute vestibular neuritis	Inflammation of vestibular nerve caused by viral infection.
Cholesteatoma	Cyst/sac of keratin debris in middle ear.
Otosclerosis	Abnormal bone growth in the middle ear.
Perilymphatic fistula	Abnormal connection between the middle ear and inner ear.

• Vertigo is derived from the Latin word vertō which means "a whirling or spinning movement".

Classification

Classification of Vertigo

Based on Location of Dysfunction

Peripheral Accounts for over 90% of all causes of vertigo

Central

Lesion in inner ear or vestibulocochlear nerve

Lesion in brainstem or cerebellum

Meniere’s disease Benign positional paroxysmal vertigo Acute labyrinthitis Acute vestibular neuronitis Cholesteatoma Otosclerosis Perilymphatic fistula Acoustic Neuroma

Brainstem Stroke Vestibular Migraine Multiple Sclerosis Cerebellar ischemia or hemorrhage Cerebellar tumors lateral medullary syndrome Chiari malformation

Causes

• Peripheral causes of vertigo includes:

Disease	Main Feature
Ménière’s disease	Increased endolymph volume in semicircular canals. Recurrent vertigo, aural fullness, hearing loss and tinnitus
Benign positional paroxysmal vertigo	Dislodged otoliths stimulate vestibular sense organ. Recurrent vertigo, nausea, vomiting, torsional nystagmus
Acute labyrinthitis	Inflammation of labyrinth/ viral or bacterial. Temporary hearing loss, vertigo, off balance, tinnitus
Acute vestibular neuritis	Inflammation of vestibular nerve caused by viral infection. Vertigo, hearing intact
Cholesteatoma	Cyst/sac of keratin debris in middle ear. Fullness/pressure in the ear, vertigo, hearing loss, pain
Otosclerosis	Abnormal bone growth in middle ear. Vertigo, tinnitus and, sensorineural hearing loss
Perilymphatic fistula	Abnormal connection between the middle ear and inner ear. Fullness/pressure in the ear, vertigo, hearing loss/sensitive hearing

• Central causes of vertigo includes:

Disease	Main Feature
Brainstem Stroke	Vertigo, imbalance, double vision, slurred speech, and altered consciousness.
Vestibular Migraine	Mostly unilateral severe throbbing headache, vertigo lasting minutes to hours, sensitivity to motion/light/smell/noise, nausea, vomiting, imbalance.
Multiple Sclerosis	Vertigo may accompany other symptoms like vision problem, fatigue, numbness/tingling, limited mobility, bladder/bowel/speech/swallowing impairment.
Cerebellar tumors	meningioma or schwannoma in cerebellopontine angle can cause vertigo due to pressure on vestibular nerve.
Lateral medullary syndrome	Results from ischemia in the lateral part of the brainstem(medulla oblongata). Associated with ataxia, nystagmus, vertigo, dysphagia, dysarthria.
Chiari malformation	Extension of brainstem into spinal canal. Associated with numbness/tingling of hands and feet, dysphagia, vertigo, unsteady gait, hoarseness.

Differentiating Vertigo from other Diseases

• Vertigo is a type of dizziness therefore it must be differentiated from other diseases that causes imbalance, dizziness, and lightheadedness.

Epidemiology and Demographics

• Among the patient who presents with dizziness in the primary care setting, fifty-four percent have vertigo upon investigation.

Screening

• There is insufficient evidence to recommend routine screening for vertigo.

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 the underlying cause:
  • In vestibular migraine recognized triggers including altered sleep patterns, menstrual cycle, chocolate, red wine, ripened/aged cheese, should be avoided.
  • Avoid drugs or toxins that may cause vertigo.

Natural History, Complications and Prognosis

• Complications include:
  • Anxiety
  • Depression
  • Difficulty performing daily tasks
  • Diminished quality of life
  • Impaired balance and coordination
• Prognosis of vertigo depends upon treating the underlying cause. However, vertigo due to a tumor has a poor prognosis compared to other causes of vertigo.

Diagnosis

Diagnostic Study of Choice

• There are no established criteria for the diagnosis of vertigo. Associated signs and symptoms should be identified to reach the underlying cause of vertigo.

History and Symptoms

• It is important to differentiate between other causes of dizziness before evaluating for 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.

Physical Examination

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

Echocardiography or Ultrasound

CT scan

MRI

• An MRI is indicated if the cause of vertigo is central in origin.
• An MRI can identify if the underlying cause is a brain tumor like a acoustic neuroma(vestibular schwannoma) or other pathology in the cerebellopontine angle.

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Surgery

Primary Prevention

Secondary Prevention