6/11/2018 Vertigo

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Vertigo
Aka: Vertigo, Vestibular Exam, Vertigo Examination, Vertigo Lab, Vertigo Diagnostic Testing, Triggered Vestibular Syndrome,
Episodic Vestibular Syndrome, Acute Vestibular Syndrome

See Also Page Contents

Vertigo Causes

Peripheral Causes of Vertigo

Central Causes of Vertigo

Vertigo Management

Meniere's Disease

Motion Sickness

Vestibular Neuronitis

Benign Paroxysmal Positional Vertigo

Perilymphatic Fistula

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II. De nitions: Vertigo

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A. Sensation of motion (e.g. room spinning) with Disorientation in space

B. Results from stimuli mismatch of three systems: vestibular, visual, somatosensory

III. Epidemiology

A. Vertigo is the most common cause of Dizziness (54% of cases)

1. Kroenke (1992) Ann Intern Med 117:898-904 [PubMed]

IV. Pathophysiology

A. See Vertigo Causes

B. Peripheral Causes of Vertigo
1. Inner ear receptor conditions (e.g. Benign Paroxysmal Positional Vertigo, Meniere's Disease)
2. Vestibulocochlear Nerve conditions ( Vestibular Neuronitis)
C. Central Causes of Vertigo (affecting the Brainstem, including the vestibular nuclei and Cerebellum)
1. Posterior circulation Cerebrovascular Accident (vertebrobasilar CVA)
2. Non-Vascular Central Causes of Vertigo (e.g. Acoustic Neuroma, Brainstem lesions, MS)

V. History: Types by Precipitating or Provocative Event

A. Triggered Vestibular Syndrome (TVS)

1. Trigger examples: Head movement (e.g. peripheral Vertigo such as BPPV), body position (e.g.
Orthostasis)
2. Contrast with AVS (see below) which is not triggered (but is worse with certain maneuvers such
as head turning)
3. Perform Dix-Hallpike Maneuver and Orthostatic Blood Pressure and pulse
B. Spontaneous Episodic Vestibular Syndrome (EVS)
1. Distinct episodes without obvious trigger, and asymptomatic between episodes (as well as often
on presentation)
2. Perform a careful Neurologic Exam and consider TIA Risk Factors

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3. Differential diagnosis is broad (more likely vestibular if occurs while supine)

a. Transient Ischemic Attack (TIA)
b. Meniere Disease
c. Vestibular Migraine
d. Anxiety Disorder or Panic Attack
e. Reflex Mediated Syncope
C. Acute Vestibular Syndrome (AVS)
1. Acute, rapid onset (<1 hour) that is persistent, continuous Vertigo or Dizziness (for weeks to
months)
2. Vertigo is worsened by (but not triggered by) position change
3. Associated with Nystagmus, Nausea or Vomiting, head motion intolerance and gait unsteadiness
4. Perform HiNTs Exam
5. Differential Diagnosis (unlike TVS, which is triggered by position change, AVS includes CVA)
a. Posterior CVA
i. Consider head imaging (includes MRI for reliable assessment for Posterior
Circulation CVA)
ii. Caused by Posterior Circulation in 25% of cases
iii. Tarnutzer (2011) CMAJ 183(9): E571-92 [PubMed]
b. Medication Causes of Vertigo (responsible for >20% of Dizziness in older patients)
c. Vestibular Neuronitis
d. Middle Ear Barotrauma (Barotitis Media) or Inner Ear Barotrauma (round or oval window
rupture)
i. See Scuba Diving
D. References
1. Marcolini (2016) Emerg Med News, 38(12): 1

VI. History: Associated Conditions and Exposures

A. Preceding Head Trauma

1. Concussion
2. Perilymphatic Fistula
3. Benign Paroxysmal Positional Vertigo
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B. Preceding viral illness

1. Vestibular Neuronitis
2. Viral Labyrinthitis
C. Hearing Loss or ear fullness (muffled)
1. Viral Labyrinthitis (distinguishes from Vestibular Neuronitis)
2. Meniere Disease (also with Tinnitus)
D. Ototoxic Drug exposure (e.g. Aspirin, Aminoglycosides)
1. See Ototoxic Drug
E. Cerebrovascular Accident Risk Factors or symptoms
1. Acute cerebellar stroke
2. Vertebrobasilar Insufficiency
3. Acute lateral Medullary stroke (Wallenberg Syndrome)
F. Recent neck Trauma or manipulation
1. Vertebral Artery dissection
G. Cranial Nerve deficits or facial numbness or weakness
1. Acute cerebellar stroke
2. Vertebrobasilar Insufficiency
3. Acute lateral Medullary stroke (Wallenberg Syndrome)
4. Vertebral Artery dissection
5. Cranial Nerve VIII tumor (e.g. Acoustic Neuroma)
H. Ataxia
1. Vertebral Artery dissection
2. Acute cerebellar stroke
3. Vertebrobasilar Insufficiency
I. Optic Neuritis
1. Multiple Sclerosis
J. Horner Syndrome
1. Acute lateral Medullary stroke (Wallenberg Syndrome)

VII. Symptoms

A. Vertigo pattern
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1. Sensation of movement (usually spinning)

a. Room is spinning around patient or
b. Patient has sensation of self-motion while still
2. Episodic (Discrete attacks)
a. Onset: Sudden
b. Duration: several hours
c. May experience residual queasy feeling for days
3. Provocative: Change in head position
4. Palliative: Rest
B. Associated Symptoms
1. Nausea or Vomiting
2. Hearing Loss
3. Tinnitus
C. Symptoms suggesting other cause of Dizziness (not Vertigo)
1. Patient senses spinning on the inside
2. Constant chronic unremitting Dizziness (beyond Acute Vestibular Syndrome)
3. No Nystagmus present

VIII. Signs: General

A. Vital Signs
1. Orthostatic Blood Pressure and Pulse
B. Cardiovascular Exam
C. Neurologic Exam
1. Cranial Nerves
2. Carotid Bruits
a. Do not perform Carotid Sinus Massage
3. Cerebellar tests
a. Rapid Alternating Movements
b. Romberg Test
i. Unsteadiness is present in central Vertigo with or without eyes open
c. Gait Exam
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i. Profoundly abnormal in many central Vertigo cases

ii. Evaluate prior to discharge to assess fall risk
D. Complete Head and Neck Exam
1. Ear Exam
a. Middle Ear Anatomy
i. Tympanic Membrane Perforation or erythema
ii. Tympanic Membrane vessicles: Herpes Zoster Oticus
iii. Cholesteatoma (Posterior superior aspect of TM)
b. Tuning Fork Tests
i. Weber Test and Rinne Test
ii. See Hearing Loss
E. Specific vestibular tests (see below)
1. HiNTs Exam
2. Dix-Hallpike Maneuver

IX. Signs: HiNTs Exam

A. See HiNTs Exam

B. Indications
1. Acute Vestibular Syndrome with ongoing Vertigo and Nystagmus at time of exam
C. Positive HiNTs Exam Criteria (at least 1 of 3 positive) suggests cerebellar CVA or Brainstem CVA (100%
sensitive, 96% specific)
1. See HiNTs Exam (Three-Step Bedside Oculomotor Examination)
2. Normal Horizontal Head Impulse Test (no saccade/correction on head rotation) OR
3. Nystagmus that changes direction (or Vertical Nystagmus or torsional Nystagmus) OR
4. Skew Deviation on Alternate Eye Cover Test in which uncovered eye demonstrates quick vertical
gaze corrections
D. Head impulse test
1. See Horizontal Head Impulse Test (Head Thrust Test, h-HIT)
2. Grasp head with both hands
3. Rapidly rotate head 20 degrees

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4. Normally one eye lags in response to maintain forward gaze (other eye will lack corrective
saccades)
a. Eye will normally make quick saccade movement to catch-up or correct (HiNTs-Peripheral)
b. An abnormal test (no saccade), or HiNTs-Central
i. Suggests a central cause of Acute Vestibular Syndrome (AVS)
ii. Saccades may also be absent if the Vertigo has resolved
E. Direction Changing Nystagmus (or Nystagmus that is vertical or torsional)
1. See Nystagmus
2. Patient follows examiner's finger as they move it slowly in all direction
a. Examiner moves finger up, down, left or right and to eccentric positions (off-center)
3. Nystagmus should be present in all cases of acute vestibular system whether of peripheral or
central cause
a. Nystagmus direction is assigned based on the quick component or saccade corrective
movement
b. Right Nystagmus suggests a left-sided lesion, and left Nystagmus a right-sided lesion
4. Findings suggestive of peripheral Vertigo
a. Horizontal Nystagmus suggests a peripheral cause (although it does not exclude a central
cause)
5. Findings suggestive of central Vertigo (e.g. posterior CVA)
a. Vertical Nystagmus
b. Torsional Nystagmus
c. Nystagmus that changes direction
i. Rightward Nystagmus with rightward gaze
ii. Leftward Nystagmus with leftward gaze
F. Alternate Eye Cover Testing (Test of Skew)
1. See Skew Deviation
2. Cover and uncover each eye and observe for vertical saccade movements in response
3. Identifies Skew Deviation where one eye corrects by looking up and the other by looking down
4. Associated with a Head Tilt
5. May be associated with Horner's Syndrome

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X. Signs: Other Nystagmus Testing

A. Dix-Hallpike Maneuver (Provoked Nystagmus)

1. Unreliable in identifying central Vertigo (with Acute Vestibular Syndrome)
2. However, may be helpful in Triggered Vestibular Syndrome
a. Abnormal in Benign Paroxysmal Positional Vertigo (BPPV)
B. Spontaneous Nystagmus (Check with non-fixated gaze)
1. Formal testing might include Frenzel Lenses to measure the degree of Nystagmus
2. Occlusive Ophthalmoscopy
a. Cover one of patient's eyes
b. Use ophthalmoscope to focus on the optic disk
c. Note Nystagmus movements

XI. Precautions: Red Flags (Brainstem or cerebellar cause)

A. Brief duration does not exclude Posterior Circulation event (e.g. TIA)
B. Vertical Nystagmus or Direction Changing Nystagmus
C. Skew Deviation
D. Normal Horizontal Head Impulse Test
E. Severe imbalance (gait Ataxia)
F. Associated neurologic findings
1. Hand Incoordination
2. Unilateral limb weakness
3. Loss of sensation
4. Diplopia
5. Dysarthria
G. Concurrent changes in taste, swallowing or speech
1. Suggests a Brainstem lesion
2. Brainstem lesion (e.g. CVA) that affects vestibular function is likely to affect taste, swallowing and
speech
3. Vestibular nucleus in close proximity to other CN nucleii in the Brainstem

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a. Nucleus Solitarius (CN 7, CN 9, CN 10)

b. Nucleus Ambiguous (CN 9, CN 10)

XII. Labs

A. Rarely useful in the Vertigo evaluation (<1% of cases)

1. Colledge (1996) BMJ 313:788-92 [PubMed]
2. Hoffman (1999) Am J Med 107(5): 468-78 [PubMed]
B. Indicated for other causes of Dizziness (e.g. Syncope or Presyncope, chronic comorbidity)
1. Complete Blood Count (CBC)
2. Chemistry panel (electrolytes including Potassium and Glucose)
3. Thyroid Stimulating Hormone

XIII. Diagnostics

A. Acute Vertigo
1. Electrocardiogram indications
a. Central Vertigo
i. Evaluate for Atrial Fibrillation for thrombosis source
b. Other Dizziness evaluation
i. Evaluate for Syncope or Presyncope
B. Chronic or persistent Vertigo
1. Audiogram
a. Vertigo with Hearing Loss
b. Meniere's Disease suspected
2. Electronystagmography (ENG)
a. Quantifies and records Nystagmus

XIV. Imaging: Indications

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A. Acute Vertigo with suspected central Vertigo

1. Emergency department yield on CT Head imaging in undifferentiated acute Vertigo is <2.2%
a. In contrast, follow-up MRI demonstrates CVA in 16%
b. Reserve imaging for those at risk for CVA and presentations suggestive of central CVA (see
red flags above)
c. Lawhn-Heath (2012) Emerg Radiol 20(1):45-9 [PubMed]
2. Obtain CT/CTA Head and Neck (or MRI/MRA if outside CVA intervention window)
3. Assess for cerebrovascular cause
a. Vertebrobasilar infarction or insufficiency
b. Labyrinthine artery thrombosis
c. Anterior Inferior Cerebellar Artery insufficiency or infarction
d. Posterior Inferior Cerebellar Artery insufficiency or infarction
e. Subclavian Steal Syndrome
B. Chronic Vertigo with Sensorineural Hearing Loss
1. Obtain MRI Brain
2. Assess for structural abnormality
a. Acoustic Neuroma
b. Other mass lesion

XV. Di erential Diagnosis: Dizziness

A. Vertigo Causes
1. Peripheral Causes of Vertigo
2. Central Causes of Vertigo
3. Miscellaneous Causes
a. Motion Sickness
b. Vertigo Caused by Medication
c. Psychological cause
B. Non-Vertigo cause
1. Dysequilibrium or Ataxia
2. Syncope and Presyncope
3. Light Headedness
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4. Muscle Weakness

XVI. Evaluation

A. Distinguish from non-Vertigo Causes with distinct diagnostic pathways

1. Precaution
a. Dizziness in older patients may be difficult to categorize (e.g. Presyncope versus Vertigo)
2. Syncope or Presyncope
3. Dysequilibrium or Ataxia
4. Muscle Weakness
B. Episodic Vertigo
1. Precaution
a. Follow continuous algorithm (see below) if symptoms are constant, even if worsened with
maneuvers
b. Acute Vestibular Syndrome (AVS) symptoms are often made worse with provocative
maneuvers
i. However, unlike episodic Vertigo, AVS symptoms are still present between episodes
2. Triggered Episodic Vertigo
a. Perform Dix-Hallpike Maneuver (positive if provokes Vertigo, even if no Nystagmus seen)
b. Positive Test: Benign Paroxysmal Positional Vertigo
c. Negative Test: Consider Orthostatic Hypotension
3. Spontaneous Episodic Vertigo
a. Meniere Disease (Hearing Loss, Tinnitus)
b. Vestibular Migraine (Migraine Headache, light sensitivity)
c. Anxiety Disorder
C. Continuous Vertigo
1. Consider known exposures
a. Medication Causes of Vertigo (causes >20% of Vertigo cases in older patients, esp. if on
>5 medications)
b. Ear Barotrauma (see Scuba Diving)
2. Perform HiNTs Exam
a. Positive HiNTs Exam
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i. Head imaging for posterior CVA (follow CVA protocols)

ii. Consider MRI Head if CT negative (Head CT is insensitive for posterior CVA
diagnosis)
b. Negative HiNTs Exam
i. Peripheral Vertigo (e.g. Vestibular Neuronitis)
ii. Consider exposures listed above (e.g. medications, ear barotrauma)

XVII. Management

A. See Vertigo Management

XVIII. References

A. Ondrejka (2014) Crit Dec Emerg Med 28(10): 11-7

B. Baloh (1999) Postgrad Med 105(2):161-72 [PubMed]
C. Knox (1997) Am Fam Physician 55(4):1185-90 [PubMed]
D. Labuguen (2006) Am Fam Physician 73:244-51 [PubMed]
E. Muncie (2017) Am Fam Physician 95(3): 154-62 [PubMed]
F. Tusa (2005) Neurol Clin 23:655-673 [PubMed]
G. Tusa (2003) Med Clin N Am 87:609-41 [PubMed]

Images: Related links to external sites (from Bing)

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These images are a random sampling from a Bing search on the term "Vertigo." Click on the image (or right
click) to open the source website in a new browser window. Search Bing for all related images

Related Studies (from Trip Database)  Open in New Window

DynaMed Plus 01 Jan 2017

Benign paroxysmal positional vertigo (BPPV)
(http://www.dynamed.com/topics/dmp~AN~T113695/Benign-paroxysmal-positional-vertigo-(BPPV))

BMJ Best Practice 01 Mar 2017

Overview of vertigo
(http://bestpractice.bmj.com/best-practice/monograph/965.html)

Current medical research and opinion 22 Mar 2018

Pilot cluster randomized controlled trial of a complex intervention to improve management of vertigo
in primary care (PRIMA-Vertigo): study protocol.
(http://www.ncbi.nlm.nih.gov/pubmed/29565189)

BMJ Best Practice 18 Apr 2016

B
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Benign paroxysmal positional vertigo
(http://bestpractice.bmj.com/best-practice/monograph/73.html)

American Academy of Otolaryngology - Head and Neck Surgery 01 Jan 2017

Benign Paroxysmal Positional Vertigo (BPPV)
(http://journals.sagepub.com/doi/full/10.1177/0194599816689667)

Continue searching the Trip Database (http://www tripdatabase com/search?criteria Vertigo)

Ontology: Vestibular Diseases (C0042594)

Definition Pathological processes of the VESTIBULAR LABYRINTH which contains part of the balancing
(MSH) apparatus. Patients with vestibular diseases show instability and are at risk of frequent falls.

Concepts Disease or Syndrome (T047)

MSH D015837

ICD10 H81.9 , H81, H81.90

SnomedCT 194695008, 267761002, 194379003, 20425006

English Disease, Vestibular, Diseases, Vestibular, Vestibular Disease, VESTIBULAR DISORDER, Disor vestib
funct, unspec, Disorder of vestibular function, unspecified, [X]Disor vestib funct, unspec, [X]Disorder
of vestibular function, unspecified, VESTIBULAR DIS, Vestibular function disorder, Disorder
vestibular, Vestibular disorder NOS, Vestibular Diseases, Unspecified disorder of vestibular function,
Unspecified disorder of vestibular function, unspecified ear, Disorders of vestibular function,
Vestibular Diseases [Disease/Finding], disorder vestibular, problems vestibular, vestibular disease,
disorders system vestibular, vestibular disorder, Disorder;vestibular system, disorders vestibular,
vestibular problem, vestibular diseases, disorder of vestibular function, disorder of vestibular function
(diagnosis), Vestibular disorders, [X]Disorder of vestibular function, unspecified (disorder), Vestibular
syndromes/disorders, Vertigo, vestibular disorders, Vestibular disorder, disease (or disorder);
labyrinth, ear, disorder; vestibular function, vestibular function; disorder, Vestibular disorder, NOS,
vestibular system disorder

Italian Disturbo vestibolare, Disturbo vestibolare NAS, Disturbo della funzione vestibolare, Malattie del
vestibolo

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Dutch vestibulaire functie aandoening, aandoening vestibulair, vestibulaire stoornis NAO, aandoening;
labyrint, oor, stoornis; vestibulaire functie, vestibulaire functie; stoornis, Vestibulaire functiestoornis,
niet gespecificeerd, vestibulaire aandoening, Vestibulaire functiestoornissen, Vestibulumziekte,
Vestibulumziekten, Ziekte, vestibulum-, Ziekten, vestibulum-

French Trouble vestibulaire SAI, Trouble de la fonction vestibulaire, TROUBLES VESTIBULAIRES, Trouble
vestibulaire, Maladies vestibulaires, Maladies du vestibule

German vestibulare Stoerung NNB, vestibulaere Funktionsstoerung, Stoerung der Vestibularfunktion, nicht
naeher bezeichnet, Stoerungen der Vestibularfunktion, VESTIBULARISSTOERUNG, vestibulaere
Stoerung, Vestibulariskrankheiten

Portuguese Afecção vestibular, Perturbação vestibular NE, Perturbação da função vestibular, ALTERACAO
VESTIBULAR, Anomalia vestibular, Doenças Vestibulares

Spanish Trastorno vestibular NEOM, Trastorno de la función vestibular, VESTIBULO, TRASTORNO,

[X]trastorno de la función vestibular, no especificado (trastorno), [X]trastorno de la función vestibular,
no especificado, trastorno vestibular, Trastorno vestibular, Enfermedades Vestibulares

Japanese 前庭障害, 前庭機能障害, 前庭障害ＮＯＳ, ｾﾞﾝﾃｲｷﾉｳｼｮｳｶﾞｲ, ｾﾞﾝﾃｲｼｮｳｶﾞｲ, ｾﾞﾝﾃｲｼｮｳｶﾞｲNOS

Swedish Vestibulära sjukdomar

Czech vestibulární nemoci, Vestibulární porucha, Vestibulární porucha NOS, Porucha vestibulární funkce

Finnish Tasapainoelimen sairaudet

Russian VESTIBULIARNOGO APPARATA BOLEZNI, ВЕСТИБУЛЯРНОГО АППАРАТА БОЛЕЗНИ

Korean 전정기능의 장애, 상세불명의 전정기능 장애

Croatian VESTIBULARNE, BOLESTI

Polish Choroby narządu przedsionkowego

Hungarian Vestibularis dysfunctio, vestibularis betegség, vestibularis betegség k.m.n., betegség, vestibularis

Norwegian Not Translated[Vestibular Diseases]

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Derived from the NIH UMLS (Uni ed Medical Language System)

Ontology: Acute vestibular syndrome (C1504381)

Concepts Disease or Syndrome (T047)

Italian Sindrome vestibolare acuta

Japanese 急性前庭症候群, ｷｭｳｾｲｾﾞﾝﾃｲｼｮｳｺｳｸﾞﾝ

Czech Akutní vestibulární syndrom

French Syndrome vestibulaire aigu

Hungarian Acut vestibularis syndroma

English Acute vestibular syndrome

Dutch acuut vestibulair syndroom

Portuguese Síndrome vestibular agudo

German akuter Vestibularisausfall

Spanish Síndrome vestibular agudo

Derived from the NIH UMLS (Uni ed Medical Language System)

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