II. Definitions

  1. Vertigo
    1. Sensation of motion (e.g. room spinning) with Disorientation in space
    2. Results from stimuli mismatch of three systems: vestibular, visual, somatosensory

III. Epidemiology

  1. Vertigo is the most common cause of Dizziness (54% of cases)
    1. Kroenke (1992) Ann Intern Med 117:898-904 [PubMed]

IV. Pathophysiology

  1. See Vertigo Causes
  2. Peripheral Causes of Vertigo
    1. Inner ear receptor conditions (e.g. Benign Paroxysmal Positional Vertigo, Meniere's Disease)
    2. Vestibulocochlear Nerve conditions ( Vestibular Neuronitis)
  3. 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

  1. 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
    4. Differential Diagnosis
      1. Benign Paroxysmal Positional Vertigo
      2. Orthostatic Hypotension
  2. 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
    3. Differential diagnosis is broad (more likely vestibular if occurs while supine)
      1. Transient Ischemic Attack (TIA)
      2. Vertebrobasilar Insufficiency
      3. Meniere Disease
      4. Vestibular Migraine
      5. Anxiety Disorder or Panic Attack
      6. Reflex Mediated Syncope
  3. 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)
      1. Ischemic Posterior CVA
        1. Consider head imaging (includes MRI for reliable assessment for Posterior Circulation CVA)
        2. Consider Vertebral Artery Dissection in young patients or recent Cervical Spine manipulation
        3. Caused by Posterior Circulation in 25% of cases
        4. Tarnutzer (2011) CMAJ 183(9): E571-92 [PubMed]
      2. Posterior fossa Hemorrhage
      3. Medication Causes of Vertigo (responsible for >20% of Dizziness in older patients)
      4. Vestibular Neuronitis
      5. Wernicke Encephalopathy
      6. Closed Head Injury (e.g. Post-Concussion Syndrome, Skull Fracture, Whiplash, Vertebral Artery Dissection)
      7. Middle Ear Barotrauma (Barotitis Media) or Inner Ear Barotrauma (round or oval window rupture)
        1. See Scuba Diving
  4. References
    1. Marcolini (2016) Emerg Med News, 38(12): 1

VII. Symptoms

  1. Vertigo characteristics
    1. Sensation of movement (usually spinning)
    2. Room is spinning around patient OR patient has Sensation of self-motion while still
  2. Timing
    1. Timing of Continuous Vertigo (Acute Vestibular Syndrome or AVS)
      1. Spontanous Onset (e.g. posterior CVA, Vestibular Neuritis)
        1. Acute onset with possible waxing and waning course
      2. Trauma or Toxin Related
        1. Single episode with discrete onset after exposure
        2. May last days to weeks even after the exposure is removed
    2. Timing of Episodic Vertigo (Discrete attacks, contrast with the continuous Vertigo of AVS)
      1. Triggered Vertigo (e.g. BPPV, Orthostasis)
        1. Sudden onset Vertigo occurs only with specific head rotation
        2. Vertigo is absent when at rest without head position changes
        3. Lasts seconds to minutes
      2. Spontaneous Episodic Vertigo (Spontaneous Episodic Vestibular Syndrome, e.g. TIA, Meniere Disease, Vestibular Migraine)
        1. Sudden unprovoked onset even at rest (although may be exacerbated by head position changes)
        2. Lasts minutes to hours
        3. May experience residual queasy feeling for days
  3. Modifying Factors
    1. Provocative
      1. Change in head position
        1. Differentiate triggered Vertigo (peripheral Vertigo) from exacerbated continuous Vertigo (possible central Vertigo)
      2. Change in Posture
        1. Orthostasis
    2. Palliative
      1. Rest without head turning
      2. Supine Position (Orthostasis)
  4. Associated Symptoms
    1. Nausea or Vomiting
    2. Hearing Loss (e.g. Meniere Disease, Viral Labyrinthitis)
    3. Tinnitus
  5. 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

  1. Vital Signs
    1. Orthostatic Blood Pressure and Pulse
  2. Cardiovascular Exam
  3. Neurologic Exam
    1. Cranial Nerves
    2. Carotid Bruits
      1. Do not perform Carotid Sinus Massage
    3. Cerebellar tests
      1. Rapid Alternating Movements
      2. Romberg Test
        1. Unsteadiness is present in central Vertigo with or without eyes open
      3. Gait Exam
        1. Profoundly abnormal in many central Vertigo cases
        2. Evaluate prior to discharge to assess Fall Risk
  4. Complete Head and Neck Exam
    1. See Nystagmus testing below
    2. Trauma Exam
      1. See Primary Trauma Evaluation
      2. See Secondary Trauma Evaluation
    3. Ear Exam
      1. Middle Ear Anatomy
        1. Tympanic Membrane Perforation or erythema
        2. Tympanic Membrane vessicles: Herpes Zoster Oticus
        3. Cholesteatoma (Posterior superior aspect of TM)
      2. Tuning Fork Tests
        1. Weber Test and Rinne Test
        2. See Hearing Loss
  5. Specific vestibular tests (see below)
    1. HiNTs Exam (see below)
      1. Differentiates peripheral Vertigo from central Vertigo in patients with continuous Vertigo (AVS) and Nystagmus
    2. Dix-Hallpike Maneuver
      1. Indicated in episodic, triggered Vertigo
      2. Positive in Benign Paroxysmal Positional Vertigo
      3. Transient upbeat or torsional Nystagmus on Dix-Hallpike Maneuver suggests BPPV (posterior canal)
      4. Transient downbeat Nystagmus on Dix-Hallpike Maneuver suggests BPPV (anterior canal)
    3. Canalith Repositioning Procedure (Epley Maneuver)
      1. First-line management and curative in Benign Paroxysmal Positional Vertigo (BPPV)
      2. Consider performing instead of Dix-Hallpike Maneuver, as it is also diagnostic, with predictable BPPV provocation
    4. Orthostatic Blood Pressure (and Heart Rate)
      1. Consider in episodic triggered Vertigo, when Dix-Hallpike Maneuver is negative

IX. Signs: HiNTs Exam

  1. See HiNTs Exam
  2. Indications
    1. Acute Vestibular Syndrome with ongoing Vertigo and Nystagmus at time of exam
    2. Do NOT use the HiNTs Exam when Nystagmus is absent (no benefit)
  3. 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
  4. 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
    4. Normally one eye lags in response to maintain forward gaze (other eye will lack corrective saccades)
      1. Eye will normally make quick saccade movement to catch-up or correct (HiNTs-Peripheral)
      2. An abnormal test (no saccade), or HiNTs-Central
        1. Suggests a central cause of Acute Vestibular Syndrome (AVS)
        2. Saccades may also be absent if the Vertigo has resolved
  5. 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
      1. 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
      1. Nystagmus direction is assigned based on the quick component or saccade corrective movement
      2. Right Nystagmus suggests a left-sided lesion, and left Nystagmus a right-sided lesion
    4. Findings suggestive of peripheral Vertigo
      1. Horizontal Nystagmus (esp. unidirectional) suggests a peripheral cause (although it does not exclude a central cause)
    5. Findings suggestive of central Vertigo (e.g. posterior CVA)
      1. Vertical Nystagmus
      2. Torsional Nystagmus
      3. Nystagmus that changes direction
        1. Rightward Nystagmus with rightward gaze
        2. Leftward Nystagmus with leftward gaze
  6. 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

X. Signs: Other Nystagmus Testing

  1. Dix-Hallpike Maneuver (Provoked Nystagmus)
    1. Unreliable in identifying central Vertigo (with Acute Vestibular Syndrome)
    2. However, may be helpful in Triggered Vestibular Syndrome
      1. Abnormal in Benign Paroxysmal Positional Vertigo (BPPV)
  2. Visual Fixation
    1. Observe for Nystagmus while patient fixes their gaze on an object in the room
      1. Suppression of Nystagmus by Visual Fixation on an object suggests peripheral Vertigo
    2. Next, place a blank sheet of paper in front of the eyes to prevent Visual Fixation
      1. Nystagmus is expected to return when Visual Fixation is not possible
  3. Spontaneous Nystagmus (Check with non-fixated gaze)
    1. Formal testing might include Frenzel Lenses to measure the degree of Nystagmus
    2. Occlusive Ophthalmoscopy
      1. Cover one of patient's eyes
      2. Use ophthalmoscope to focus on the Optic Disk
      3. Note Nystagmus movements

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

  1. Brief duration does not exclude Posterior Circulation event (e.g. TIA)
  2. Vertical Nystagmus or Direction Changing Nystagmus (aside from transient with the Dix-Hallpike Maneuver)
  3. Skew Deviation
  4. Normal Horizontal Head Impulse Test
  5. Severe imbalance with gait Ataxia
  6. Truncal Ataxia while sitting upright
  7. Associated neurologic findings
    1. Hand Incoordination or dysmetria
    2. Unilateral limb weakness
    3. Loss of Sensation
    4. Diplopia
    5. Dysarthria
  8. 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
      1. Nucleus Solitarius (CN 7, CN 9, CN 10)
      2. Nucleus Ambiguous (CN 9, CN 10)

XII. Labs

  1. Labs are indicated when central Vertigo is suspected (e.g. Cerebrovascular Accident)
  2. Labs are rarely useful in the peripheral Vertigo evaluation (<1% of cases)
    1. Colledge (1996) BMJ 313:788-92 [PubMed]
    2. Hoffman (1999) Am J Med 107(5): 468-78 [PubMed]
  3. Labs are 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
    4. Continuous ECG Monitor (14 to 28 days)

XIII. Diagnostics

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

XIV. Imaging: Indications

  1. Acute Vertigo with suspected central Vertigo
    1. Emergency department yield on CT Head imaging in undifferentiated acute Vertigo is <2.2%
      1. In contrast, follow-up MRI demonstrates CVA in 16%
      2. Reserve imaging for those at risk for CVA and presentations suggestive of central CVA (see red flags above)
      3. 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
      1. Vertebrobasilar infarction or insufficiency
      2. Labyrinthine artery thrombosis
      3. Anterior Inferior Cerebellar Artery insufficiency or infarction
      4. Posterior Inferior Cerebellar Artery insufficiency or infarction
      5. Subclavian Steal Syndrome
  2. Chronic Vertigo with Sensorineural Hearing Loss (or other neurologic deficits)
    1. Obtain MRI Brain
    2. Assess for structural abnormality
      1. Acoustic Neuroma
      2. Other mass lesion
      3. Demyelinating disease (e.g. Multiple Sclerosis)
      4. Chiari Malformation
      5. Inner ear disruptions (e.g. Fractures, semicicular canal dehiscence)
        1. May also be seen on CT Head

XVI. Evaluation

  1. Distinguish from non-Vertigo Causes with distinct diagnostic pathways
    1. Precaution
      1. 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
  2. Episodic Vertigo
    1. Precaution
      1. Follow continuous algorithm (see below) if symptoms are constant, even if worsened with maneuvers
      2. Acute Vestibular Syndrome (AVS) symptoms are often made worse with provocative maneuvers
        1. However, unlike episodic Vertigo, AVS symptoms are still present between episodes
    2. Triggered Episodic Vertigo
      1. Perform Dix-Hallpike Maneuver (positive if provokes Vertigo, even if no Nystagmus seen)
      2. Positive Test: Benign Paroxysmal Positional Vertigo
      3. Negative Test: Consider Orthostatic Hypotension
    3. Spontaneous Episodic Vertigo
      1. Meniere Disease (Hearing Loss, Tinnitus)
      2. Vestibular Migraine (Migraine Headache, light sensitivity)
      3. Anxiety Disorder
  3. Continuous Vertigo
    1. Consider known exposures
      1. Medication Causes of Vertigo (causes >20% of Vertigo cases in older patients, esp. if on >5 medications)
      2. Ear Barotrauma (see Scuba Diving)
    2. Perform HiNTs Exam
      1. Positive HiNTs Exam
        1. Head imaging for posterior CVA (follow CVA protocols)
        2. Consider MRI Head if CT negative (Head CT is insensitive for posterior CVA diagnosis)
      2. Negative HiNTs Exam
        1. Peripheral Vertigo (e.g. Vestibular Neuronitis)
        2. Consider exposures listed above (e.g. medications, ear Barotrauma)

XVII. Management

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