Vertigo

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

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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
  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. Meniere Disease
      3. Vestibular Migraine
      4. Anxiety Disorder or Panic Attack
      5. 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. Posterior CVA
        1. Consider head imaging (includes MRI for reliable assessment for Posterior Circulation CVA)
        2. Consider Vertebral Artery Dissection in young patients
        3. Caused by Posterior Circulation in 25% of cases
        4. Tarnutzer (2011) CMAJ 183(9): E571-92 [PubMed]
      2. Medication Causes of Vertigo (responsible for >20% of Dizziness in older patients)
      3. Vestibular Neuronitis
      4. 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

VI. History: Associated Conditions and Exposures

  1. Preceding Head Trauma
    1. Concussion
    2. Perilymphatic Fistula
    3. Benign Paroxysmal Positional Vertigo
  2. Preceding viral illness
    1. Vestibular Neuronitis
    2. Viral Labyrinthitis
  3. Hearing Loss or ear fullness (muffled)
    1. Viral Labyrinthitis (distinguishes from Vestibular Neuronitis)
    2. Meniere Disease (also with Tinnitus)
  4. Ototoxic Drug exposure (e.g. Aspirin, Aminoglycosides)
    1. See Ototoxic Drug
  5. Cerebrovascular Accident Risk Factors or symptoms (e.g. Atrial Fibrillation, Diabetes Mellitus, Cardiac Risk Factors)
    1. Acute Cerebellar Stroke
    2. Vertebrobasilar Insufficiency
    3. Acute lateral Medullary stroke (Wallenberg Syndrome)
  6. Recent neck Trauma or neck manipulation (e.g. chiropractor)
    1. Vertebral Artery Dissection
  7. 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)
  8. Ataxia
    1. Vertebral Artery Dissection
    2. Acute Cerebellar Stroke
    3. Vertebrobasilar Insufficiency
  9. Optic Neuritis
    1. Multiple Sclerosis
  10. Horner Syndrome
    1. Acute lateral Medullary stroke (Wallenberg Syndrome)

VII. Symptoms

  1. Vertigo pattern
    1. Sensation of movement (usually spinning)
      1. Room is spinning around patient or
      2. Patient has Sensation of self-motion while still
    2. Episodic (Discrete attacks)
      1. Onset: Sudden
      2. Duration: several hours
      3. May experience residual queasy feeling for days
    3. Provocative: Change in head position
    4. Palliative: Rest
  2. Associated Symptoms
    1. Nausea or Vomiting
    2. Hearing Loss
    3. Tinnitus
  3. 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. 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
    2. Dix-Hallpike Maneuver

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 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. 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
  3. Skew Deviation
  4. Normal Horizontal Head Impulse Test
  5. Severe imbalance (gait Ataxia)
  6. Associated neurologic findings
    1. Hand Incoordination
    2. Unilateral limb weakness
    3. Loss of Sensation
    4. Diplopia
    5. Dysarthria
  7. 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. 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]
  2. 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

  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
    1. Obtain MRI Brain
    2. Assess for structural abnormality
      1. Acoustic Neuroma
      2. Other mass lesion

XV. Differential Diagnosis: Dizziness

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

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

  1. See Vertigo Management

XVIII. References

  1. Ondrejka (2014) Crit Dec Emerg Med 28(10): 11-7
  2. Baloh (1999) Postgrad Med 105(2):161-72 [PubMed]
  3. Knox (1997) Am Fam Physician 55(4):1185-90 [PubMed]
  4. Labuguen (2006) Am Fam Physician 73:244-51 [PubMed]
  5. Muncie (2017) Am Fam Physician 95(3): 154-62 [PubMed]
  6. Tusa (2005) Neurol Clin 23:655-673 [PubMed]
  7. Tusa (2003) Med Clin N Am 87:609-41 [PubMed]

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