Vertigo

What is Vertigo?

Vertigo is the presence of dizziness and an abnormal and false sensation of the rotational or spinning motion of the surrounding environment and objects. It is caused due to a disturbance in the normal functioning of the vestibular system which is essential for providing a sense of balance and spatial orientation.

Is Vertigo condition a Medical emergency?

Vertigo is not a medical emergency.

Types

Vertigo may be of the following types:

• Peripheral Vertigo: It is usually caused by conditions affecting the inner ear and the semicircular canals
• Central Vertigo: It is usually caused by conditions affecting the brain, cerebellum, and vertebrobasilar system

Causes

Vertigo is caused when there is a dysfunction of the vestibular system either due to peripherally acting conditions affecting the semicircular canals within the inner ear or centrally acting conditions that affect the brain, cerebellum, etc. These conditions lead to an asymmetry in the vestibular system and result in a disturbance of balance and spatial orientation.

Some common conditions that result in Vertigo include:

• Vertigo is due to peripheral causes:
  • Benign paroxysmal positional Vertigo – due to the accumulation of debris within the semicircular canals
  • Meniere’s disease – due to an increased volume of endolymph within the semicircular canals
  • Ramsay hunt syndrome – reactivation of the herpes zoster virus within the geniculate ganglion and inflammation of the eighth cranial nerve
  • Acute labyrinthitis – due to viral infection
  • Vestibular neuritis – due to viral infection
  • Cholesteatoma – a complication of middle ear infection
  • Otosclerosis – abnormal growth of bones in the middle ear
  • Perilymphatic fistula – due to trauma
  • Multiple sclerosis
• Vertigo is due to central causes:
  • Ischemic or hemorrhagic strokes affecting the cerebellum,
  • Cerebellopontine angle tumors – such as brainstem glioma, medulloblastoma, and vestibular schwannoma
  • Vestibular migraines
  • Multiple sclerosis
• Other causes:
  • Medications – such as anticonvulsants
  • Psychological disorders – such as mood or anxiety disorders

Risk factors

• Gender – more common in women
• Age – risk increases with aging
• History of cardiovascular disease
• History of psychological illness
• Trauma to the head
• Diseases affecting the inner ear or middle ear

Triggering factors

Vertigo may sometimes be triggered by:

• Looking up or down
• Sudden movements of the head
• Rolling over in bed
• Titling of the head
• Stress
• Lack of sleep
• Change in atmospheric pressure
• Dehydration

Symptoms & signs

The signs and symptoms of Vertigo include:

• Peripheral Vertigo
  • A sensation of dizziness and a false sensation of spinning of the surrounding environment and objects
  • Nausea and vomiting
  • Headache
  • Abnormal rhythmic eye movements (nystagmus)
  • Hearing loss
  • Tinnitus
  • Fullness or pain in the ears
  • Facial nerve weakness on one side
• Central Vertigo
  • A sensation of dizziness and a false sensation of spinning of the surrounding environment and objects
  • Nausea and vomiting
  • Headache
  • Slurred speech
  • Double vision
  • Inability to stand or walk
  • Abnormal rhythmic eye movements (pathological nystagmus)

Investigations

Some investigations that are advised for the evaluation of Vertigo include:

• Clinical Evaluation:
  • Dix-Hallpike Maneuver – the individual is rapidly moved from a sitting position to a sleeping position with the head turned 45⁰to the right and checked for the presence of abnormal eye movements. The procedure is repeated with the head turned to the left side after a gap of 20-30 seconds.
  • HINTS Test (Head Impulse – Nystagmus – Test for Skew)
• Other tests include:
  • Electronystagmography – to detect the presence and timing of abnormal eye movements.
  • Caloric tests
  • Infrared Nystagmography
  • Audiogram
• Imaging tests – when central lesions are suspected
  • MRI scan
  • MR Angiography
  • CT scan of the brain stem and cerebellum – only if MRI is not available

Diagnosis

A diagnosis of the underlying cause of Vertigo is established based on medical history, clinical evaluation, and results of the investigations done.

Treatment

The treatment of Vertigo depends on identifying the underlying cause and then treating it.

Medical management

Medical management of Vertigo may include:

• Vestibular-suppressant medications – such as antihistamines, benzodiazepines, and anti-emetics help to reduce the intensity of the symptoms
• Diuretics – for the management of Meniere’s disease not responding to vestibular-suppressant medications

Interventional including surgery and indications for surgery

Surgical interventions may be advised if the symptoms are very severe and aim to reduce the severity of Vertigo. Resolution of symptoms may take a few weeks to months after the surgical procedures. These procedures may include:

• Labyrinthectomy
• Posterior Canal Occlusion/plugging – it is the most commonly performed surgery, and very effective
• Singular neurectomy
• Vestibular nerve section
• Transtympanic aminoglycoside application

Role of diet/ Exercise/ Lifestyle changes/ Preventive measures

Some measures that are taken to manage benign paroxysmal positional Vertigo include:

• Canalith Repositioning Maneuvers – these are simple exercises that are done to reposition the canalith (crystals) within the inner ear. They may be done by a physician or can be taught to the individual to be performed at home. They include the following:
  • Epley Maneuver
  • Semont Maneuver
  • Brandt – Daroff Exercises
  • Roll Maneuver

Some other measures that need to be taken by individuals with benign paroxysmal positional Vertigo include:

• Walking with a cane or aid to avoid the risk of falls
• Avoiding sudden movements of the head
• Being cautious while changing positions such as rising from the bed, chair, etc.
• Sitting down immediately if feeling dizzy or disoriented

Some measures that help individuals with Meniere’s disease include lifestyle modifications such as:

• Avoiding a high salt diet
• Avoiding caffeinated drinks
• Avoiding alcohol
• Avoiding known triggers of Vertigo

Complications

Vertigo can result in loss of balance and falls, which may, in turn, lead to head trauma or fractures of the long bones or pelvis.

Prognosis

The prognosis of Vertigo depends on the severity of the condition as well as the underlying cause. Peripheral causes are associated with lesser morbidity, while central causes require immediate attention and are associated with a higher degree of morbidity.

When to contact the doctor or hospital? / How to identify the emergency or complications?

It is advisable to seek medical attention if the signs and symptoms of Vertigo are noticed. Immediate medical attention is warranted if there is an increase in the intensity of symptoms, or if accompanied with new symptoms such as severe headaches, loss of consciousness, blurring of vision, etc.

Indications for hospitalization if required

Hospitalization is not required for the management of Vertigo unless surgical interventions are advised.

Suggested clinical specialist/ Department to consult for this condition

• Otorhinolaryngology (ENT)
• Neurology