🌟 Vertigo

 🎯 Pathology

• definition: hallucination of movement of the patient or the surroundings

  • the movement is often rotatory

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💡 Causes

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Peripheral vertigo​

• conditions that affect the vestibular nerve

• causes:

  • benign positional paroxysmal vertigo (BPPV)

  • vestibular neuronitis

  • viral labyrinthitis

  • Meniere’s disease

  • acoustic neuroma

  • drugs

Central vertigo

• conditions that affect the brainstem or cerebellum

• causes:

  • vestibular migraine

  • multiple sclerosis

  • tumour

  • infarction of the anterior inferior cerebellar artery

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🕵️‍♂️ Assessment

• full ENT, neurological and visual exam

• otoscopy

• for BPPV

  • Dix-Hallpike manoeuvre —> rotatory nystagmus (positive result)

  • treat with Epley manoeuvre

• audiometry

• neuroimaging (CT/MRI head) to exclude central causes

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🧩 Differential diagnosis of vertigo

Benign positional paroxysmal vertigo (BPPV)

• vertigo that occurs with head movement

• the episode lasts for a few seconds

• no deafness or tinnitus

Vestibular neuronitis

• vertigo preceded by an upper respiratory tract infection

Viral labyrinthitis

• same as vestibular neuronitis + hearing loss

Meniere’s disease

• “hearing loss + tinnitus + vertigo + aural fullness”

• due to build up of endolymph in the semicircular canals

• attacks can last more than 20 minutes

Drug-induced

• loop diuretics, cisplatin, aspirin, and aminoglycosides can cause ototoxicity

Ramsay Hunt syndrome (herpes zoster)

• “vesicular rash around ear + facial nerve paralysis + vertigo/tinnitus/hearing loss”

Acoustic neuroma

• cranial nerves V, VII and VIII are affected

  • CN V: absent corneal reflex + paraesthesia in the trigeminal nerve distribution

  • CN VII: facial nerve palsy + impaired lacrimation (by sublingual and submandibular glands) + vertigo/tinnitus/hearing loss + loss of taste sensation from the anterior 2/3rds of the tongue

  • CN VIII: vertigo/tinnitus/hearing loss

• note that bilateral vestibular schwannomas are associated with neurofibromatosis type 2

Posterior circulation stroke

• especially if the anterior inferior cerebellar artery (AICA) is affected causing lateral pontine syndrome, compromising the vestibular and cochlear nuclei

Vertebrobasilar insufficiency

• dizziness with neck extension in an elderly patient

Trauma

• CN VIII may be affected following damage to the petrous temporal bone potentially leading to vertigo/tinnitus/hearing loss

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🧲 High-yield tips

• HINTS examination is used to differentiate between peripheral and central causes of vertigo​​