Vertigo – 2

Again, our differential diagnosis of VERTIGO:

CAUSES OF VERTIGO

Peripheral Benign Paroxysmal Positional Vertigo Acute Labyrinthitis Herpes Zoster Meniere’s Disease Labyrinthine Concussion Perilymphatic Fistula Middle Ear Diseases Impacted Cerumen

Central Stroke (Brainstem or Cerebellar) Vertebral Artery Dissection Brainstem / Cerebellar TIA Multiple Sclerosis Migrainous Vertigo

Last posting Vertigo – 1, we discussed BPPV (far & away the most common cause of patient complaints), & saw how to differentiate Acute Labyrinthitis from more serious central causes.  Now let’s conclude with the other peripheral etiologies, some of which can be disabling.  And a comment on Migrainous Vertigo.

**  Herpes Zoster Oticus  —  Varicella-zoster virus reactivation from the geniculate ganglion, which governs the 7^th and 8^th Cranial Nerves.  Also called the Ramsay Hunt Syndrome.  Findings may include:

• Ear pain (unilateral)
• Hearing loss, Tinnitus  (unilateral)
• Facial palsy (“Bell’s”)
• Vesicles on the external ear or in the canal — clinches the Dx for sure, but are often absent.

Zoster usually occurs >60 y.o., which is stroke age.  If the vertigo is moderate-severe, I might prefer the ER do an image.  But if there are unilateral ear symptoms, with maybe only a CN7 deficit (other cranial nerves all fine), and no other Stroke findings as noted last posting, the diagnosis is pretty safe.  See also our recent post on Bell’s Palsy.

If the patient is young, you don’t worry about stroke.  But anybody <50 with zoster should get an HIV test.

**  Meniere’s Disease  —  I couldn’t find for sure if there should be an “apostrophe S” or not.  At any rate, this idiopathic condition may / may not be due to accumulation of fluid or ions in the inner ear, but at any rate, it’s not uncommon, can be disabling, and no true treatment exists.

Onset occurs between 20-40 years-old.  Recurrent attacks each last 20 minutes to 24 hrs. (distinguishing it from BPPV and Labyrinthitis).  Diagnosis requires the following:

• Recurrent Vertigo
• Sensorineural Hearing Loss
• Tinnitus or Ear Fullness

The tinnitus is usually low-pitched.  The ear symptoms assure us that the condition is peripheral (tho there is such a thing as a labyrinthine stroke; very rare).

For anyone with recurrent Vertigo, order formal audiometry, because hearing loss of Meniere’s may be progressive and permanent.  The most common pattern is low frequency hearing loss; some patients have both high- and low-frequency deficits, but maintain function in between.  Other conditions mimicking the vertigo of Meniere’s lack the hearing loss.

Acoustic Neuroma causes hearing loss similar to Meniere’s, but isn’t in our differential — there’s no vertigo, since tunor growth is so slow that the brain compensates.  There may, however, be a sense of imbalance or swaying.

“Cogan’s Syndrome,” is a very rare autoimmune condition with vertigo and interstitial keratitis.  If your Meniere’s patient gets bad eye pain, consider it.

**  Labyrinthine Concussion  —  Diagnosethis if symptoms begin at the moment of head trauma.  Don’t invoke it if the vertigo began down the line.

**  Perilymphatic Fistula  —  This very hard-to-diagnose leak of fluid from inner to middle ear can mimic many of the disorders in our table.  It’s caused by barotraumas, including bomb blasts, airplane flights, & blowing your nose or suppressing a sneeze.  Presentation ranges from fulminant vertigo, hearing loss, & tinnitus, to vague manifestations of those symptoms which come & go.  Prevalence is debated, as is diagnosis & treatment.

Moral: If a patient complains of vertigo that’s temporally related to some form of barotrauma, ask ENT to consider the possibility.

**  Middle Ear Conditions  —  If you see an otitis media in a patient with vertigo or hearing loss, treat it & follow symptoms.  If you see an ear canal completely impacted with cerumen, remove it and see if their chief complaint has disappeared.  Clues that might generate a surgical ENT referral include:

• Cholesteatoma  [click here for a picture]
• Loud Noise induces vertigo & nystagmus (Tullio phenomenon)
• Pressure on canal [push on the tragus] causes vertigo & nystagmus  (Hennebert sign)

Other unusual symptoms that might have bona fide ear pathology include pulsatile tinnitus along with the vertigo, and the complaint of, “I can hear my eyes moving.”  If all other thought content seems normal, send to ENT before Psych, to “R/O Superior semicircular canal dehiscence syndrome.”

**   Migrainous Vertigo.  Not uncommon, though I’m not sure what to make of this.  The only universal finding is recurrent vertigo attacks of at least moderate severity. Other parameters I’ve read about don’t seem helpful to me:

• Duration is “seconds, minutes, hours, or days.”  [how can this be useful?]
• “May or may not have an associated headache.”  [certainly not useful]
• Phonophobia & Photophobia.  [this may be somewhat convincing]
• Aura  [also convincing, but most migraines lack this]
• Nausea / Vomiting  [any vertigo causes this].
• Suspect if there’s already a diagnosis of migraine headache  [but can’t a migraine sufferer have another cause of vertigo?]

If a known migraine patient has vertigo during typical attacks of headache, well, fine.  But I’d never venture this diagnosis for recurrent episodic vertigo without first considering:

• Formal audiometry: if there’s hearing loss, it’s probably Meniere’s.
• Perilymphatic fistula might cause recurrent vertigo with hearing loss during the episodes, but maybe not at other times.  Worth an ENT referral.
• Multiple Sclerosis: send to Neuro to decide about ordering MRI, visual evoked responses, and/or spinal tap (for oligoclonal bands)

I also read about a cause of vertigo called “Recurrent Vestibulopathy,” in which attacks of vertigo recur.  Unknown etiology.  No gold standard for Dx.  Just medicalese for saying, “Well, you get recurrent attacks, we don’t know why, but it’s nothing serious, & you do get better.”  See “Migrainous Vertigo” above for proven diseases needing rule out.

SUMMARY APPROACH TO PATIENT WITH VERTIGO

So a patient presents with “dizziness,” & we’ve determined that it is indeed Vertigo per se.

1.  Decide if it’s BPPV.  If symptoms only occur with change of head position, and last <1 min., that’s it.

• Inquire about Stroke Sx (diplopia, dysarthria, dysphagia) — should be negative
• Examine Cranial Nerves & Cerebellar function  —  should be normal
• Examine the Ears  —  canals & TM should be normal
• Perform a Dix-Hallpike test to confirm BPPV, but even if negative, stand by your Dx.
• Attempt the Epley Maneuver; teach it for pt to do at home prn.  If no help, try it on the other side.  Try it again a few times.
• Still doesn’t work?  Well, if the Sx are truly <1 min duration, & only occur with head movement, reassure patient they’ll recover, & encourage the Epley anyway.

2.  If the vertigo is new & acute, no prior episodes, occurs without head movement, & persists (or recurs often, duration >1 min.), do one of the following:

• Dx Acute Labyrinthitis
• Send to an E.D. to R/O Stroke or Vertebral Artery Dissection.

Base this decision on any positives within the following table:

Stroke Risk Factors Age >60 Hypertension Diabetes Connective tissue disorder Stroke Symptoms diplopia dysarthria dysphagia Suggestion of Vertebral Artery Dissection Severe head or neck pain Recent trauma

Signs of Vertebro-Basilar Stroke on Exam EOM deficit Rotary or vertical nystagmus Horner’s (unilateral ptosis, miosis, absent sweating) Deficits in CN 9-12 (incl. hoarseness) Unilateral deficit in coordination Loss of pinprick: one side of face & opposite side of trunk Abnormal Romberg with eyes open If objective nystagmus is present on exam, look for abnormalities in the 3 Bedside Maneuvers

If the only positives are “Stroke Risk Factors,” it’s OK to not refer if you have reason to Dx Herpes Zoster Oticus:

• Unilateral ear pain, hearing loss, tinnitus
• Facial palsy (“Bell’s”)
• Vesicles on external ear or in canal [100% specific, but often absent]

Of course, if you see Otitis Media or other middle ear pathology, or Impacted Cerumen while examining the ear, you’ve got a diagnosis.

3.  If today’s episode of vertigo is a RECURRENCE (Hx of prior similar episodes), consider the following diagnoses:

** Meniere’s Disease

• Onset 20-40 y.o.
• Attacks last 20 minutes to 24 hrs.
• Diagnosis:  Vertigo + Sensorineural Hearing Loss + Tinnitus

**  Labyrinthine Concussion  —  Vertigo after head injury

**  Perilymphatic Fistula  —  Vertigo caused by prior barotrauma

• May be severe, or just come & go
• If suspicious, send to ENT for Dx & Tx

**  Middle Ear Diseases  —  Send to ENT if:

• Abnormal TM
• Cholesteatoma
• Loud Noise induces vertigo & nystagmus (Tullio phenomenon)
• Pressure on canal [push on the tragus] causes vertigo & nystagmus  (Hennebert sign)
• Weird symptoms, e.g. “I hear my eyes moving,” constant pulsatile tinnitus

**  Multiple Sclerosis  —  Ask re: prior episodes, dur. ≥24 hrs., of typical MS Sx:

• Sensory symptoms
• Lhermitte’s Sign
• Visual disturbances
• Double vision
• Weakness (focal); disturbed gait
• Urinary incontinence / retention
• Uhthoff Phenomenon: above symptoms worsen with heat (fever, hot showers)
• Check eyes (optic atrophy, afferent pupillary deficit)
• Pinprick testing on areas of sensory Sx

Any of above findings:  Send to Neuro for Dx

**  Migrainous Vertigo  —  Recurrent vertigo, moderate-severe.

• Uncertain reality of condition
• Vertigo w/ phonophobia & photophobia
• Vertigo w/ aura
• Vertigo in migraine sufferer
• Let Neuro Dx & Tx

**  Stroke ???   (maybe past episodes were TIAs, & this is the big one)

4.  If the patient complains of vertigo that’s now resolved (maybe it was present when they called for an appointment), consider the same diseases as in #3 above.

 

Work up vertebro-basilar insufficiency with MRI brain & MRA (head & neck) for anyone with:

• Hx of Stroke Symptoms during the vertigo
• Maybe if significant Stroke Risk Factors
• NOT if prominent ear Sx along with the vertigo (address Meniere’s & other ear conditions above)

And that’s it for Vertigo.  Hope it wasn’t too dizzying.