Vertigo

Vertigo: Excerpt from Handbook of Signs & Symptoms (Third Edition)

Vertigo is an illusion of movement in which the patient feels that he’s revolving in space (subjective vertigo) or that his surroundings are revolving around him (objective vertigo). He may complain of feeling pulled sideways, as though drawn by a magnet.

A common symptom, vertigo usually begins abruptly and may be temporary or permanent, mild or severe. It may worsen when the patient moves and subside when he lies down. It’s often confused with dizziness — a sensation of imbalance and light-headedness that is nonspecific. However, unlike dizziness, vertigo is commonly accompanied by nausea, vomiting, nystagmus, and tinnitus or hearing loss. Although the patient’s limb coordination is unaffected, vertiginous gait may occur.

Vertigo may result from a neurologic or otologic disorder that affects the equilibratory apparatus (the vestibule, semicircular canals, eighth cranial nerve, vestibular nuclei in the brain stem and their temporal lobe connections, and eyes). However, this symptom may also result from alcohol intoxication, hyperventilation, and postural changes (benign postural vertigo). It may also be an adverse effect of certain drugs, tests, or procedures.

History and physical examination

Ask your patient to describe the onset and duration of his vertigo, being careful to distinguish this symptom from dizziness. Does he feel that he’s moving or that his surroundings are moving around him? How often do the attacks occur? Do they follow position changes, or are they unpredictable? Find out if the patient can walk during an attack, if he leans to one side, and if he’s ever fallen. Ask if he experiences motion sickness and if he prefers one position during an attack. Obtain a recent drug history, and note any evidence of alcohol abuse.

Perform a neurologic assessment, focusing particularly on eighth cranial nerve function. Observe the patient’s gait and posture for abnormalities.

Medical causes

Acoustic neuroma

Acoustic neuroma is a tumor of the eighth cranial nerve that causes mild, intermittent vertigo and unilateral sensorineural hearing loss. Other findings include tinnitus, postauricular or suboccipital pain, and — with cranial nerve compression — facial paralysis.

Benign positional vertigo

With benign positional vertigo, debris in a semicircular canal produces vertigo on head position change, which lasts a few minutes. It’s usually temporary and can be effectively treated with positional maneuvers.

Brain stem ischemia

Brain stem ischemia produces sudden, severe vertigo that may become episodic and later persistent. Associated findings include ataxia, nausea, vomiting, increased blood pressure, tachycardia, nystagmus, and lateral deviation of the eyes toward the side of the lesion. Hemiparesis and paresthesia may also occur.

Head trauma

Persistent vertigo, occurring soon after injury, accompanies spontaneous or positional nystagmus and, if the temporal bone is fractured, hearing loss. Associated findings include headache, nausea, vomiting, and decreased (LOC). Behavioral changes, diplopia or visual blurring, seizures, motor or sensory deficits, and signs of increased intracranial pressure may also occur.

Herpes zoster

Infection of the eighth cranial nerve produces sudden onset of vertigo accompanied by facial paralysis, hearing loss in the affected ear, and herpetic vesicular lesions in the auditory canal.

Labyrinthitis

Severe vertigo begins abruptly with labyrinthitis, an inner ear infection. Vertigo may occur in a single episode or may recur over months or years. Associated findings include nausea, vomiting, progressive sensorineural hearing loss, and nystagmus.

Ménière’s disease

With Ménière’s disease, labyrinthine dysfunction causes abrupt onset of vertigo, lasting minutes, hours, or days. Unpredictable episodes of severe vertigo and unsteady gait may cause the patient to fall. During an attack, any sudden motion of the head or eyes can precipitate nausea and vomiting.

Multiple sclerosis (MS)

Episodic vertigo may occur early and become persistent. Other early findings include diplopia, visual blurring, and paresthesia. MS may also produce nystagmus, constipation, muscle weakness, paralysis, spasticity, hyperreflexia, intention tremor, and ataxia.

Seizures

Temporal lobe seizures may produce vertigo, usually associated with other symptoms of partial complex seizures.

Vestibular neuritis

With vestibular neuritis, severe vertigo usually begins abruptly and lasts several days, without tinnitus or hearing loss. Other findings include nausea, vomiting, and nystagmus.

Other causes

Diagnostic tests

Caloric testing (irrigating the ears with warm or cold water) can induce vertigo.

Drugs and alcohol

High or toxic doses of certain drugs or alcohol may produce vertigo. These drugs include salicylates, aminoglycosides, antibiotics, quinine, and hormonal contraceptives.

Surgery and other procedures

Ear surgery may cause vertigo that lasts for several days. Also, administration of overly warm or cold eardrops or irrigating solutions can cause vertigo.

Special considerations

Place the patient in a comfortable position, and monitor his vital signs and LOC. Keep the side rails up if he’s in bed, or help him to a chair if he’s standing when vertigo occurs. Darken the room and keep him calm. Administer drugs to control nausea and vomiting and meclizine or dimenhydrinate to decrease labyrinthine irritability.

Prepare the patient for diagnostic tests, such as electronystagmography, EEG, and X-rays of the middle and inner ears.

Pediatric pointers

Ear infection is a common cause of vertigo in children. Vestibular neuritis may also cause this symptom.

Book Source Details

• Book Title: Handbook of Signs & Symptoms (Third Edition)
• Author(s): Springhouse
• Year of Publication: 2006
• Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2006 Lippincott Williams & Wilkins.

More About Vertigo

• Back to disease: Vertigo: Introduction
• Next Book Extract About Vertigo: Syncope (A Pocket Manual of Differential Diagnosis)
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Handbook of Signs & Symptoms (Third Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2006 ISBN: 1-58255-402-1

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