Vertigo

Context

Vertigo is a common problem. A systematic review of 20 studies of the epidemiology of balance disorders in the community estimated the lifetime prevalence of vertigo to be 3–10% in adults (1). Consequently, it is a frequent presenting problem and acute vertigo can account for up to 12% of neurological presentations to the Emergency department (2).

It is difficult to separate vertigo from the general diagnosis of dizziness and vertigo is also an area of Emergency Medicine that is poorly understood by many Emergency Physicians (EPs). The misdiagnosis rates for patients with vertigo is estimated between 74 to 81% (3).

Definition

Vertigo is a false perception, experienced by the patient, of rotation or movement of the external world (objective vertigo) or of the individual in space (subjective vertigo). It always implies an imbalance in the vestibular system although the symptom does not indicate where the imbalance originates.

It is vital that the EP differentiates vertigo from dizziness, which is a common lay description covering a multitude of meanings. It is useful to classify dizziness into different clinical categories. The most commonly described classification (4) is as below:

1. Vertigo – an illusion of motion of either the subject or the environment
2. Presyncope – a feeling of impending faint or loss of consciousness
3. Disequilibrium – impaired balance and gait in the absence of abnormal head sensation (dizziness of the feet!)
4. Light-headedness – a non-specific description of symptoms that cannot be identified as one of the above types

Of these four types, vertigo accounts for approximately 30% of dizzy patients in primary care (5). Recent prospective studies using a large database reported dizziness as a presenting symptom in 47% to 75% of patients with posterior circulation strokes (6, 7).

Learning Bite

Dizziness is not a diagnosis and the EP must learn to differentiate this symptom into specifically defined types.

Vertigo can be physiological or pathological. Pathological vertigo is usefully divided into two types; central and peripheral. Differentiation of these types is crucial to the investigation and management of a patient with vertigo presenting to the ED.

The ability of the body to maintain a position of equilibrium relies on sensory inputs from the vestibular apparatus, visual system and proprioceptive stimuli from the neck and rest of the body. The vestibular apparatus consists of the membranous labyrinth contained within the bony labyrinth lying in the petrous temporal bone, which connects via the vestibulocochlear nerve to the vestibular nuclei in the brainstem. These nuclei interconnect with neurones in the cerebellum, spinal cord and cerebral cortex.

The membranous labyrinth consists of the three semicircular canals and two chambers, the saccule and utricle. Flow of fluid (endolymph) in the canals stimulates cilia attached to a sensory organ located in the ampulla of each canal, the crista ampullaris. In the saccule and utricle, movement of calcified calcium carbonate crystals (statoconia or otoliths) stimulates cilia of another sensory organ, the macula. Therefore movement of the head in any plane modifies neural impulses transmitted via the vestibular nerve, connected to each of the sensory organs, to nuclei in the brain stem. Vertigo results from an imbalance of either the received signals or information processing in the brainstem.

Learning Bite

Vertigo is caused by an imbalance in either the nerve impulses transmitted by the vestibular system or in the processing of this and other sensory inputs in the brain.

Nystagmus is an important clinical sign which may indicate the underlying cause of vertigo. It consists of an initial smooth movement in one direction followed by a rapid movement (saccade) in the opposite direction. Nystagmus is described according to the direction of its fast component. The fast component is also interchangeably used with the term beat, for example, when the fast component is downwards = downbeat nystagmus. Nystagmus can be physiological (e.g. looking out of the window of a moving train) or pathological. It is normal to see a few self-limiting beats of nystagmus on extreme lateral gaze. When pathological, it is very useful in determining whether the vertigo has a central or peripheral cause.

Learning Bite

Nystagmus is a useful clinical sign in determining whether vertigo has a central or peripheral origin.

The first decision for the EP, when assessing a patient, is to differentiate vertigo from dizziness of another type. A patient’s description of the sensation of vertigo may be subjective [I feel like I am moving (or spinning)] or objective [I feel like the world is moving (or spinning)]. Vertigo is not light-headedness when moving to a standing position (orthostatic hypotension) or a feeling that one is about to pass out (pre-syncope).

The next step is to try and differentiate between central and peripheral vertigo. In general terms, patients with central vertigo require early radiological investigations and hospital admission, whereas most patients with peripheral vertigo can be safely discharged home with appropriate follow-up.

Learning Bite

Differentiating between central and peripheral vertigo is the cornerstone of the diagnosis and management of patients with vertigo in the ED.

The first clues in deciding whether there is a central or peripheral cause is provided by the history (8);

	Peripheral vertigo	Central vertigo
Onset	Sudden	Occasionally very sudden but usually gradual
Nausea and vomiting	Severe	Variable, usually minimal systemic upset
Effect of head position	Worsened by position, often single critical position	Little change, associated with more than one position
Associated auditory findings (aural fullness, tinnitus, hearing loss etc.)	May be present	Rare
Associated neurological symptoms (dysarthria/ diplopia, hemiparesis etc.)	None	Usually present

Learning Bite

Speed of onset, systemic upset, effect of head position and associated auditory and neurological symptoms are the key features of the history which help to differentiate central from peripheral vertigo.

Other factors which are useful when taking a history are:

• Is the episode a new event or is there a history of recurrent episodes? For example, short spells of sudden onset vertigo associated with a change in head position are likely to be caused by benign positional paroxysmal vertigo (BPPV)
• Past history of vascular disease, hypertension or stroke, all increase the likelihood of a central cause for vertigo
• Recent trauma or infection of the ear makes a peripheral cause more likely
• Drugs that are associated with vertigo include ACE inhibitors, amiodarone, aminoglycosides, beta blockers, cocaine, phenytoin, salicylates, sildenafil

Examination of the patient must include a general assessment, particularly of the cardiovascular system as vertigo may be associated with conditions such as vascular disease and atrial fibrillation.

A general neurological examination may reveal cranial nerve or peripheral nerve deficits associated with a cerebrovascular event or neoplastic lesion e.g. cerebellopontine tumours may present with both vertigo and 5th, 7th cranial nerve palsies. Limb ataxia, revealed by an abnormal finger-nose or heel shin test, suggests cerebellar disease.

The ears must be examined for evidence of vesicles (Ramsay Hunt syndrome) or presence of a tympanic membrane perforation or cholesteatoma.

Gross hearing should be tested by placing a ticking wristwatch (alternatives are whispering or rubbing the fingers together) close to each ear. If a reduction in hearing is found in one ear, then Webers and Rinnes tests must be performed. Watch this video for a standard technique looking for evidence of sensorineural hearing loss. Hearing loss or tinnitus almost always indicates a peripheral cause for vertigo.

Learning Bite

Examination of a patient with vertigo must include otoscopy, hearing assessment and examination of the cardiovascular and neurological systems, as abnormal findings may indicate the cause of the vertigo.

Nystagmus

The HiNTs examination is a clinical test to differentiate between central and peripheral causes, in patients with vertigo. In some studies it has shown a greater sensitivity than MRI to exclude posterior circulation stroke in these patients.(9)

The HiNTs exam comprises three elements, head impulse, nystagmus, and test-of-skew. It is only valid in patients who have continuous, ongoing vertigo at the time of assessment.

Head impulse

The patient stands in front of the examiner, with their head held between the examiner’s hands. The patient is asked to fixate on the tip of the examiner’s nose, and their head is rotated 20 to 40 degrees in each direction, before being rapidly brought back to neutral.

The normal response, which is preserved in posterior stroke, is to maintain a continuous direction of gaze. In peripheral causes of vertigo, the vestibulo-ocular reflex is disrupted, so they lose eye contact and correct with a saccade.

Nystagmus

The patient is asked to look straight ahead, to the left, and to the right, while the direction of nystagmus is observed.

Nystagmus due to a peripheral cause is always horizontal, and will always have the fast phase in the same direction, and is often accentuated when the patient looks in the direction of the fast phase. Any vertical or rotational element, or if the direction changes with direction of gaze, is suggestive of a central cause of vertigo.

Test-of-skew

The patient stands in front of the examiner and is asked to fixate on the tip of their nose. The eyes are alternately covered.

In a central cause of vertigo, the vertical alignment of the eyes may be different, and a vertical corrective movement will be seen as the eye is covered and uncovered. In peripheral causes, this finding is absent.

A video demonstration of the examination can be viewed here.

Acute Vestibular Neuritis

The most common presentation of prolonged peripheral vertigo seen in the ED. This problem typically occurs in young and middle aged adults and is postulated to be caused by a viral infection, possibly herpes simplex. It is caused by acute inflammation of the vestibular nerve (10) and is correctly termed vestibular neuritis notlabyrinthitis, a label which is often confusingly used and which correctly refers to a separate condition.

The presentation is typical of peripheral vertigo;

• acute onset within minutes / hours
• exacerbated by movements of the head
• accompanying severe nausea and vomiting
• no other neurological deficit

There is however no disturbance of hearing which is often otherwise found in peripheral vertigo.

Spontaneous nystagmus is found in 2/3 of patients (11) and is peripheral in character i.e.

• horizontal
• unidirectional
• suppressed by visual fixation
• fast phase away from the affected ear and most evident when looking to the unaffected side (see vnsmall.avi at http://www.dizziness-and-balance.com/sitedvd.htm)

Learning Bite

Acute vestibular neuritis is caused by inflammation of the vestibular nerve and is a separate condition to acute labyrinthitis.

Cerebellar Stroke

An important differential diagnosis to exclude. Compared to acute vestibular neuritis, patients are usually older with pre-existing risk factors e.g. atrial fibrillation, diabetes etc.

Onset of symptoms is hyperacute within a few seconds.

The vertigo is central in character i.e.

• unaffected by head position
• little systemic upset
• generally there are co-existing neurological deficits e.g. ataxia, depressed level of consciousness. Rarely, vertigo may be the only finding.

Nystagmus is also typically central:

• • Horizontal, rotatory or vertical. See video here.
• Bidirectional
• Not suppressed by visual fixation

Learning Bite

Patients with a cerebellar stroke or TIA usually have co-existing risk factors and present with very sudden onset of central vertigo and nystagmus.

Otomastoiditis

Both acute and chronic ear infections may either directly infect or release toxins into the labyrinth, causing an acute labyrinthitis and peripheral vertigo. The patient will normally complain of fever, ear pain, headache and hearing loss. Otoscopy will reveal evidence of infection.

Paroxysmal Vertigo

Paroxysmal Vertigo can be recurrent or of first onset.

For patients presenting with paroxysmal vertigo, it is useful to subdivide them into vertigo without and with hearing loss.

Without hearing loss

Transient Ischaemic Attack (TIA)

Although a TIA rarely presents as isolated central vertigo, the temporary features are identical to those of cerebellar stroke.

Benign Positional Paroxysmal Vertigo (BPPV)

Very common and caused by the dislocation of statoconia into the posterior semicircular canal. Vertigo is related to changes in head position e.g. turning over in bed or reaching upwards, and typically affects women between 60 and 70.

The vertigo is peripheral and short lasting with fatiguing nystagmus in one direction. Diagnosis is confirmed by the Hallpike manoeuvre and can be treated with the Epley manoeuvre which, once taught, can be effectively self administered (12). Both manoeuvres can be viewed here http://www.emedicine.com/emerg/topic57.htm

Learning Bite

The vertigo associated with BPPV is short lasting and characteristically related to changes in head position.

Migraine

Migraine typically presents with episodic headaches accompanied by photophobia, nausea and vomiting. Vertigo with either central or peripheral features (13) may occur in up to 25% of patients with acute migrainous vertigo (14).

With Hearing Loss

Meniere’s Disease

The commonest cause of acute paroxysmal vertigo with hearing loss and is caused by an increase in the pressure and volume of endolymph. A patient will normally present with an initial aura of aural fullness, followed by increasing tinnitus, fluctuating hearing loss and peripheral vertigo. It is a clinical diagnosis and all investigations serve to rule out other diagnoses.

Acoustic Neuroma

Acoustic neuroma is more correctly called a vestibular schwannoma – a benign tumour of myelin forming cells of the vestibulocochlear nerve. Unusually for a central cause of vertigo, gradual progressive hearing loss and tinnitus are common symptoms. Episodic central vertigo may also be a feature.

It is not always possible to make a definite diagnosis in patients with vertigo. The key to managing patients with vertigo in the ED is to separate central from peripheral vertigo. All patients with central vertigo need further investigation either as an in-patient or urgent out-patient basis.

If peripheral vertigo is diagnosed, most patients can be discharged home with arrangements for follow-up either with their GP or in an appropriate ENT clinic, provided they have an appropriate carer to look after them. Some patients may benefit from occupational therapy and/or social services. A few required admission for intravenous rehydration due to inability to tolerate oral fluids even after treatment.

In all cases of prolonged vertigo, both the sensation of vertigo and the commonly associated nausea and vomiting, are distressing to the patient. Vestibular suppressants and antiemetics are the mainstays of treatment.

Vestibular suppressants include low dose benzodiazepines (e.g. diazepam 2mg, lorazepam 0.1mg), anticholinergics (e.g. hyoscine) and antihistamines with anticholinergic (and antiemetic) properties e.g. cinnarizine, cyclizine. Antiemetics such as prochlorperazine and metoclopramide are also commonly used but may be associated with acute dystonic reactions.

It is widely thought that recovery from, and brain adaptation to, short lasting peripheral vestibular dysfunction (e.g. vestibular neuritis) may be hampered by immobilisation and the continuing use of vestibular suppressants (15).

Physical therapies utilising vestibular exercises have been shown to significantly improve symptoms, and function, for peripheral causes of vertigo, when compared to controls, or no intervention.

Patients with other than mild, short-lived, self-limiting vertigo because of vestibular dysfunction may, therefore, benefit from vestibular exercises.

In a simple exercise, patients with acute peripheral vertigo can be advised to focus on an object, while moving their head side to side then up and down. Movements should be slow and slight to start with to prevent nausea, but can gradually be increased and repeated for several minutes 2-3 times per day.

Specific management options exist for several causes of vertigo.

BPPV

Canalith repositioning manoeuvres have been used in an attempt to move canaliths out of the semicircular canal to treat BPPV.

The Epley manoeuvre is used to treat BPPV due to posterior canal canaliths (>90% of cases of BPPV) and has been shown to be safe, and effective, at least in the short term. It can be used in the ED. However, recurrence rates may be as high as 50% over 5 years, although the manoeuvre can be repeated or even taught.

Anterior canal BPPV is rare, and can be a complication of canalith repositioning manoeuvres because the canaliths migrate from the posterior canal into the anterior canal. Such cases may respond to other specialist manoeuvres.

The Epley (canalith repositioning) manoeuvre.

Vestibular neuritis

There is evidence that corticosteroids (methylprednisolone) given acutely may improve longer-term vestibular function in patients with presumed viral vestibular neuritis.(16)

Meniere’s Disease

Betahistine, or diuretics, are often prescribed for dizziness symptoms in Meniere’s Disease, and these are generally well tolerated; though evidence of the efficacy of these treatments is lacking.

Specialist treatments such as intratympanic gentamicin may be of benefit in selected cases.

• Dizziness is not a diagnosis. It must be differentiated into one of four more specific types to aid assessment and management. (level of evidence 5)
• Separation of vertigo into central and peripheral types is the key to investigating and managing patients presenting to the ED with vertigo. (level of evidence 4)
• Nystagmus is a useful clinical sign and identification of the effect of visual fixation, fatigability, the direction and duration of nystagmus are all features which help to differentiate a central from a peripheral cause of vertigo. (level of evidence 5)
• Laboratory investigations are very unlikely to be of use in the diagnosis of vertigo. (level of evidence 4)
• Vestibular neuritis is caused by an acute inflammation of the vestibular nerve and is a separate entity to acute labyrinthitis, which is caused by spread of infection from the middle ear. (level of evidence 5)
• Patients presenting with a cerebellar stroke or TIA usually have co-existing risk factors and describe a very sudden onset of central vertigo and nystagmus. (level of evidence 5)
• Patients prescribed a vestibular suppressant for vertigo should be encouraged to mobilise and to use their medication for the shortest time possible. (level of evidence 5)

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