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ULY CLINIC

20 Septemba 2025, 01:47:46

Vertigo

Vertigo is an illusion of movement in which a patient feels either that he is moving (subjective vertigo) or that his surroundings are moving (objective vertigo). Patients may describe sensations of being pulled sideways, tilted, or spun around. Vertigo differs from nonspecific dizziness, as it is often associated with nausea, vomiting, nystagmus, tinnitus, or hearing loss, while limb coordination usually remains intact.

Pathophysiology

Vertigo results from dysfunction in the vestibular system, which includes:

Peripheral components: Vestibule, semicircular canals, and eighth cranial (vestibulocochlear) nerve.
Central components: Vestibular nuclei in the brainstem, cerebellar connections, and temporal lobe projections.

Peripheral vertigo is commonly caused by inner ear disorders affecting the vestibular apparatus (e.g., benign positional vertigo, labyrinthitis, Ménière’s disease), while central vertigo arises from brainstem or cerebellar lesions (e.g., multiple sclerosis, stroke). Additional causes include toxic, metabolic, or postural factors and medication effects.

History and Physical Examination

History

Characterize the vertigo: subjective vs. objective, onset, duration, and frequency.
Identify triggers: head position changes, motion sickness, or unpredictable episodes.
Assess functional impact: gait disturbance, falls, or leaning to one side.
Obtain drug and alcohol history, recent trauma, or systemic illnesses.

Physical Examination

Neurologic assessment: cranial nerves (especially VIII), coordination, and balance.
Observe gait, posture, and nystagmus.
Otologic examination: inspect ears for infection or vesicular lesions.

Medical causes

Cause	Pathophysiology	Key Clinical Findings
Acoustic neuroma	Benign tumor of VIII cranial nerve → gradual nerve compression → vestibular dysfunction	Mild, intermittent vertigo; unilateral sensorineural hearing loss, tinnitus, facial paralysis
Benign positional vertigo	Debris (otoconia) in semicircular canals → abnormal endolymph movement → vertigo triggered by head position	Brief vertigo episodes with head movement, usually minutes long; resolves with positional maneuvers
Brainstem ischemia	Reduced perfusion → transient dysfunction of vestibular nuclei	Sudden severe vertigo, ataxia, nystagmus, lateral deviation of eyes, hemiparesis, nausea, vomiting
Head trauma	Vestibular labyrinth or temporal bone injury → inflammation or nerve damage	Persistent vertigo, nystagmus, hearing loss, headache, nausea, vomiting, altered LOC
Herpes zoster (Ramsay Hunt syndrome)	VZV infection of VIII cranial nerve → inflammation and nerve injury	Vertigo, facial paralysis, hearing loss, vesicular lesions in auditory canal
Labyrinthitis	Bacterial or viral infection → inflammation of vestibular labyrinth	Severe abrupt vertigo, nausea, vomiting, sensorineural hearing loss, nystagmus
Ménière’s disease	Endolymphatic hydrops → fluctuating pressure in vestibular apparatus	Recurrent vertigo lasting minutes to hours/days, hearing loss, tinnitus, nausea, unsteady gait
Multiple sclerosis (MS)	Demyelination in CNS → impaired vestibular conduction	Episodic vertigo, diplopia, visual blurring, paresthesia, nystagmus, ataxia, tremor
Seizures (temporal lobe)	Abnormal cortical activity → vertiginous aura	Vertigo associated with other seizure symptoms (confusion, automatisms)
Vestibular neuritis	Viral or post-viral inflammation of vestibular nerve	Abrupt, severe vertigo lasting days, nausea, vomiting, nystagmus; hearing intact

Other causes

Diagnostic tests: Caloric testing or ear irrigation can induce vertigo.
Drugs and alcohol: Toxic doses of salicylates, aminoglycosides, antibiotics, quinine, hormonal contraceptives.
Surgery/procedures: Ear surgery or excessively warm/cold eardrops.

Special considerations

Place patient in a safe, comfortable position; monitor vital signs and LOC.
Use darkened rooms and maintain calm.
Administer antiemetics for nausea and meclizine or dimenhydrinate for labyrinthine irritation.
Prepare for diagnostic tests: electronystagmography, EEG, and temporal bone imaging.

Patient counseling

Advise the patient to move with assistance and avoid sudden positional changes.
Avoid hazardous activities until vertigo resolves.
Encourage adherence to therapy for underlying causes.

Pediatric pointers

Commonly caused by ear infections or vestibular neuritis.
Observe for signs of balance disturbance and recurrent vertigo.

References

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