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peripheral vertigo
Etiology:
1) benign positional vertigo
- most common
- no hearing loss
- duration of symptoms: minutes to hours; < 24 hours; generally 10-30 seconds
2) Meniere's disease
- hearing loss
- tinnitus
- duration of symptoms: minutes to hours; < 24 hours
- symptoms resolve completely between episodes
3) labyrinthitis
- hearing loss
- duration of symptoms > 24 hours (unremitting)
- post viral infection
4) vestibular neuronitis
- no hearing loss
- duration of symptoms > 24 hours
- post viral infection
6) Herpes zoster oticus (Ramsay Hunt syndrome type 2)
- unilateral disorder
- initially, deep burning pain of ear
- drainage of clear fluid from ear may occur
- ipsilateral facial paralysis (Bell's palsy)
- vertigo, tinnitus, hearing loss (ipsilateral)
- horizontal torsional nystagmus
7) acoustic neuroma of cranial nerve 8
8) ischemia
9) trauma
10) toxins
Clinical manifestations:
1) general
a) nausea/vomiting
b) unsteadiness
c) hearing loss
d) oscillopsia
2) distinguishing features from central vertigo
a) nystagmus
- unidirectional; fast phase opposite lesion (except Meniere's disease where direction is variable)
- purely horizontal nystagmus without torsional component is uncommon
- vertical or purely torsional nystagmus is NEVER present
b) visual fixation inhibits nystagmus & vertigo
c) severity of vertigo is generally marked
d) direction of spin is toward fast phase
e) direction of fall is toward slow phase
f) duration of symptoms is finite (minutes, days, weeks), but recurrent
g) tinnitus &/or hearing loss is often present
h) associated CNS abnormalities are NOT present
i) Hallpike maneuver
- ellicited vertigo fatigues with peripheral vertigo but does not fatigue with central vertigo
j) head impulse testing shows satch-up saccades with peripheral vertigo but not central vertigo [3]
Management:
1) depends upon specific type
2) bed rest:
- if vertigo persists beyond a few days, ambulation (despite discomfort) to induce central compensatory mechanisms
3) systematic exercise for chronic symptoms
- vestibular rehabilitation
4) pharmaceutical agents
a) antihistamines
1] meclizine
2] dimenhydrinate
3] promethazine
b) centrally acting anticholinergics
- scopolamine
c) benzodiazepines
- diazepam (Valium)
d) prednisone for labyrinthitis [3]
5) surgery is rarely necessary
Related
labyrinthitis
Meniere's disease; labyrinthine hydrops; endolymphatic hydrops
vestibular neuronitis (acoustic neuritis)
Specific
benign positional vertigo; benign paroxysmal positional vertigo
recurrent spontaneous vertigo; benign recurrent vertigo; recurrent vestibular vertigo
General
vertigo
References
- Saunders Manual of Medical Practice, Rakel (ed), WB Saunders,
Philadelphia, 1996, pg 1013-15
- Harrison's Principles of Internal Medicine, 14th ed.
Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 104-107
- Medical Knowledge Self Assessment Program (MKSAP) 19.
American College of Physicians, Philadelphia 2021
- Medical Knowledge Self Assessment Program (MKSAP) 19
Board Basics. An Enhancement to MKSAP19.
American College of Physicians, Philadelphia 2022