Vertigo

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This article is about the type of dizziness. For the film of the same name, see Vertigo (film). For other uses, see Vertigo (disambiguation).Not to be confused with Vitiligo, a skin condition in which a loss of melanin pigment occurs.
Vertigo
Optokinetic nystagmus.gif
Horizontal nystagmus,
a sign that may accompany vertigo
Pronunciation
Specialty Otorhinolaryngology
Symptoms Feeling of spinning or swaying, vomiting, difficulty walking [1] [2]
Causes Benign paroxysmal positional vertigo (BPPV), Ménière's disease, vestibular neuritis, stroke, brain tumors, brain injury, multiple sclerosis, migraine [1] [2]
Differential diagnosis Presyncope, disequilibrium, non-specific dizziness [2]
Frequency20–40% at some point [3]

Vertigo is a condition in which a person has the sensation of movement or of surrounding objects moving when they are not. [1] Often it feels like a spinning or swaying movement. [1] [2] It may be associated with nausea, vomiting, perspiration, or difficulties walking. [2] It is typically worse when the head is moved. [2] Vertigo is the most common type of dizziness. [2]

Contents

The most common disorders that result in vertigo are benign paroxysmal positional vertigo (BPPV), Ménière's disease, and vestibular neuritis. [1] [2] Less common causes include stroke, brain tumors, brain injury, multiple sclerosis, migraines, trauma, and uneven pressures between the middle ears. [2] [4] [5] Physiologic vertigo may occur following being exposed to motion for a prolonged period such as when on a ship or simply following spinning with the eyes closed. [6] [7] Other causes may include toxin exposures such as to carbon monoxide, alcohol, or aspirin. [8] Vertigo typically indicates a problem in a part of the vestibular system. [2] Other causes of dizziness include presyncope, disequilibrium, and non-specific dizziness. [2]

Benign paroxysmal positional vertigo is more likely in someone who gets repeated episodes of vertigo with movement and is otherwise normal between these episodes. [9] Benign vertigo episodes generally last less than one minute. [2] The Dix-Hallpike test typically produces a period of rapid eye movements known as nystagmus in this condition. [1] In Ménière's disease there is often ringing in the ears, hearing loss, and the attacks of vertigo last more than twenty minutes. [9] In vestibular neuritis the onset of vertigo is sudden, and the nystagmus occurs even when the person has not been moving. [9] In this condition vertigo can last for days. [2] More severe causes should also be considered, [9] especially if other problems such as weakness, headache, double vision, or numbness occur. [2]

Dizziness affects approximately 20–40% of people at some point in time, while about 7.5–10% have vertigo. [3] About 5% have vertigo in a given year. [10] It becomes more common with age and affects women two to three times more often than men. [10] Vertigo accounts for about 2–3% of emergency department visits in the developed world. [10]

Classification

Vertigo is classified into either peripheral or central depending on the location of the dysfunction of the vestibular pathway, [11] although it can also be caused by psychological factors. [12]

Vertigo can also be classified into objective, subjective, and pseudovertigo. Objective vertigo describes when the person has the sensation that stationary objects in the environment are moving. [13] Subjective vertigo refers to when the person feels as if they are moving. [13] The third type is known as pseudovertigo, an intensive sensation of rotation inside the person's head. While this classification appears in textbooks, it is unclear what relation it has to the pathophysiology or treatment of vertigo. [14]

Peripheral

Vertigo that is caused by problems with the inner ear or vestibular system, which is composed of the semicircular canals, the vestibule (utricle and saccule), and the vestibular nerve is called "peripheral", "otologic", or "vestibular" vertigo. [15] [16] The most common cause is benign paroxysmal positional vertigo (BPPV), which accounts for 32% of all peripheral vertigo. [16] Other causes include Ménière's disease (12%), superior canal dehiscence syndrome, vestibular neuritis, and visual vertigo. [16] [17] Any cause of inflammation such as common cold, influenza, and bacterial infections may cause transient vertigo if it involves the inner ear, as may chemical insults (e.g., aminoglycosides) [18] or physical trauma (e.g., skull fractures). Motion sickness is sometimes classified as a cause of peripheral vertigo.[ citation needed ]

People with peripheral vertigo typically present with mild to moderate imbalance, nausea, vomiting, hearing loss, tinnitus, fullness, and pain in the ear. [16] In addition, lesions of the internal auditory canal may be associated with facial weakness on the same side. [16] Due to a rapid compensation[ clarification needed ] process, acute vertigo as a result of a peripheral lesion tends to improve in a short period of time (days to weeks). [16]

Central

Vertigo that arises from injury to the balance centers of the central nervous system (CNS), often from a lesion in the brainstem or cerebellum, [9] [15] [19] is called "central" vertigo and is generally associated with less prominent movement illusion and nausea than vertigo of peripheral origin. [20] Central vertigo may have accompanying neurologic deficits (such as slurred speech and double vision), and pathologic nystagmus (which is pure vertical/torsional). [16] [20] Central pathology can cause disequilibrium, which is the sensation of being off balance. The balance disorder associated with central lesions causing vertigo is often so severe that many people are unable to stand or walk. [16]

A number of conditions that involve the central nervous system may lead to vertigo including: lesions caused by infarctions or hemorrhage, tumors present in the cerebellopontine angle such as a vestibular schwannoma or cerebellar tumors, [9] [11] epilepsy, [21] cervical spine disorders such as cervical spondylosis, [11] degenerative ataxia disorders, [9] migraine headaches, [9] lateral medullary syndrome, Chiari malformation, [9] multiple sclerosis, [9] parkinsonism, as well as cerebral dysfunction. [16] Central vertigo may not improve or may do so more slowly than vertigo caused by disturbance to peripheral structures. [16] Alcohol can result in positional alcohol nystagmus (PAN).

Signs and symptoms

A drawing showing the sensation of vertigo 3D still showing Vertigo.jpg
A drawing showing the sensation of vertigo

Vertigo is a sensation of spinning while stationary. [22] It is commonly associated with nausea or vomiting, [21] unsteadiness (postural instability), [19] falls, [23] changes to a person's thoughts, and difficulties in walking. [24] Recurrent episodes in those with vertigo are common and frequently impair the quality of life. [10] Blurred vision, difficulty in speaking, a lowered level of consciousness, and hearing loss may also occur. The signs and symptoms of vertigo can present as a persistent (insidious) onset or an episodic (sudden) onset. [25]

Persistent onset vertigo is characterized by symptoms lasting for longer than one day [25] and is caused by degenerative changes that affect balance as people age. Nerve conduction slows with aging, and a decreased vibratory sensation is common as a result. [26] Additionally, there is a degeneration of the ampulla and otolith organs with an increase in age. [27] Persistent onset is commonly paired with central vertigo signs and symptoms. [25]

The characteristics of an episodic onset vertigo are indicated by symptoms lasting for a smaller, more memorable amount of time, typically lasting for only seconds to minutes. [25]

Pathophysiology

The neurochemistry of vertigo includes six primary neurotransmitters that have been identified between the three-neuron arc [28] that drives the vestibulo-ocular reflex (VOR). Glutamate maintains the resting discharge of the central vestibular neurons and may modulate synaptic transmission in all three neurons of the VOR arc. Acetylcholine appears to function as an excitatory neurotransmitter in both the peripheral and central synapses. Gamma-Aminobutyric acid (GABA) is thought to be inhibitory for the commissures of the medial vestibular nucleus, the connections among the cerebellar Purkinje cells, the lateral vestibular nucleus, and the vertical VOR.

Three other neurotransmitters work centrally. Dopamine may accelerate vestibular compensation. Norepinephrine modulates the intensity of central reactions to vestibular stimulation and facilitates compensation. Histamine is present only centrally, but its role is unclear. Dopamine, histamine, serotonin, and acetylcholine are neurotransmitters thought to produce vomiting. [9] It is known that centrally acting antihistamines modulate the symptoms of acute symptomatic vertigo. [29]

Diagnosis

Tests for vertigo often attempt to elicit nystagmus and to differentiate vertigo from other causes of dizziness such as presyncope, hyperventilation syndrome, disequilibrium, or psychiatric causes of lightheadedness. [1] Tests of vestibular system (balance) function include electronystagmography (ENG), [1] Dix-Hallpike maneuver, [1] rotation tests, head-thrust test, [9] caloric reflex test, [9] [30] and computerized dynamic posturography (CDP). [31]

The HINTS test, which is a combination of three physical examination tests that may be performed by physicians at the bedside, has been deemed helpful in differentiating between central and peripheral causes of vertigo. [32] The HINTS test involves the horizontal head impulse test, observation of nystagmus on primary gaze, and the test of skew. [33] CT scans or MRIs are sometimes used by physicians when diagnosing vertigo. [21]

Tests of auditory system (hearing) function include pure tone audiometry, speech audiometry, acoustic reflex, electrocochleography (ECoG), otoacoustic emissions (OAE), and the auditory brainstem response test. [31]

A number of specific conditions can cause vertigo. In the elderly, however, the condition is often multifactorial. [10]

A recent history of underwater diving can indicate a possibility of barotrauma or decompression sickness involvement, but does not exclude all other possibilities. The dive profile (which is frequently recorded by dive computer) can be useful to assess a probability for decompression sickness, which can be confirmed by therapeutic recompression. [34]

Benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo (BPPV) is the most common vestibular disorder [3] and occurs when loose calcium carbonate debris has broken off of the otoconial membrane and enters a semicircular canal thereby creating the sensation of motion. [1] [9] People with BPPV may experience brief periods of vertigo, usually under a minute, [9] which occur with change in the position. [35]

This is the most common cause of vertigo. [10] It occurs in 0.6% of the population yearly with 10% having an attack during their lifetime. [10] It is believed to be due to a mechanical malfunction of the inner ear. [10] BPPV may be diagnosed with the Dix-Hallpike test and can be effectively treated with repositioning movements such as the Epley maneuver. [10] [35] [36] [37]

Ménière's disease

Ménière's disease is an inner ear disorder of unknown origin, but is thought to be caused by an increase in the amount of endolymphatic fluid present in the inner ear (endolymphatic hydrops). [1] However, this idea has not been directly confirmed with histopathologic studies, but electrophysiologic studies have been suggestive of this mechanism. [38] Ménière's disease frequently presents with recurrent, spontaneous attacks of severe vertigo in combination with ringing in the ears (tinnitus), a feeling of pressure or fullness in the ear (aural fullness), severe nausea or vomiting, imbalance, and hearing loss. [9] [25] [38] As the disease worsens, hearing loss will progress.

Vestibular neuritis

Vestibular neuritis presents with severe vertigo [10] with associated nausea, vomiting, and generalized imbalance and is believed to be caused by a viral infection of the inner ear, although several theories have been put forward and the cause remains uncertain. [9] [39] Individuals with vestibular neuritis do not typically have auditory symptoms, but may experience a sensation of aural fullness or tinnitus. [39] Persisting balance problems may remain in 30% of people affected. [10]

Vestibular migraine

Vestibular migraine is the association of vertigo and migraines and is one of the most common causes of recurrent, spontaneous episodes of vertigo. [3] [10] The cause of vestibular migraines is currently unclear; [3] [40] however, one hypothesized cause is that the stimulation of the trigeminal nerve leads to nystagmus in individuals with migraines. [1] Approximately 40% of all migraine patients will have an accompanying vestibular syndrome, such as vertigo, dizziness, or disruption of the balance system. [40]

Other suggested causes of vestibular migraines include the following: unilateral neuronal instability of the vestibular nerve, idiopathic asymmetric activation of the vestibular nuclei in the brainstem, and vasospasm of the blood vessels supplying the labyrinth or central vestibular pathways resulting in ischemia to these structures. [21] Vestibular migraines are estimated to affect 1–3% of the general population [1] [10] and may affect 10% of people with migraine . [1] Additionally, vestibular migraines tend to occur more often in women and rarely affect individuals after the sixth decade of life. [3]

Motion sickness

Motion sickness is common and is related to vestibular migraine. It is nausea and vomiting in response to motion and is typically worse if the journey is on a winding road or involves many stops and starts, or if the person is reading in a moving car. It is caused by a mismatch between visual input and vestibular sensation. For example, the person is reading a book that is stationary in relation to the body, but the vestibular system senses that the car, and thus the body, is moving.

Alternobaric vertigo

Alternobaric vertigo is caused by a pressure difference between the middle ear cavities, usually due to blockage or partial blockage of one eustachian tube, usually when flying or diving underwater. It is most pronounced when the diver is in the vertical position; the spinning is toward the ear with the higher pressure and tends to develop when the pressures differ by 60 cm of water or more. [41] [42]

Decompression sickness

Vertigo is recorded as a symptom of decompression sickness in 5.3% of cases by the U.S. Navy as reported by Powell, 2008 [41] including isobaric decompression sickness.

Decompression sickness can also be caused at a constant ambient pressure when switching between gas mixtures containing different proportions of different inert gases. This is known as isobaric counterdiffusion, and presents a problem for very deep dives. [43] For example, after using a very helium-rich trimix at the deepest part of the dive, a diver will switch to mixtures containing progressively less helium and more oxygen and nitrogen during the ascent. Nitrogen diffuses into tissues 2.65 times slower than helium, but is about 4.5 times more soluble. Switching between gas mixtures that have very different fractions of nitrogen and helium can result in "fast" tissues (those tissues that have a good blood supply) increasing their total inert gas loading. This is often found to provoke inner ear decompression sickness, as the ear seems particularly sensitive to this effect. [44]

Stroke

A stroke (either ischemic or hemorrhagic) involving the posterior fossa is a cause of central vertigo. [33] Risk factors for a stroke as a cause of vertigo include increasing age and known vascular risk factors. Presentation may more often involve headache or neck pain, additionally, those who have had multiple episodes of dizziness in the months leading up to presentation are suggestive of stroke with prodromal TIAs. [33] The HINTS exam as well as imaging studies of the brain (CT, CT angiogram, MRI) are helpful in diagnosis of posterior fossa stroke. [33]

Vertebrobasilar insufficiency

Vertebrobasilar insufficiency, notably Bow Hunter's syndrome, is a rare cause of positional vertigo, especially when vertigo is triggered by rotation of the head. [45] [46]

Management

Definitive treatment depends on the underlying cause of vertigo. [9] People with Ménière's disease have a variety of treatment options to consider when receiving treatment for vertigo and tinnitus including: a low-salt diet and intratympanic injections of the antibiotic gentamicin or surgical measures such as a shunt or ablation of the labyrinth in refractory cases. [47] Common drug treatment options for vertigo may include the following: [48]

All cases of decompression sickness should be treated initially with 100% oxygen until hyperbaric oxygen therapy (100% oxygen delivered in a high-pressure chamber) can be provided. [50] Several treatments may be necessary, and treatment will generally be repeated until either all symptoms resolve, or no further improvement is apparent.

Etymology

Vertigo is from the Latin word, vertō , which means "a whirling or spinning movement". [51]

See also

Related Research Articles

<span class="mw-page-title-main">Ménière's disease</span> Disorder of the inner ear

Ménière's disease (MD) is a disease of the inner ear that is characterized by potentially severe and incapacitating episodes of vertigo, tinnitus, hearing loss, and a feeling of fullness in the ear. Typically, only one ear is affected initially, but over time, both ears may become involved. Episodes generally last from 20 minutes to a few hours. The time between episodes varies. The hearing loss and ringing in the ears can become constant over time.

A balance disorder is a disturbance that causes an individual to feel unsteady, for example when standing or walking. It may be accompanied by feelings of giddiness, or wooziness, or having a sensation of movement, spinning, or floating. Balance is the result of several body systems working together: the visual system (eyes), vestibular system (ears) and proprioception. Degeneration or loss of function in any of these systems can lead to balance deficits.

<span class="mw-page-title-main">Vestibular system</span> Sensory system that facilitates body balance

The vestibular system, in vertebrates, is a sensory system that creates the sense of balance and spatial orientation for the purpose of coordinating movement with balance. Together with the cochlea, a part of the auditory system, it constitutes the labyrinth of the inner ear in most mammals.

<span class="mw-page-title-main">Dizziness</span> Neurological condition causing impairment in spatial perception and stability

Dizziness is an imprecise term that can refer to a sense of disorientation in space, vertigo, or lightheadedness. It can also refer to disequilibrium or a non-specific feeling, such as giddiness or foolishness.

<span class="mw-page-title-main">Labyrinthitis</span> Medical condition

Labyrinthitis is inflammation of the labyrinth, a maze of fluid-filled channels in the inner ear. Vestibular neuritis is inflammation of the vestibular nerve. Both conditions involve inflammation of the inner ear. Labyrinths that house the vestibular system sense changes in the head's position or the head's motion. Inflammation of these inner ear parts results in a sensation of the world spinning and also possible hearing loss or ringing in the ears. It can occur as a single attack, a series of attacks, or a persistent condition that diminishes over three to six weeks. It may be associated with nausea, vomiting, and eye nystagmus.

<span class="mw-page-title-main">Benign paroxysmal positional vertigo</span> Medical condition

Benign paroxysmal positional vertigo (BPPV) is a disorder arising from a problem in the inner ear. Symptoms are repeated, brief periods of vertigo with movement, characterized by a spinning sensation upon changes in the position of the head. This can occur with turning in bed or changing position. Each episode of vertigo typically lasts less than one minute. Nausea is commonly associated. BPPV is one of the most common causes of vertigo.

<span class="mw-page-title-main">Electronystagmography</span>

Electronystagmography (ENG) is a diagnostic test to record involuntary movements of the eye caused by a condition known as nystagmus. It can also be used to diagnose the cause of vertigo, dizziness or balance dysfunction by testing the vestibular system. Electronystagmography is used to assess voluntary and involuntary eye movements. It evaluates the cochlear nerve and the oculomotor nerve. The ENG can be used to determine the origin of various eye and ear disorders.

<span class="mw-page-title-main">Vestibular nerve</span> Branch of the vestibulocochlear nerve

The vestibular nerve is one of the two branches of the vestibulocochlear nerve. In humans the vestibular nerve transmits sensory information transmitted by vestibular hair cells located in the two otolith organs and the three semicircular canals via the vestibular ganglion of Scarpa. Information from the otolith organs reflects gravity and linear accelerations of the head. Information from the semicircular canals reflects rotational movement of the head. Both are necessary for the sensation of body position and gaze stability in relation to a moving environment.

<span class="mw-page-title-main">Otolithic membrane</span>

The otolithic membrane is a fibrous structure located in the vestibular system of the inner ear. It plays a critical role in the brain's interpretation of equilibrium. The membrane serves to determine if the body or the head is tilted, in addition to the linear acceleration of the body. The linear acceleration could be in the horizontal direction as in a moving car or vertical acceleration such as that felt when an elevator moves up or down.

The Dix–Hallpike or Nylén–Bárány test is a diagnostic maneuver from the group of rotation tests used to identify benign paroxysmal positional vertigo (BPPV).

<span class="mw-page-title-main">DizzyFIX</span>

The DizzyFIX is a home medical device designed to assist in the treatment of benign paroxysmal positional vertigo (BPPV) and its associated vertigo. The device is a head-worn representation of semi-circular canals. The device is filled with fluid and a particle representing the otoconia associated with BPPV. The device works like a visual set of instructions and guides the user through the treatment maneuver for BPPV. This maneuver is called the particle repositioning maneuver or Epley maneuver.

The semicircular canal dehiscence (SCD) is a category of rare neurotological diseases/disorders affecting the inner ears, which gathers the superior SCD, lateral SCD and posterior SCD. These SCDs induce SCD syndromes (SCDSs), which define specific sets of hearing and balance symptoms. This entry mainly deals with the superior SCDS.

The Epley maneuver or repositioning maneuver is a maneuver used by medical professionals to treat one common cause of vertigo, benign paroxysmal positional vertigo (BPPV) of the posterior or anterior canals of the ear. The maneuver works by allowing free-floating particles, displaced otoconia, from the affected semicircular canal to be relocated by using gravity, back into the utricle, where they can no longer stimulate the cupula, therefore relieving the patient of bothersome vertigo. The maneuver was developed by the physician, John M. Epley, and was first described in 1980.

<span class="mw-page-title-main">Nystagmus</span> Dysfunction of eye movement

Nystagmus is a condition of involuntary eye movement. People can be born with it but more commonly acquire it in infancy or later in life. In many cases it may result in reduced or limited vision.

Vestibular migraine (VM) is vertigo with migraine, either as a symptom of migraine or as a related neurological disorder.

The righting reflex, also known as the labyrinthine righting reflex, is a reflex that corrects the orientation of the body when it is taken out of its normal upright position. It is initiated by the vestibular system, which detects that the body is not erect and causes the head to move back into position as the rest of the body follows. The perception of head movement involves the body sensing linear acceleration or the force of gravity through the otoliths, and angular acceleration through the semicircular canals. The reflex uses a combination of visual system inputs, vestibular inputs, and somatosensory inputs to make postural adjustments when the body becomes displaced from its normal vertical position. These inputs are used to create what is called an efference copy. This means that the brain makes comparisons in the cerebellum between expected posture and perceived posture, and corrects for the difference. The reflex takes 6 or 7 weeks to perfect, but can be affected by various types of balance disorders.

Benign paroxysmal vertigo of childhood is an uncommon neurological disorder which presents with recurrent episodes of dizziness. The presentation is usually between the ages of 2 years and 7 years of age and is characterised by short episodes of vertigo of sudden onset when the child appears distressed and unwell. The child may cling to something or someone for support. The episode lasts only minutes and resolves suddenly and completely. It is a self-limiting condition and usually resolves after about eighteen months, although many go on to experience migrainous vertigo when older.

<span class="mw-page-title-main">Vestibular rehabilitation</span> Form of physical therapy for vestibular disorders

Vestibular rehabilitation (VR), also known as vestibular rehabilitation therapy (VRT), is a specialized form of physical therapy used to treat vestibular disorders or symptoms, characterized by dizziness, vertigo, and trouble with balance, posture, and vision. These primary symptoms can result in secondary symptoms such as nausea, fatigue, and lack of concentration. All symptoms of vestibular dysfunction can significantly decrease quality of life, introducing mental-emotional issues such as anxiety and depression, and greatly impair an individual, causing them to become more sedentary. Decreased mobility results in weaker muscles, less flexible joints, and worsened stamina, as well as decreased social and occupational activity. Vestibular rehabilitation therapy can be used in conjunction with cognitive behavioral therapy in order to reduce anxiety and depression resulting from an individual's change in lifestyle. However, there is often confusion about whether vestibular rehabilitation falls under physical therapy (PT) or occupational therapy (OT).

Inner ear decompression sickness, (IEDCS) or audiovestibular decompression sickness is a medical condition of the inner ear caused by the formation of gas bubbles in the tissues or blood vessels of the inner ear. Generally referred to as a form of decompression sickness, it can also occur at constant pressure due to inert gas counterdiffusion effects.

<span class="mw-page-title-main">Anita Bhandari</span> Indian surgeon

Anita Bhandari is an Indian neurotologist, otorhinolaryngologist, entrepreneur and author based in Jaipur. She is the co-founder and director of NeuroEquilibrium, which has set up over 175 dizziness and balance disorder clinics in India and abroad.

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  51. ↑ "Definition of vertigo". Merriam-Webster Online Dictionary. Archived from the original on 2007-10-07. Retrieved 2007-09-19.
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