Peripheral vertigo
Summary
TLDRThis video script delves into peripheral vertigo, a condition stemming from inner ear vestibular system issues. It distinguishes peripheral vertigo from central vertigo, caused by central nervous system problems. The script explains various causes of peripheral vertigo, including Benign Paroxysmal Positional Vertigo (BPPV), Meniere's disease, labyrinthitis, and other less common conditions. It outlines symptoms, diagnosis methods, and treatments for each, emphasizing the importance of identifying the specific cause to provide effective care.
Takeaways
- 🌀 Peripheral vertigo is caused by issues with the vestibular system in the inner ear, specifically the semicircular canals.
- 🔍 Central vertigo, in contrast, is caused by problems within the central nervous system and is not the focus of this script.
- 💡 The vestibulocochlear nerve (cranial nerve eight) connects the semicircular canals to the central nervous system and can be a source of vertigo.
- 👂 Dizziness can have various meanings for patients, with 'vertigo' referring to a spinning sensation or false sense of motion.
- 🏥 Benign Paroxysmal Positional Vertigo (BPPV) is often caused by displaced otoconia in the semicircular canals, leading to brief, head movement-triggered episodes of vertigo.
- 🌪 Meniere's disease involves increased volume or pressure of endolymph in the semicircular canals, causing episodes of vertigo lasting up to 24 hours, along with hearing loss and tinnitus.
- 🔥 Labyrinthitis is an inflammation of the vestibular nerve, often resulting from a viral infection, and presents with acute vertigo, nausea, and hearing loss.
- 🦠 Ramsay Hunt syndrome, or Herpes Zoster Oticus, is caused by the reactivation of the latent herpes zoster virus, affecting the facial nerve and causing facial pain, paralysis, and a rash.
- 🛡 Perilymphatic fistula and semicircular canal dehiscence syndrome are caused by trauma to the inner ear, leading to leakage of perilymph and symptoms triggered by pressure changes.
- 👁 Kogen syndrome is thought to be an autoimmune condition affecting the eye and causing episodes of hearing loss, vertigo, and vision changes.
- 💊 Aminoglycoside toxicity can cause bilateral vestibular damage, potentially leading to disequilibrium or oscillopsia but not necessarily vertigo due to the lack of conflicting inputs.
Q & A
What is peripheral vertigo?
-Peripheral vertigo refers to a sensation of dizziness or spinning caused by a problem with the vestibular system in the inner ear, specifically the semicircular canals, which are crucial for maintaining balance.
What is the difference between peripheral vertigo and central vertigo?
-Peripheral vertigo is caused by issues within the inner ear's vestibular system, while central vertigo is caused by problems in the central nervous system, often related to the brain or brainstem.
What is the vestibulocochlear nerve, and what is its role in vertigo?
-The vestibulocochlear nerve, also known as cranial nerve eight, connects the inner ear's semicircular canals and cochlea to the central nervous system. Problems with this nerve can lead to vertigo due to disruptions in balance and hearing signals.
What is the definition of vertigo according to the script?
-Vertigo is defined as a spinning sensation or a false sense of motion, which patients may describe when experiencing this condition. It is one of several meanings that patients might attribute to the term 'dizziness.'
What are the typical symptoms of Benign Paroxysmal Positional Vertigo (BPPV)?
-BPPV symptoms include brief, reproducible episodes of vertigo, rotary nystagmus, and nausea, triggered by head movements and typically lasting seconds to about a minute.
How is BPPV diagnosed and treated?
-BPPV is diagnosed clinically, often with the Dix-Hallpike maneuver to trigger nystagmus. Treatment involves the Epley maneuver, a canalith repositioning procedure, and sometimes antihistamines to manage symptoms.
What is Meniere's disease and how is it diagnosed?
-Meniere's disease is characterized by increased volume or pressure of endolymph in the semicircular canals, leading to episodes of vertigo, hearing loss, and tinnitus. Diagnosis involves clinical assessment and may include Weber and Rinne tests, as well as regular audiometry.
What are the symptoms of Labyrinthitis?
-Labyrinthitis symptoms include acute episodes of vertigo, nausea, vomiting, hearing loss, gait instability, and can last up to several days. It is often associated with a viral or post-viral process.
How is the diagnosis of Labyrinthitis confirmed?
-Labyrinthitis is diagnosed through an abnormal head thrust test and by ruling out other causes of vertigo with brain imaging, such as pontine stroke, tumors, cerebellar hemorrhage, or infarction.
What is the treatment for Labyrinthitis?
-Treatment for Labyrinthitis involves the use of steroids, ideally given within 72 hours of symptom onset, and antihistamines like meclizine for acute relief of vertigo.
What is the difference between peripheral and central causes of vertigo in terms of diagnosis and treatment?
-Peripheral vertigo is diagnosed based on symptoms related to the inner ear and treated with maneuvers like the Epley for BPPV or lifestyle changes and medication for Meniere's disease. Central vertigo requires brain imaging to diagnose issues like stroke or tumors and is treated based on the underlying cause.
What is the role of the Epley maneuver in treating BPPV?
-The Epley maneuver is a series of head movements designed to reposition the displaced crystalline deposits, or otoconia, in the semicircular canals, thereby alleviating the vertigo symptoms associated with BPPV.
What are the typical symptoms of Herpes Zoster Oticus (Ramsay Hunt Syndrome)?
-Herpes Zoster Oticus presents with ipsilateral facial pain, facial paralysis, a dermatomal vesicular rash in the external auditory canal, and may also include auditory or vestibular problems such as tinnitus, hyperacusis, vertigo, and nausea.
How is a Perilymphatic Fistula diagnosed?
-A Perilymphatic Fistula can be diagnosed clinically with symptoms of progressive sensorineural hearing loss and episodic vertigo triggered by pressure changes. A CT scan may also reveal fluid around the round window, indicating a fistula.
What is the treatment for a Perilymphatic Fistula?
-Treatment for a Perilymphatic Fistula starts conservatively with bed rest, head elevation, and limiting activities that increase inner ear pressure. If persistent, surgical patching of the broken otic capsule may be required.
What is the significance of the Tulio phenomenon in the context of a Perilymphatic Fistula?
-The Tulio phenomenon is significant as it can induce nystagmus by clapping or playing a loud noise in the ear, which is a result of a high-pressure sound wave transmitted into the vestibular system, indicating a possible fistula.
What is Aminoglycoside toxicity and how does it affect the vestibular system?
-Aminoglycoside toxicity refers to damage caused by gentamicin and other aminoglycosides to the vestibular system. It can cause bilateral vestibular damage, potentially leading to disequilibrium or oscillopsia, but not necessarily vertigo due to the lack of conflicting inputs from both sides.
Outlines
🌀 Understanding Peripheral Vertigo and Its Causes
This paragraph introduces the concept of peripheral vertigo, which is caused by issues with the vestibular system in the inner ear, specifically the semicircular canals. It contrasts peripheral vertigo with central vertigo, which stems from problems in the central nervous system. The paragraph also explains the vestibulocochlear nerve's role in connecting the inner ear to the central nervous system and mentions various causes of vertigo, emphasizing the importance of distinguishing between different types of dizziness reported by patients. Benign Paroxysmal Positional Vertigo (BPPV) is highlighted as the most common cause, with its diagnosis and treatment methods, such as the Epley maneuver, being discussed in detail.
🔍 Exploring Other Causes of Peripheral Vertigo
The second paragraph delves into other causes of peripheral vertigo, including Meniere's disease, characterized by increased endolymph volume or pressure in the semicircular canals, labyrinthitis, which involves inflammation of the vestibular nerve, and herpes zoster oticus, a condition resulting from the reactivation of the latent herpes zoster virus. The paragraph outlines the symptoms, diagnosis, and treatment for each condition. Meniere's disease is treated with lifestyle changes and medication, labyrinthitis is typically treated with steroids, and herpes zoster oticus requires a combination of steroids and acyclovir. Additionally, the paragraph touches on less common causes like perilymphatic fistula and semicircular canal dehiscence syndrome, which involve trauma to the inner ear structures.
🌐 Rare Causes of Peripheral Vertigo and Their Management
The final paragraph discusses less common causes of peripheral vertigo, such as Kogen syndrome, which is thought to be an autoimmune condition affecting the eye, and vestibular schwannoma, a slow-growing tumor of the vestibular part of cranial nerve eight. It also mentions aminoglycoside toxicity, which can cause bilateral vestibular damage but not necessarily vertigo due to the lack of conflicting inputs. The paragraph provides insights into the diagnosis and treatment options for these conditions, including immunosuppressants for Kogen syndrome, surgical resection or radiation for vestibular schwannoma, and clinical diagnosis for aminoglycoside toxicity. The summary underscores the importance of recognizing these rare causes for accurate diagnosis and management.
Mindmap
Keywords
💡Peripheral Vertigo
💡Vestibular System
💡Semicircular Canals
💡Benign Paroxysmal Positional Vertigo (BPPV)
💡Meniere's Disease
💡Labyrinthitis
💡Herpes Zoster Oticus (Ramsay Hunt Syndrome)
💡Perilymphatic Fistula
💡Vestibular Neuritis
💡Aminoglycoside Toxicity
💡Vestibular Schwannoma
Highlights
Peripheral vertigo is caused by a problem with the vestibular system in the inner ear.
The most common causes of peripheral vertigo include benign paroxysmal positional vertigo (BPPV), Meniere's disease, and labyrinthitis.
Central vertigo is caused by a problem in the central nervous system.
Cranial nerve eight, the vestibulocochlear nerve, connects the vestibular system to the central nervous system.
Patients often describe vertigo as dizziness, which can mean various things such as vertigo, disequilibrium, pre-syncope, or lightheadedness.
BPPV is caused by crystalline deposits in the semicircular canals, leading to brief episodes of vertigo triggered by head movement.
The Epley maneuver is a treatment for BPPV that helps reposition the crystalline deposits.
Meniere's disease is characterized by episodes of vertigo, sensory neural hearing loss, and tinnitus, caused by increased pressure of endolymph in the semicircular canals.
Treatment for Meniere's disease includes lifestyle changes, diuretics, antihistamines, and in severe cases, an endolymphatic shunt.
Labyrinthitis, often post-viral, causes inflammation of the vestibular nerve leading to acute episodes of vertigo, nausea, vomiting, and hearing loss.
Steroids are the primary treatment for labyrinthitis if given within 72 hours.
Herpes zoster oticus, or Ramsay Hunt syndrome, involves reactivation of the herpes zoster virus, causing facial paralysis and vertigo.
Perilymphatic fistula and semicircular canal dehiscence syndrome are caused by trauma that breaks the otic capsule, leading to episodic vertigo and nystagmus triggered by pressure changes.
Treatment for perilymphatic fistula includes bed rest, head elevation, and in severe cases, surgical patching.
Less common causes of peripheral vertigo include Cogan syndrome, vestibular schwannoma, and aminoglycoside toxicity.
Vestibular schwannoma is a slow-growing tumor causing unilateral hearing loss and tinnitus, diagnosed with audiometry and MRI.
Aminoglycoside toxicity causes bilateral vestibular damage, leading to disequilibrium or oscillopsia without vertigo.
Transcripts
this is a short video on peripheral
vertigo peripheral vertigo refers to
vertigo that's caused by a problem with
the vestibular system in the inner ear
these are the semicircular canals which
kind of help you with balance
and the most common causes of peripheral
vertigo are these three up here but i'll
be talking about all of these causes
one by one in contrast there's central
vertigo which is caused by a problem in
the central nervous system this is a
list of causes of central vertigo but i
won't be talking about these here
the semicircular canals connect to the
central nervous system via the
vestibulocochlear
nerve this is cranial nerve eight
and it has two components it has a
vestibular component from the
semicircular canals and a cochlear
component from the cochlear canals here
so um a problem with the with the with
cranial nerve eight with the vestibular
cochlear nerve can also cause vertigo so
let's start going through these one by
one
well first before we do that let's first
define what we mean by vertigo
when a patient comes in they're not
going to immediately tell you they have
vertigo they might mention they have
dizziness and dizziness can mean a lot
of things unfortunately it's not very
specific but there's a
there's a there's a paper by a couple
family docs i think that kind of went
through what patients meant by dizziness
on average and it seemed like in 50 of
cases they actually meant vertigo
patients were able to describe a
spinning sensation or a false sense of
motion that was consistent with vertigo
in about 15 of cases they really meant
disequilibrium which is a patient
feeling off balance in another 15 of
cases they meant pre-syncope the
patients felt like they were blacking
out like they were going to pass out or
lose consciousness and in about ten
percent of cases the patient really
meant lightheaded which is like a vague
disconnection from your surroundings so
a patient won't tell you they're feeling
vertigo or feeling vertigonous symptoms
unless they've had those before they
might tell you they're feeling dizzy and
it's your job to tease that out tease
out that they're having a spinning
sensation or a false sense of motion
that might indicate vertigo
okay now let's talk about the first one
bppv benign paroxysmal positional
vertigo the pathophysiology here is
crystalline deposits or canalites in the
semicircular canals
these are
they're also called otoconia they're
displaced in the semicircular canals and
they can disrupt the normal vestibular
fluid flow when they do that one side of
your face is going to give you
contradictory signals from the other
side and this will be interpreted in
your brain as a spinning sensation or
vertigo the symptoms you get here are
brief reproducible episodes of vertigo
you can also get rotary nystagmus and
nausea and they're triggered by head
movement these episodes last anywhere
from seconds to about one minute usually
not much more than one minute
but they're triggered by head movement
so somebody will be lying down and as
soon as they move they experience this
whatever 30 seconds of bppv and then it
goes away the diagnosis is made
clinically usually with a story like
like what i just described you can also
do the dix hall pike maneuver to trigger
nystagmus and that's something you can
do in the clinic you lie the patient
down supine and you have their head
rotated 45 degrees and that can trigger
nystagmus
the treatment here is
a little
unusual for clinic treatments you can do
this epley maneuver it's a canalith
repositioning maneuver it's essentially
a series of steps in which you're trying
to get these crystalline deposits to go
back to right where they're supposed to
be
so you're moving the head in a certain
direction to get those odiconia out of
the way you can also use antihistamines
just to help with the vertiginous
symptoms and otherwise if you don't do
anything about it it'll resolve
spontaneously but it might take a while
and it can recur so really this epley
maneuvers is a good way to get rid of it
next is meniere's disease the
pathophysiology here is increased volume
or pressure of endolymph in the
semicircular canals so inside these
canals is endolymph and if you have too
high a pressure of it you can end up
with meniere's disease this is also
called endolymphatic high drops the
symptoms here are again episodes of
vertigo this time they last about 20
minutes to 24 hours you'll also have
sensory neural hearing loss and tinnitus
the sensory neural hearing loss can
start unilateral at low frequencies and
it can progress to all frequencies so it
starts um low frequencies progresses to
all frequencies the diagnosis is again
clinical you could do the weber and
rhine tests with the tuning fork to
confirm sensory neural hearing loss and
you should be doing regular audiometry
to monitor it
in a patient with meniere's disease the
treatment first will start
conservatively with lifestyle changes
you can restrict sodium nicotine
caffeine and alcohol you might also use
diuretics we're not really sure why the
diuretics work but they seem to help
if that doesn't work you can escalate to
antihistamines benzos and anti-medics
for acute episodes and if that doesn't
work the there is like a invasive option
the endolymphatic shunt
can be placed if it's severe and
intractable
meniere's disease
next is labyrinthitis the
pathophysiology here is inflammation of
the vestibular nerve that's part of the
cranial nerve eight that i mentioned
earlier so this usually happens as a
viral process or a post-viral process so
a patient might describe having an upper
respiratory infection about four weeks
ago maybe two to four weeks ago
they'll have an acute episode of vertigo
nausea vomiting hearing loss gait
instability and this can last up to
several days
one way to diagnose labyrinthitis which
is also called vestibular neuritis is
with an abnormal head thrust test it's
usually a diagnosis of exclusion so you
might want to do brain imaging to rule
out other causes of vertigo like pontine
stroke and tumors as well as cerebellar
hemorrhage or infarction those would be
causes of central vertigo
before you diagnose somebody with
labyrinthitis
treatment for labyrinthitis is steroids
you ideally want to give these as soon
as possible within 72 hours within three
days they
do help the labyrinthitis to resolve
it's possible that you have balance and
hearing problems that are compromised
longer term though you can also give
meklizine for just acute relief of
vertigo
next one worth knowing is herpes zoster
utakai
oticus this is also known as ramsay hunt
syndrome the pathophysiology here is
reactivation of latent herpes zoster
virus from the genticulate ganglion it
disrupts the facial nerve function so
the signs and symptoms that you'll see
are kind of shown in this picture here
you'll have ipsilateral face pain you
can have facial facial paralysis that
shows you this asymmetry shown here and
you can have a dermatomal vesicular rash
in the external auditory canal as shown
here patient might also have auditory or
vestibular problems like tinnitus and
hyperacusis for the auditory symptoms
and vertigo and nausea vomiting from the
vestibular side if the if the herpes
zoster spreads to cranial nerve eight
you can also have systemic symptoms like
fever but that's relatively rare less
than one in five people get that the
diagnosis for herpes zosteroticus is
clinical mainly
there's this triad the ipsilateral ear
pain facial paralysis and dermatomal
vesicular rash in the auditory canal
that's pretty characteristic treatment
here is steroids and acyclovir if you
give it within three days it can help
speed resolution and limit the adverse
outcomes patients sometimes have
residual face weakness but if you treat
them early they're less likely to have
that you also want to protect the eye
on the affected side with like
artificial ears
to make sure they don't damage their eye
while their face is weak or droopy
next is perilymphatic fistula and i'll
also mention semicircular canal
dehiscence syndrome since the
pathophysiology is kind of similar the
pathophysiology is trauma that breaks
the odoc capsule so the oda capsule is
the bony
outside of the inner ear of the
semicircular ducts and the rest of the
inner ear and if you break that you'll
have a fistula a leakage of the
perilymph that's the fluid inside these
canals and you'll essentially transfer
pressure to the outside it often breaks
at the oval and round windows but it can
break in other places like semicircular
canal dehiscence would be a break in the
semicircular canals
the symptoms that this presents with is
sensory neural hearing loss that's
progressive you also have episodic
vertigo and nystagmus that's triggered
by pressure changes so again if you have
a if you have a fistula between the
vestibular system and the outside and
you have an increase in pressure on the
outside such as by doing a valsalva
by elevating in pressure by sneezing by
coughing by straining then you'll have
pressure that's transferred to the
inside of the system and that can
trigger an episode of vertigo there's
another tulio phenomenon that's worth
knowing you can clap or play a loud
noise in someone's ear and that'll
induce nystagmus
which is essentially the same thing a
clap is a sound wave high pressure
that's transmitted into the vestibular
system inducing this uh nystagmus so
that'd be one way to diagnose it
clinically
you can also do a ct scan that might
show fluid around the round window so if
you see that on ct scan that might be a
sign that there's a perilymphatic
fistula
the treatment for these people you can
start conservatively with bed rest head
elevation and limiting activities that
increase the inner ear pressure so tell
them to avoid straining maybe give them
laxatives or miralax just to help them
avoid straining on the toilet if it's
persistent you can progress to having a
surgical patch if it's if it's
refractory
but that would require going in and
actually patching up the broken odoc
capsule
lastly these are some other things that
are worth mentioning worth knowing a
less common cause of peripheral vertigo
is this kogen syndrome the
pathophysiology here is uncertain but
it's thought to be autoimmune
inflammation of the eye patients will
have episodes of hearing loss vertigo
nausea vomiting ataxia and vision
changes you can diagnose it by doing a
slit lamp exam and also inflammatory
markers like crp esr there is a new mri
test that might be able to identify the
auto antibodies but
that's currently being studied
there's
the treatment for this would be
immunosuppressants such as steroids a
couple others that are worth mentioning
vestibular schwannoma or an acoustic
neuroma this is a schwann cell derived
tumor of the vestibular part of cranial
nerve eight
it's a slow growing tumor so it'll
firstly affect your hearing it'll cause
unilateral hearing loss and tinnitus
it doesn't always cause vestibular
problems and that's because it's a slow
growing tumor so you can kind of have
central vestibular compensation so if
it's a fast-growing tumor you might have
vestibular symptoms the vertigo the
dizziness
but usually the body's able to
compensate for that and you don't have
vestibular symptoms if it's bilateral
you want to think about
neurofibromatosis type 2
and
the diagnosis for this would be clinical
you would hear about somebody having
hearing problems maybe vestibular
problems but that's unusual you can then
do audiometry find out that they have uh
asymmetric sensory neural hearing loss
and then confirm it with mri you'll see
a mass in the cerebral pontine angle
treatment for that would be surgical
resection or radiation
lastly there's aminoglycoside toxicity
this is interesting because gentamicin
and aminoglycoside is vestibulotoxic so
it can cause bilateral vestibular damage
however because you have both sides
damaged because it's not unilateral
because it's bilateral vestibular damage
you're not getting conflicting inputs so
you're not getting a left-right
imbalance of inputs so you usually don't
have vertigo as we've been talking about
it you might have disequilibrium
or oscillopsia but you might not have
vertigo with aminoglycoside toxicity
that being said they can still have
hearing loss bilateral hearing loss from
that
the diagnosis here would be made
clinically you can do an abnormal
horizontal head impulse test and you
might have reduced visual acuity during
the head shake
so that was kind of a short overview of
peripheral causes of vertigo i hope it
was helpful thank you for listening
5.0 / 5 (0 votes)