An Approach to Vertigo
Summary
TLDRThis video by Eric from Strong Medicine offers a comprehensive guide on diagnosing vertigo, distinguishing it from lightheadedness and disequilibrium, which are often confused with dizziness. It outlines the differences, common causes of vertigo such as BPPV and Meniere's disease, and emphasizes the importance of the Hints exam in identifying central versus peripheral causes. The video also provides an evaluation algorithm and highlights the necessity of considering neuroimaging to rule out serious conditions like stroke.
Takeaways
- 📝 Dizziness is a nonspecific term that can refer to vertigo, pre-syncope, or disequilibrium, and it's crucial to distinguish between these conditions for accurate diagnosis.
- 🎢 Vertigo is characterized by the illusion of motion while stationary, often described as a spinning sensation, and is associated with nausea due to disruptions in vestibular pathways.
- 🕊 Benign Paroxysmal Positional Vertigo (BPPV) is the most common cause of vertigo, caused by dislodged otolith crystals in the semicircular canals, and is diagnosed using the Dix-Hallpike maneuver.
- 🌀 Meniere's disease is another cause of episodic vertigo, associated with progressive hearing loss and tinnitus, and is suggested by symptoms like episodic hearing loss and tinnitus.
- 💉 Vestibular neuritis, likely due to viral inflammation, is a common peripheral cause of vertigo that can be distinguished from central causes through physical examination.
- 🏥 Central causes of vertigo, such as stroke or multiple sclerosis, are less common but require immediate attention, and may necessitate brain MRI or MRA for diagnosis.
- 🔍 The history and physical examination are primarily used to diagnose vertigo, with blood tests being rarely helpful, and imaging reserved for suspected central causes.
- 👁️ The head impulse test, nystagmus examination, and test of skew, collectively known as the HINTS exam, are critical for differentiating between central and peripheral vertigo.
- 🚑 An abnormal HINTS exam, especially in older patients with stroke risk factors or additional neurologic symptoms, should prompt immediate neuroimaging to rule out central causes like stroke.
- 📉 Audiometry is important when Meniere's disease is suspected, helping to distinguish it from other causes of vertigo based on hearing test results.
- 🔄 The diagnostic approach to vertigo involves a stepwise evaluation starting from patient history, physical examination, and specific maneuvers, followed by additional tests as needed based on the suspected cause.
Q & A
What is the main difference between vertigo, lightheadedness, and disequilibrium?
-Vertigo is the illusion of motion while stationary, often described as a spinning sensation. Lightheadedness, or pre-syncope, is the sensation of transiently slowed consciousness or feeling faint, which can progress to a brief loss of consciousness. Disequilibrium is difficulty maintaining balance, usually associated with frequent falls without loss of consciousness.
What is the most common symptom associated with vertigo?
-The most frequently associated symptom with vertigo is nausea.
How can benign paroxysmal positional vertigo (BPPV) be triggered?
-BPPV can be triggered by changes in head position, such as moving from lying to sitting or standing, or when turning the head while supine.
What is Meniere's disease and what are its typical symptoms?
-Meniere's disease is believed to be associated with an increased volume of endolymph, a fluid in the inner ear. Symptoms include discrete episodes of vertigo lasting between 20 minutes and a day, progressive hearing loss, and tinnitus.
What is the general mechanism behind lightheadedness?
-The general mechanism of lightheadedness is a transient reduction of cerebral perfusion.
What is vestibular neuritis and what is its likely cause?
-Vestibular neuritis is a benign self-limited disorder thought to be most likely due to viral or post-viral inflammation of one or both vestibular nerves.
How can an acoustic neuroma present symptoms of vertigo?
-An acoustic neuroma, also known as a vestibular schwannoma, is a benign tumor of the vestibular nerve. As it grows slowly, unilateral hearing loss is a more common symptom than vertigo, but the central vestibular centers can adapt to the lack of unilateral vestibular inputs.
What is the purpose of the Dix-Hallpike maneuver in the evaluation of vertigo?
-The Dix-Hallpike maneuver is a test specifically for BPPV. It helps to confirm the diagnosis of BPPV by inducing nystagmus with the maneuver.
What does the HINTS exam stand for and why is it important in the evaluation of vertigo?
-The HINTS exam stands for Head Impulse, Nystagmus, and Test of Skew. It is important in the evaluation of vertigo because it helps to distinguish central from peripheral causes of vertigo with high predictive values.
What are some additional tests that might be indicated in the evaluation of vertigo?
-Additional tests that might be indicated include audiometry for suspected Meniere's disease, and a brain MRI plus or minus MRA if a central cause cannot be ruled out from the history and exam alone.
What is the key takeaway from the video regarding the evaluation of vertigo?
-The key takeaway is that the diagnosis of vertigo is predominantly based on history and physical exam, with the HINTS exam being an important component. An abnormal HINTS exam should warrant an MRI plus or minus an MRA to look for central causes such as a posterior circulation stroke or multiple sclerosis.
Outlines
🌀 Understanding Vertigo and Its Distinctions
This paragraph clarifies the difference between vertigo, lightheadedness, and disequilibrium, which are often collectively referred to as dizziness. Vertigo is characterized by the illusion of motion while stationary, often described as a spinning sensation, and is associated with nausea. It can be caused by disruptions in the vestibular pathways. Lightheadedness, or pre-syncope, involves a sensation of faintness and can lead to brief loss of consciousness. Disequilibrium is the difficulty in maintaining balance, often without loss of consciousness. The paragraph emphasizes the importance of distinguishing these conditions for accurate diagnosis.
👂 Causes of Vertigo: Peripheral and Central Ideologies
The second paragraph delves into the causes of vertigo, categorizing them into peripheral and central ideologies. Peripheral causes include benign paroxysmal positional vertigo (BPPV), Meniere's disease, perilymphatic fistula, and Cogan syndrome, which involve the inner ear or vestibular nerves. Central causes, less common, can be vascular or non-vascular and include conditions like transient ischemic attacks, migraines, and multiple sclerosis. The paragraph highlights the importance of identifying the cause to determine the appropriate diagnostic and treatment approach.
🔍 Diagnostic Framework for Vertigo
This paragraph discusses the diagnostic framework for vertigo, emphasizing the differentiation between peripheral and central causes. It describes the history-taking process, focusing on the nature of the sensory disturbance, the time course, and triggers of vertigo. The paragraph also mentions associated symptoms, such as hearing loss and tinnitus, which can point towards specific conditions like Meniere's disease. The diagnostic process relies heavily on the patient's history and physical examination, with the Dix-Hallpike maneuver being a key test for BPPV.
📝 The HINTS Exam and Dix-Hallpike Maneuver
The fourth paragraph introduces the HINTS exam (Head Impulse, Nystagmus, and Test of Skew) as a critical component in evaluating vertigo, with high predictive values for distinguishing central from peripheral causes. It details the steps and significance of the head impulse test, nystagmus test, and skew test. The Dix-Hallpike maneuver is also described for diagnosing BPPV, with the presence of nystagmus indicating a positive test. The paragraph advises on the appropriate use of these tests based on the patient's symptoms and history.
🛑 Algorithm for Evaluating Vertigo
The final paragraph presents an algorithm for evaluating vertigo, starting with discerning between dizziness, lightheadedness, and disequilibrium. It outlines the steps for further workup based on the patient's clinical presentation, such as the Dix-Hallpike maneuver for BPPV or audiometry for Meniere's disease. The paragraph also discusses the importance of neuroimaging in cases of suspected central vertigo, especially in patients with risk factors for stroke. It concludes with the emphasis on the accuracy of the HINTS exam and the need for caution to avoid missing serious conditions like posterior circulation strokes.
Mindmap
Keywords
💡Vertigo
💡Dizziness
💡Pre-syncope
💡Disequilibrium
💡Benign Paroxysmal Positional Vertigo (BPPV)
💡Meniere's Disease
💡Vestibular Neuronitis
💡Acoustic Neuroma
💡Central Causes
💡HINTS Exam
💡Dix-Hallpike Maneuver
Highlights
Vertigo is distinguished from dizziness and pre-syncope by the illusion of motion while stationary.
Dizziness is a nonspecific term that can refer to vertigo, pre-syncope, or disequilibrium.
Vertigo can be caused by disruptions in the vestibular pathways in the inner ear, cranial nerve, brain stem, or cerebellum.
Lightheadedness, or pre-syncope, is a transient reduction in cerebral perfusion causing a sensation of faintness.
Disequilibrium involves difficulty maintaining balance and is associated with frequent falls without loss of consciousness.
Benign Paroxysmal Positional Vertigo (BPPV) is a common peripheral cause of vertigo, caused by dislodged otolith crystals.
Meniere's disease is associated with episodes of vertigo, progressive hearing loss, and tinnitus.
A perilymphatic fistula can cause episodic vertigo triggered by changes in middle ear pressure.
Cogan syndrome is a rare autoimmune disease presenting with vertigo, hearing loss, and interstitial keratitis.
Vestibular neuritis is likely due to viral inflammation of the vestibular nerve.
Acoustic neuroma is a benign tumor that can cause unilateral hearing loss and vertigo.
Ramsey Hunt syndrome presents with unilateral facial paralysis, ear pain, and vertigo due to shingles affecting the ear.
Vestibular paroxysmia is a poorly understood condition causing brief, frequent attacks of vertigo.
Central causes of vertigo include vascular issues such as transient ischemic attacks or strokes.
Vestibular migraines and multiple sclerosis are nonvascular central causes of vertigo.
The Dix-Hallpike maneuver is a specific test for BPPV, confirming the diagnosis if nystagmus is induced.
The HINTS exam is crucial for distinguishing central from peripheral causes of vertigo.
An abnormal HINTS exam should prompt an MRI to rule out central causes such as stroke or multiple sclerosis.
Vertigo diagnosis is primarily based on history and physical exam, with imaging reserved for unclear cases or central suspicions.
The most common cause of vertigo is BPPV, which can be diagnosed and treated without extensive testing.
Transcripts
hello it's Eric from strong medicine and
today I'm discussing and approached the
Vertigo the first step is to confirm
that what a patient is describing to you
is in fact vertigo English speaking
patients rarely use the actual word
vertigo and instead will use the word
dizziness
unfortunately dizziness is nonspecific a
patient reporting this symptom might
mean vertigo or they might mean
something called pre syncope or
something sometimes called
disequilibrium let's discuss the
difference between those three I'll
start with a primary symptom of interest
for this video vertigo vertigo is the
illusion of motion while a person is
stationary most but not all patients
describe a spinning sensation if you've
ever played the game dizzy bat the
sensation that generates is vertigo
vertigo can last as briefly as a few
seconds or it can persist for weeks the
most frequently associated symptom is
nausea and the general mechanism by
which vertigo occurs is a disruption of
vestibular pathways which can happen in
the inner ear along the course of
cranial nerve eight within the best
tubular nuclei in the brain stem or
within the cerebellum
the next symptom that is frequently
referred to by patients as dizziness is
lightheadedness also known as pre
syncope this is the sensation of
transiently slowed consciousness or
feeling faint it can progress to a brief
loss of consciousness known as syncope
when lightheadedness occurs it is almost
always brief lasting seconds to no more
than a few minutes it can be associated
with a feeling of warmth throughout the
entire body and visual changes such as
blurring or graying out of the vision in
both eyes the general mechanism of
lightheadedness is a transient reduction
of cerebral perfusion
last and least understood is this
equilibrium this is difficulty
maintaining balance it can last a few
seconds or persist for weeks it's
usually associated with frequent Falls
without a loss of consciousness which
would otherwise suggest syncope affected
patients may become fearful of walking
the general mechanism is usually sensory
deficits in multiple modalities
while it's not always as unambiguous as
this chart might suggest a clinician can
usually place a patient's dizziness into
one of these three categories
now focusing just on vertigo the
diagnostic framework is best divided
into peripheral versus central
ideologies as a general rule the
peripheral ideologies are relatively
common compared to the central ones
starting with the peripheral causes
causes within the labyrinth include
benign paroxysmal positional vertigo
usually abbreviated BPPV in BPPV
the crystals known as odorless become
dislodged and flow freely in one of
these semicircular canals partially
responsible for balance
when these crystals move within the
canals in response to changes in
position they lead to excessive
activation of the canals sensory cells
so change in position which should only
be a transient sensation during the
actual movement persists for seconds to
as long as a few minutes BPPV
classically causes episodes of brief
vertigo triggered by moving from a lying
to sitting position or standing position
or when turning one's head while supine
a less common cause of episodic vertigo
due to a problem in the inner ear is
Meniere's disease this is believed to be
caused by or at least is associated with
an increased volume of a fluid called
endolymph which is responsible for
transmitting sound waves to receptor
cells in the cochlea and for detecting
angular acceleration within the
semicircular canals symptoms of nares
disease include discrete episodes of
vertigo lasting between 20 minutes and a
day associated with progressive hearing
loss and with ringing in the ears which
can either be a Poisson ik or can be
constant
a peri lymphatic fistula is a tear in
the membrane that separates the inner
and mental ear a rare complication of
head trauma or Barrow trauma which
causes episodic vertigo and our hearing
loss that's triggered by anything
associated with abrupt changes in
pressure within the middle ear
this can include sneezing coughing
straining or even loud noises
and last in this category is the rare
autoimmune disease Kogan syndrome which
presents with a combination of veneers
like attacks of transient vertigo and
hearing loss along with interstitial
keratitis and sometimes various forms of
systemic vasculitis
- the main nerves that are involved in
vestibular sensory function they include
cranial nerve eight also known as the
vestibular cochlear nerve which has two
branches one of which is the vestibular
nerve which receives signals from the
vestibular hair cells of the inner ear
that are directly responsible for
sensing position and movement the most
common etiology in this category is
called vestibular neuritis this is a
benign self-limited disorder thought to
be most likely due to viral or post
viral inflammation of one or both nerves
but a viral mechanism has not been
definitively established some clinicians
use the term vestibular neuritis
interchangeably with the term
labyrinthitis while others reserved the
latter term for only those patients who
also experience temporary hearing
abnormalities along with a vertigo
an acoustic neuroma also known as a
vestibular schwannoma is a benign
Schwann cell derived tumor of the
vestibular nerve as a consequence of the
slow growth of the tumor unilateral
hearing loss is a more common symptom
than vertigo since central vestibular
centers can gradually adapt to the lack
of unilateral vestibular inputs
sometimes acoustic neuromas are
classified as an etiology of central
vertigo presumably because their
presentation is more similar to central
ideologies but as it affects a part of
the peripheral nervous system to me it
feels more appropriately categorized
here
Ramsey hunt syndrome also known as
herpes zoster otakus is essentially
shingles affecting the ear manifesting
as unilateral facial paralysis ear pain
vesicles within the auditory canal and
on the auricle hearing loss and of
course vertigo the final peripheral
causes of vertigo I mentioned is called
vestibular Parkes is MIA which is a rare
poorly understood chronic condition
manifesting as very brief attacks of
vertigo occurring several times a day
sometimes with auditory symptoms during
attacks moving to the less common
central causes of vertigo they can be
separated into vascular versus non
vascular ideologies
among vascular causes the most notable
is a transient ischemic attack or stroke
of the posterior circulation to specific
entities here include lateral medullary
syndrome also known as Wallenberg
syndrome and infarct or hemorrhage of
the cerebellum both of these would
almost always be associated with
significant other neurological deficits
among nonvascular central causes are
migraines which are called vestibular
migraines
when vertigo is a prominent symptom and
multiple sclerosis the most common cause
of vertigo is BPPV
and those conditions which specifically
cause episodic vertigo include BPPV
Meniere's disease prairie lymphatic
fistula Kogan syndrome vestibular park's
is MIA and vestibular migraines
vertigo usually requires an asymmetry
between right and left particular inputs
and processing so any condition or
exposure that results in symmetric
dysfunction such as aminoglycoside
toxicity or alcohol intoxication tends
to cause vestibular dysfunction such as
impaired balance but without the
specific symptom of vertigo
one nice thing about the diagnostic
workup for vertigo is that even more so
than with the other symptoms I've
discussed in this video series the
diagnosis can usually be made from
symptoms and exam alone starting with
the history the first step is to have
the patient describe the nature of the
sensory disturbance that they are
experiencing that is you want to confirm
that the patient is reporting vertigo
and not lightheadedness disequilibrium
or other neurologic symptoms
next consider the time course how long
has it been present and is it episodic
or continuous is there a specific
trigger for the Vertigo most commonly a
change in position realize that all
vertigo worsens with head movement
it's only diagnostically helpful if the
vertigo is absent at rest and is
triggered by movement which specifically
suggests BPPV other triggers to ask
about include onset after head trauma as
well as triggering by coughing weight
lifting or straining with bowel
movements of which suggests a peri
lymphatic fistula there are a number of
associated symptoms to ask about
concurrent hearing loss and tinnitus or
ringing in the ears suggests Meniere's
disease headache and photophobia suggest
migraines concurrent ocular symptoms
beyond photophobia suggest Kogan
syndrome other concurrent or prior
neurologic symptoms suggest multiple
sclerosis or a posterior circulation
stroke if the patient has a deficit
imbalance that is more prominent than
vertigo it suggests bilateral and
symmetric vestibular damage which is
classic for immuno glucoside toxicity
but can also be seen with Meniere's
disease there are several relatively
unique symptoms that can be experienced
by patients presenting with vertigo the
first is called a tilt illusion which is
the sensation that everything in the
world is tilted with respect to gravity
drop attacks are sudden losses of
postural tone without a loss of
consciousness an ocelot Zea is a
sensation of to-and-fro movements of the
environment which may be either sudden
and jerky or smooth and regular when
smooth it's associated with a physical
finding called pendular nystagmus this
symptom is typically more prominent when
the patient is walking and the head is
in motion
questions about past medical history
should focus on atherosclerosis factors
and also ask about past migraines the
focused exam for a patient presenting
with vertigo should include an ear exam
and a thorough neuro exam there is a
specific combination of relevant exam
findings that have been bundled together
as the Hintz exam h ints which stands
for head impulse nystagmus and tests of
skew because the hints exam has been
reported to have very high positive and
negative predictive values for
distinguishing central from peripheral
ideologies it is a particularly
important part of the vertigo evaluation
for the head impulse test ask the
patient to look straight ahead at your
nose and keep their gaze on it while you
passively turn their head to the side
the most important phase of the movement
should be relatively quick but to make
sure you don't injure the patient a good
technique is to slowly turn the head
about 20 degrees to one side and then
quickly return it to the midline
it's also important to mix up the speeds
and direction of the movements a little
to prevent the patient from
unconsciously anticipating the movement
a normal response is for the patient's
gaze to remain on target while an
abnormal response is for the pierce
person's gaze to initially move followed
by a rapid corrective eye movement back
to the target this should be repeated in
both directions
in the case of vertigo in abnormal test
is actually reassuring since it suggests
a probable peripheral cause of vertigo
whereas a bilaterally normal response is
more consistent with a central cause
to test for nystagmus ask the patient to
look straight ahead and look for any
movements of either eye then ask the
patient to look to the extreme in one
direction and hold for a few moments and
then repeat in the other direction a
reassuring finding is either no
nystagmus at all or only unidirectional
horizontal nystagmus unidirectional
does not mean unilateral but rather that
the fast component of nystagmus is
always in the same horizontal direction
any other type of nystagmus
for example bi-directional nystagmus is
strongly suggestive of a central
etiology
you
last is the test of skew for this ask
the patient to look straight ahead at
your nose and then cover one eye for a
few seconds and then rapidly move to
cover the other eye instead and go back
and forth and look to see if there's any
movement of the uncovered eye adjustment
of the eye as it is uncovered implies a
vertical misalignment of the two eyes
and is considered a positive test
to summarize the hints exam indicates a
likely central ideology if any of the
following are present the patient has a
normal head impulse test bi-directional
or other unusual form of nystagmus or an
abnormal test of skew
the last part of a focused physical exam
for vertigo is the Dix Hal Pike maneuver
which is specifically a test for BPPV
for this the patient needs to be sitting
lengthwise on an exam table in which the
examiner is able to stand at the head
then with the patient's arms folded as
relaxed as possible and head turned 45
degrees towards the examiner the
examiner helps the patient to smoothly
but quickly lower the head straight back
and slightly over the edge of the table
the II vocation of nystagmus with this
maneuver is considered to be a positive
test and is indicative of BPPV it should
be repeated on both sides as a general
rule the hints exam is most
appropriately performed on a patient
with hours or days of continuous vertigo
whereas the Dix Hal pike is most
appropriately performed on a patient
with brief recurrence episodes of
vertigo it would be unusual for both the
hints and the Dix Hal pike to be
indicated in the same patient most cases
of vertigo can be successfully diagnosed
from the history and exam alone and new
team blood tests are rarely if ever
helpful however there are a couple of
additional tests occasionally indicated
specifically audiometry or a formal
hearing assessment if Meniere's disease
is suspected and a brain MRI plus or
minus an MRA if a central cause cannot
be ruled out from the history and exam
alone let's now look at an overall
algorithm for evaluating vertigo that
puts all this together
first we start with a patient reporting
dizziness and we must discern between
the three possible syndromes is it pre
syncope in which the patient clarifies
dizziness by describing a feeling of
faintness or like they're going to pass
out the symptom of pre syncope may be
triggered by upright posture certain
situations like urination a coughing fit
or emotional shock or it can be
spontaneous and it can be associated
with loss of consciousness
or is the patient describing
disequilibrium which the patient feels
unable to stay balanced when standing or
walking symptoms are worse with walking
and it's associated with frequent Falls
but without faintness or loss of
consciousness or is the patient's
dizziness vertigo in which the patient
feels like the room is spinning or that
they themselves are in motion vertigo is
worse with head movement and is often
associated with nausea
focusing just on the further workup of
vertigo there are four common clinical
presentations the patient could have
recurrent episodes lasting seconds to a
few minutes which are not only worsened
by movement but also triggered by
movement this is the typical
presentation for BP Bibi in which case
the next step is the Dix Hal Pike
maneuver an abnormal Dix Hal Pike
combined with the classic presentation
is sufficient to confirm BPPV however
this manoeuvre only tests for odourless
in the posterior canals which is the
most common but if there are free
odourless in the anterior or horizontal
canals the manoeuvre may be normal there
are some additional tests for these
uncommon forms of BP V V that are beyond
the scope of this particular video
contrast to the extremely brief episodes
of vertigo and BPPV
the recurrent episodes can last many
minutes two hours in this case the
patient probably has vestibular
migraines or Meniere's disease to
distinguish between them
check audiometry if the patient has
either episodic symptomatic hearing loss
episodic tinnitus or has low frequency
hearing loss as picked up on audiometry
which could be subclinical or
asymptomatic the patient probably has
maneras disease on the other hand if the
patient has neither auditory symptoms
nor abnormalities on audiometry they
likely have vestibular migraines if the
patient's vertigo has been a continuous
single episode and they have an abnormal
hints exam they probably have a central
ideology in which case a brain MRI plus
or minus MRA is indicated the urgency of
neuroimaging is dependent upon the
acuity of symptom onset if a diagnosis
is made you should further work it up as
indicated if the mr is unremarkable you
should consider rare causes or
potentially a false positive hence exam
in a patient with vestibular neuritis
and last if the patient's presentation
has been a single continuous episode
lasting days or less with or without an
Associated viral syndrome they probably
have vestibular neuritis for most
patients the appropriate next step is
symptomatic management and reassessment
in one to two weeks if symptoms resolve
no further workup is indicated unless
the vertigo recurs if the symptoms
persist then neuroimaging is usually
warranted now there's one big caveat to
this algorithm while the hints exam is
believed to be very accurate at
distinguishing central versus peripheral
causes of vertigo it's not perfect and
is examiner dependent this combined with
the fact that you really don't want to
miss a posterior circulation stroke
means that if you are considering
vestibular neuritis as the most likely
diagnosis but your patient is older has
stroke risk factors and certainly if
there are other neuro science and
symptoms present consider neuro imaging
without first waiting one to two weeks
the key takeaway points of this video
it's important to distinguish vertigo
from lightheadedness and disequilibrium
all three of which may be referred to as
dizziness by the patient
the most common etiology of vertigo is
benign paroxysmal positional vertigo a
diagnosis of which can usually be
confirmed by the Dix Hal pike manoeuvre
the diagnosis of a patient with vertigo
is predominantly based on history and
physical exam and last for hints exam
which stands for head impulse nystagmus
and test of skew is an important
component of the evaluation of vertigo
in abnormal hints exam should warrant an
MRI
plus or minus an MRA to look for central
ideologies such as a posterior
circulation stroke or multiple sclerosis
you
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