Peripheral vertigo

Summary

This 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

00:00

🌀 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.

05:00

🔍 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.

10:01

🌐 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.

Keywords

💡Peripheral Vertigo

Peripheral vertigo refers to a sensation of spinning or dizziness caused by issues within the vestibular system of the inner ear. It is a central theme of the video, as it differentiates from central vertigo, which originates in the central nervous system. The script discusses various causes and treatments of peripheral vertigo, such as BPPV and Meniere's disease.

💡Vestibular System

The vestibular system is a part of the inner ear that plays a crucial role in maintaining balance. It consists of the semicircular canals and is connected to the central nervous system via the vestibulocochlear nerve. The video emphasizes the importance of this system in causing peripheral vertigo when it is impaired.

💡Semicircular Canals

Semicircular canals are three fluid-filled rings within the inner ear that help detect changes in head position and maintain balance. The video explains that problems with these canals, such as the presence of crystalline deposits in BPPV, can lead to peripheral vertigo.

💡Benign Paroxysmal Positional Vertigo (BPPV)

BPPV is a common cause of peripheral vertigo, characterized by brief, triggered episodes of dizziness. The script describes the pathophysiology of BPPV involving displaced otoconia in the semicircular canals, which disrupt normal fluid flow and cause vertigo. Treatment options like the Epley maneuver are also discussed.

💡Meniere's Disease

Meniere's disease is another cause of peripheral vertigo, resulting from increased volume or pressure of endolymph in the semicircular canals. The video outlines its symptoms, including episodes of vertigo, hearing loss, and tinnitus, and discusses treatment approaches ranging from lifestyle changes to surgical options.

💡Labyrinthitis

Labyrinthitis is an inflammation of the vestibular nerve, which can cause acute episodes of vertigo, nausea, vomiting, and hearing loss. The video describes it as a viral or post-viral condition and mentions the use of steroids as a treatment to resolve the inflammation.

💡Herpes Zoster Oticus (Ramsay Hunt Syndrome)

Herpes zoster oticus, also known as Ramsay Hunt syndrome, is caused by the reactivation of the latent herpes zoster virus, affecting the facial nerve and causing symptoms like facial paralysis and ear pain. The video mentions the triad of symptoms for diagnosis and the use of steroids and acyclovir for treatment.

💡Perilymphatic Fistula

A perilymphatic fistula is a leakage of the perilymph fluid within the inner ear, often due to trauma. The video explains that this condition can cause progressive hearing loss and episodic vertigo triggered by pressure changes, such as during a sneeze or cough.

💡Vestibular Neuritis

Vestibular neuritis is an inflammation of the vestibular nerve, similar to labyrinthitis, and is diagnosed through an abnormal head thrust test. The video mentions that it is a diagnosis of exclusion, requiring brain imaging to rule out other causes before confirming.

💡Aminoglycoside Toxicity

Aminoglycoside toxicity refers to damage caused by certain antibiotics like gentamicin, which are vestibulotoxic. The video notes that while this can cause bilateral vestibular damage, it may not result in vertigo due to the lack of conflicting inputs from the inner ear, but can lead to disequilibrium or oscillopsia.

💡Vestibular Schwannoma

Vestibular schwannoma, also known as acoustic neuroma, is a slow-growing tumor of the vestibular part of the cranial nerve eight. The video explains that it primarily affects hearing but may not cause vertigo due to central compensation. Diagnosis involves audiometry and MRI, with treatment options including surgical resection or radiation.

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