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Vertigo

Clinical Findings

Symptoms and Signs

Vertigo is the cardinal symptom of vestibular disease. It is either a sensation of motion when there is no motion or an exaggerated sense of motion in response to a given bodily movement. Thus, vertigo is not just "spinning" but may present, for example, as a sense of tumbling, of falling forward or backward, or of the ground rolling beneath one's feet ("earthquake-like"). It should be distinguished from imbalance, light-headedness, and syncope, all of which are usually nonvestibular in origin. The vertigo that results from peripheral vestibulopathy is usually of sudden onset, may be so severe that the patient is unable to walk or stand, and is frequently accompanied by nausea and vomiting. Tinnitus and hearing loss may be associated and provide strong support for a peripheral origin.

A minimal physical examination of the patient with vertigo includes the Romberg test, an evaluation of gait, and observation for the presence of nystagmus. In peripheral lesions, nystagmus is usually horizontal with a rotatory component; the fast phase usually beats away from the diseased side. Visual fixation tends to inhibit nystagmus except in very acute peripheral lesions or with central nervous system disease. The Nylen-Bárány maneuvers are performed as follows: Put the patient in a sitting position on the examination table with the head turned to the right. Quickly lower the patient to the supine position with the head extending over the edge and placed 30 degrees lower than the body. Watch for nystagmus for 30 seconds. Repeat with the head turned to the left. Lastly, perform the maneuver without turning the head.

These maneuvers are intended to induce positioning nystagmus but are of limited use when the patient is able to visually fixate. This objection may be overcome either by placing +2-diopter lenses (Fresnel glasses) over the eyes or by making observations in the dark by means of electronystagmographic recording. The Fukuda test, in which the patient walks in place with eyes closed, is useful for detecting subtle defects. A positive response is observed when the patient rotates, usually toward the side of the diseased labyrinth. Vertigo arising from central lesions tends to develop gradually and then become progressively more severe and debilitating. Nystagmus is not always present but can occur in any direction and may be dissociated in the two eyes. The associated nystagmus is often nonfatigable, vertical rather than horizontal in orientation, without latency, and unsuppressed by visual fixation. Electronystagmography is useful in documenting these characteristics. The evaluation of central audiovestibular dysfunction usually requires imaging of the brain with MRI.

Episodic vertigo can occur in patients with diplopia from external ophthalmoplegia and is maximal when the patient looks in the direction where the separation of images is greatest. Cerebral lesions involving the temporal cortex may also produce vertigo, which is sometimes the initial symptom of a seizure. Finally, vertigo may be a feature of a number of systemic disorders and can occur as a side effect of certain anticonvulsant, antibiotic, hypnotic, analgesic, and tranquilizing drugs or of alcohol.

Laboratory Findings

Laboratory investigations such as audiologic evaluation, caloric stimulation, electronystagmography, CT scan or MRI, and brain stem auditory evoked potential studies are indicated in patients with persistent vertigo or when central nervous system disease is suspected. These studies will help distinguish between central and peripheral lesions and to identify causes requiring specific therapy. Electronystagmography consists of objective recording of the nystagmus induced by head and body movements, gaze, and caloric stimulation. It is helpful in quantifying the degree of vestibular hypofunction and may help with the differentiation between peripheral and central lesions. Computer-driven rotatory chairs and posturography platforms offer improved diagnostic abilities but are not widely available.