TABLE 2314 Causes of Vertigo

BENIGN POSITIONAL VERTIGO BPV is the most common form of peripheral vertigo. Generally, the patient will complain that the vertigo occurs with head movement, typically while turning over in bed or quickly turning the head to one side; it usually lasts seconds to minutes. It is most often idiopathic in nature but is also common secondary to head trauma or viral infections. The peak age of onset is during the sixth decade in the idiopathic group, with a 2:1 female predominance, and in the fourth and fifth decades in the posttraumatic group, with no gender predominance. The pathophysiology of BPV is disputed, but it has been thought to result from lesions of the otolith organs of the inner ear or from deposits in the semicircular canals. BPV is by definition paroxysmal and positional and is reproducible using the Dix-Hallpike maneuver. The nystagmus elicited is usually but not always extinguishable. 3

LABYRINTHITIS Labyrinthitis, or vestibular neuronitis, is characterized by the acute onset of a severe vertiginous episode, often accompanied by nausea or vomiting but usually without tinnitus or hearing loss. Typically the symptom develops over a period of hours and peaks the first day, with a gradual and complete recovery in days. It is usually caused by a viral infection from an upper respiratory tract pathogen.

MENIERE'S DISEASE Meniere's disease, or endolymphatic hydrops, is a diagnosis of exclusion. The classic presentation is of episodic vertigo, hearing loss, tinnitus, and a sensation of aural fullness, although not all symptoms may be present and they may not all occur simultaneously. The symptoms may last seconds to hours, and episodes typically occur in clusters followed by periods of remission. The pathophysiology is thought to be a dilatation of the endolymph-containing spaces of the inner ear, although the primary causative factor is unknown.

PERILYMPHATIC FISTULA Perilymphatic fistula is another cause of vestibular vertigo lasting minutes to hours and involves rupture of the cochlear membranes with leakage of perilymph from the middle to the inner ear. It may result from surgery, from strenuous physical activity such as weight lifting, or from excessive pressure changes such as may occur during scuba diving or flying.

Primary treatment of vestibular vertigo is often medical and aimed at suppression of the vestibular system. Antihistamines such as meclizine, phenothiazines such as prochlorperazine, and scopolamine have all been used in the treatment of peripheral vertigo. Specific treatment for Meniere's disease may also include salt restriction and diuretics. Surgery may be necessary for cases refractory to medical therapy.

For those patients in whom BPV may be diagnosed with reasonable certainty, an appropriate plan is a course of medical therapy with otolaryngologic follow-up if symptoms persist more than 1 week. All others should have prompt neurologic or otolaryngologic referral to rule out a central origin of the symptom.

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