Management of vertigo and vestibular disorders

Thomas Brandt

Vestibular syndromes are commonly characterized by a combination of phenomena involving perceived vertigo, nystagmus, ataxia, and nausea.1 These four manifestations correlate with different aspects of vestibular function and emanate from different sites within the central nervous system.

• The vertigo itself results from a disturbance of cortical spatial orientation.

• Nystagmus is secondary to a direction-specific imbalance in the vestibulo-ocular reflex, which activates brainstem ocular motor neuronal circuitry.

• Vestibular ataxia and postural imbalance are caused by inappropriate or abnormal activation of mono- and polysynaptic vestibulospinal pathways.

• The unpleasant autonomic responses with nausea, vomiting and anxiety travel along ascending (anxiety) and descending vestibulo-autonomic pathways to activate the medullary vomiting center.

Vertigo, dizziness and disequilibrium are common complaints of patients of all ages, particularly the elderly. As presenting symptoms, they occur in 5-10% of all patients seen by general practitioners and 10-20% of all patients seen by neurologists and otolaryngologists. The clinical spectrum of vertigo is broad, extending from vestibular rotatory vertigo with nausea and vomiting to presyncope light-headedness, from drug intoxication to hypoglycemic dizziness, from visual vertigo to phobias and panic attacks, and from motion sickness to height vertigo. Appropriate preventions and treatments differ for different types of dizziness and vertigo.

The prevailing good prognosis of vertigo should be emphasized, because:

(1) many forms of vertigo have a benign cause and are characterized by spontaneous recovery of vestibular function or central compensation of a peripheral vestibular tone imbalance (2) most forms of vertigo can be effectively relieved by pharmacological treatment (Table 46.1), physical therapy (Table 46.2), surgery (Table 46.3), or psychotherapy.1

Table 46.1 Pharmacological therapies for vertigo

Therapy

Vertigo

Vestibular

Symptomatic relief of nausea (in

suppressants

acute peripheral and vestibular

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