The common causes of an acute attack of vertigo are benign positional vertigo, Meniere disease, and vestibular neuronitis. It may also follow head injury.
Benign positional vertigo is the most frequent. It is characterized by brief (a minute or less) attacks of vertigo and nystagmus that occur with certain critical positions of the head, such as lying down or turning over in bed or tilting the head backward. Symptoms may recur periodically for several days or months. Hearing is unaffected. Diagnosis is confirmed by moving the patient from the sitting position to recumbency with the head tilted 30° over the end of the table and 30° to one side (Fig. 15-1A and B). This maneuver produces a brief attack of vertigo and nystagmus; return to the sitting position changes the direction of the vertigo and nystagmus. After three or more trials, the attacks can no longer be elicited. As to pathogenesis, it is generally believed that otolithic debris comes loose from the utricular macula and, with changes in head position, gravitates into the posterior semicircular canal, where it induces push-and-pull forces on the cupula, triggering an attack of vertigo (Shuknecht).
In Meniere disease, the attacks of vertigo are characteristically abrupt, several minutes to an hour in duration, and of such severity that the patient must lie still, with the faulty ear uppermost. Nystagmus, induced by rotation or caloric stimulation, is impaired or lost on the affected side. Tinnitus, a sense of head or ear fullness, and deafness are usually associated and may worsen during an attack.
Vestibular neuronitis is distinguished by the occurrence of a single protracted attack of vertigo, which persists in severe form for several days and, to a lesser degree, for several weeks. There is no response to caloric stimulation on one side, and tinnitus and deafness are absent. Rare recurrent and epidemic forms have been noted. The cause of this
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