Vertigos

The studies of these symptoms are in constant revision, and justify the attention of different medical specialties in order to manage these common disorders characterized by balance loss.

VERTIGO is a common symptom characterized by spinning, inclination or movement sensation. It may last seconds, minutes, hours or days, and be associated with hearing symptoms (3).

These hearing symptoms may be present uni or bilaterally, may involve tinnitus, hearing loss and ear fullness, and may be sudden, fluctuating or progressive.

Symptoms may be initially severe and worsened by head movements. Patients are usually more comfortable when lying over the affected ear. Other frequent symptoms are nausea, weakness, diarrhea, and sweating.

The more common causes are benign positional vertigo (BPPV), Menière disease, vestibular neuronitis, central vestibular syndromes, and psychogenic vertigo. (3-5-8-14-15-20-23).

Types of Vertigos

1. Prolonged Vertigo

This type of vertigo is due to an acute loss of peripheral or central vestibular function. It is more common in adults between 30 and 60 years of age, more often affecting women in their forties and men in their sixties. It frequently is epidemic, unilateral and follows upper airway tract infections, which suggests viral aetiology although this cannot be proven in the majority of patients.

In these patients vertigo lasting several days is accompanied by unsteadiness, nausea and vomiting, with the patient falling towards the affected side. One can also observe horizontal torsional nystagmus beating of the eyes opposite the affected side, which is faster when gaze is towards on side of its fast component. No other neurological or ear symptoms should be present. . Caloric studies utilizing the Hallpike method will show vestibular paresis on the affected side.

Vestibular recovery is prolonged and may take between 1 and 6 weeks in most patients. However some patients may present persistent symptoms or later develop BPPV.

Differential diagnosis must be made in individuals who also develop hearing loss. This is usually observed after different infectious diseases like mumps, measles and mononucleosis. The most difficult differential diagnosis is in patients with central vestibular diseases but peripheral signs and symptoms, a conditioned referred to as pseudo neuronitis. This may be caused by small infarcts in the distribution of the cerebellar arteries (AICA, PICA), or by demyelization plaques in multiple sclerosis (83, 6, 9, 14, 38). Patient history alone will not differentiate between these conditions so it is important to carry out a careful eye movement exam looking for central signs (7-22).

2. Positional Vertigo

This type of vertigo is triggered by position changes. The most common cause of vertigo is BENIGN PARIOXISTICAL POSITIONAL VERTIGO (B.P.P.V.). In about 50% of cases this vertigo is of unknown cause. It follows head trauma in about 50% of patients (2-3-13-23-24).

BPPV is characterized by short spells of vertigo when lying down on the affected ear. The diagnosis is confirmed by positional tests (Hallpike manoeuvre) which will provoke vertigo and rhythmic eye movements (nystagmus) (2-3-23-24).

Maniobra Dix HallpikeAround 70% of patients will recover spontaneously within the first two months. About 20 to 30% of patients will present frequent episodes for years. BPPV is provoked by otoconia (normal carbonate calcium crystals) being dislodged into a semicircular canal (18-40-44). Based on these scientific principles, effective manoeuvres have been designed to free the semicircular canals of these particles (2-3-4-10-13-16-21-23-25-28-33-36-37-39-44).

It is important to differentiate BPPV from positional nystagmus or vertigo of central origin (3-7-22-29), which may be produced by cerebellar lesions due to infarct, tumours, multiple sclerosis or Arnold Chiari malformation (3-6-38).

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Positional Vertigo Paroxístic

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Maniobra de Hallpike

3. Recurrent Vertigo

Recurrent non positional vertigo is of unknown aetiology in 70% of patients. Menière disease is the most common, followed by other peripheral causes: otesclerosis and perilymph fistula (3). Central causes are due to vascular injury or brain stem demyelization (3-6).

Menière disease is of unknown cause associated with endolimphatic hydrops and frequently over diagnosed. It is more common in individuals between 30 and 50 years of age, more frequently in women.

It is characterized by severe incapacitating vertigo, which usually last several hours, associated with other inner ear symptoms like hearing loss, ear fullness and tinnitus.

These symptoms are unilateral in 85% of patients. The crisis occurs at irregular intervals and postural instability may last several days.

In the early stages of the disease patients are free of symptoms in between crisis, but as the disease progresses hearing loss and tinnitus may become permanent and fluctuate between episodes. Menière disease may be difficult to diagnose after the first episode, but the diagnosis becomes simpler if the patients presents recurrent episodes of the characteristic triad: TINNITUS, HEARING LOSS and VERTIGO.

Differential diagnosis should be done with:

  • 1- Perilymph fistulas: these may follow head trauma, mastoid or stapes surgery or barotrauma. This pathology occurs between the middle ear and the perilymph.
  • 2- Neurovascular compression
  • 3- Cogan’s syndrome is characterized by hearing loss and episodic vertigo similar to Menière disease, accompanied by interstitial non syphilitic queratitis. This syndrome responds to therapy with steroids.
  • 4- Hiperviscosity syndromes.
  • 5- Otesclerosis may sometimes mimic Menière disease. Patients usually have a family history and it is accompanied by conductive hearing loss and tinnitus. A temporal bone tomography may be necessary to visualize an oval window lesion.