peripheral vertigo

Etiology

• benign positional vertigo
  • most common
  • no hearing loss
  • duration of symptoms: minutes to hours; < 24 hours; generally 10-30 seconds
• Meniere's disease
  • hearing loss
  • tinnitus
  • duration of symptoms: minutes to hours; < 24 hours
  • symptoms resolve completely between episodes
• labyrinthitis
  • hearing loss
  • duration of symptoms > 24 hours (unremitting)
  • post viral infection
• vestibular neuronitis
  • no hearing loss
  • duration of symptoms > 24 hours
  • post viral infection
• Herpes zoster oticus (Ramsay Hunt syndrome type 2)
  • unilateral disorder
  • initially, deep burning pain of ear
  • drainage of clear fluid from ear may occur
  • ipsilateral facial paralysis (Bell's palsy)
  • vertigo, tinnitus, hearing loss (ipsilateral)
  • horizontal torsional nystagmus
• acoustic neuroma of cranial nerve 8
• ischemia
• trauma
• toxins

Clinical manifestations

• general
  • nausea/vomiting
  • unsteadiness
  • hearing loss
  • oscillopsia
• distinguishing features from central vertigo
  • nystagmus
    • unidirectional; fast phase opposite lesion (except Meniere's disease where direction is variable)
    • purely horizontal nystagmus without torsional component is uncommon
    • vertical or purely torsional nystagmus is NEVER present
  • visual fixation inhibits nystagmus & vertigo
  • severity of vertigo is generally marked
  • direction of spin is toward fast phase
  • direction of fall is toward slow phase
  • duration of symptoms is finite (minutes, days, weeks), but recurrent
  • tinnitus &/or hearing loss is often present
  • associated CNS abnormalities are NOT present
  • Hallpike maneuver
    • ellicited vertigo fatigues with peripheral vertigo but does not fatigue with central vertigo
  • head impulse testing shows satch-up saccades with peripheral vertigo but not central vertigo

Management

• depends upon specific type
• bed rest:
  • if vertigo persists beyond a few days, ambulation (despite discomfort) to induce central compensatory mechanisms
• systematic exercise for chronic symptoms
  • vestibular rehabilitation
• pharmaceutical agents
  • antihistamines
    • meclizine
    • dimenhydrinate
    • promethazine
  • centrally acting anticholinergics
    • scopolamine
  • benzodiazepines
    • diazepam (Valium)
  • prednisone for labyrinthitis
• surgery is rarely necessary

More general terms

• vertigo

More specific terms

• benign positional vertigo; benign paroxysmal positional vertigo
• recurrent spontaneous vertigo; benign recurrent vertigo; recurrent vestibular vertigo

Additional terms

• labyrinthitis
• Meniere's disease; labyrinthine hydrops; endolymphatic hydrops
• vestibular neuronitis (acoustic neuritis)