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Peripheral Vertigo

Peripheral vertigo is a symptom caused by disturbances of the vestibular system or cranial nerve VIII. Common causes include benign paroxysmal positional vertigo, Meniere's disease, and vestibular neuritis. Physical exam may reveal nystagmus and loss of balance. Treatment depends on the underlying cause but may include vestibular rehabilitation therapy.

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44 views5 pages

Peripheral Vertigo

Peripheral vertigo is a symptom caused by disturbances of the vestibular system or cranial nerve VIII. Common causes include benign paroxysmal positional vertigo, Meniere's disease, and vestibular neuritis. Physical exam may reveal nystagmus and loss of balance. Treatment depends on the underlying cause but may include vestibular rehabilitation therapy.

Uploaded by

Alin Ciubotaru
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Peripheral Vertigo

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Author: Brett Baumgartner Editor: Roger S. Taylor Updated: 6/26/2023 9:10:44 PM

Introduction
It is essential to remember vertigo is a symptom, not a diagnosis. Most of us have
experienced some vertigo in our lives. However, this can be difficult for an individual to
describe, so often, vertigo is described in various ways. One of the simplest forms of
vertigo which many have experienced is the transient feeling of dizziness and
perception of ourselves or the environment spinning around us after rapidly turning in
circles. Often, nausea and vomiting will accompany these symptoms.[1]

Etiology
The etiology of vertigo is typically due to a disturbance of the vestibular system,
semicircular canals, or cranial nerve VIII. This disturbance could be related to damage
to one of these organs or simply confused neuronal input. It is important to remember
that the central nervous system receives inputs bilaterally from these
structures/systems, assembles the input and then, forms a response. The central
nervous system (CNS) also coordinates these bilateral inputs with our visual and
sensory inputs creating an overall picture of whether we are moving in space/time or if
the environment around us is moving. Suffice it to say that conflicting inputs from these
various symptoms overwhelm the central nervous system causing "dizziness," nausea,
and the perception of movement.

The following are the various causes of vertigo:

Peripheral Vertigo

 Benign paroxysmal positional vertigo (BPPV)


 Meniere disease
 Vestibular neuritis
 Labyrinthitis
 Herpes zoster
 Acoustic neuroma
 Otitis media
 Perilymphatic fistula
 Aminoglycoside toxicity
 Viral infections
 Cogan syndrome

Central Vertigo

 Brainstem ischemia/infarction
 Vertebrobasilar insufficiency
 Space-occupying lesions
 Demyelination syndromes
 Vestibular migraine
 Chiari malformation

Benign Paroxysmal Positional Vertigo

Benign paroxysmal positional vertigo is classically described as a sudden onset of


spinning brought on by a rapid head movement or a quick turn in bed before getting
up. There is no associated ear pain, tinnitus, or hearing loss. The pathophysiology
behind this is usually the displacement of otolith or calcium debris located in the
posterior semicircle canal. This type of vertigo classically can be made worse with the
Dix Hallpike maneuver and subsequently fixed with the Epley maneuver by relocating
these otoliths. Other less commonly used maneuvers include Semont, Lempert, and
Hamid.

Peripheral Vertigo Causes

 Vestibular neuritis is usually a post-viral inflammatory syndrome. Patients


typically develop rapid, severe nausea, vomiting, vertigo, and gait instability.
Despite gait instability, patients are still able to ambulate. They display the
typical peripheral vertigo physical findings discussed below. If there is an
associated unilateral hearing loss, it is then called labyrinthitis. Often, due to
the severity of the symptoms, this can be confused with a central process.
Consequently, magnetic resonance imaging is performed if clinician suspicion
is high to aid in the diagnosis.
 Meniere's disease: Excess endolymphatic fluid causes Meniere's disease.
The excess pressure causes inner ear dysfunction. Patients present with
episodic unilateral tinnitus, hearing loss, nausea, vomiting, gate instability,
and vertigo. Audiometry testing demonstrating a low sensorineural hearing
loss can aid in diagnosis.
 Cogan syndrome is an autoimmune process that presents with symptoms
similar to those of Meniere disease, so it seems relevant to mention (even
though not one of the more common causes). Caloric testing usually
demonstrates absent vestibular function.
Epidemiology
Approximately 80% of vertigo is peripheral, whereas approximately 20% is central in
origin. Of this 80%, benign paroxysmal positional vertigo (BPPV) is by far the most
common cause of peripheral vertigo.[2]

Pathophysiology
A disturbance of the vestibular system, semicircular canals, or cranial nerve 8 is the
underlying issue. This disturbance could be related to damage to one of these organs
or simply confused neuronal input. It is important to remember that the central nervous
system receives inputs bilaterally from these structures/systems, assembles the input
and then, forms a response. The CNS also coordinates these bilateral inputs with our
visual and sensory inputs creating an overall picture of whether we are moving in
space/time or if the environment around us is moving. Suffice it to say that conflicting
inputs from these various symptoms overwhelm the central nervous system causing
dizziness, nausea, and the perception of movement.[3][4]

Vertigo breaks down into two types: peripheral and central. As the main focus of this
review is on peripheral vertigo, we will only touch slightly on central vertigo to help
distinguish between the two.

Usually, peripheral vertigo is, although not always, due to a benign process, whereas
central vertigo often indicates a more serious pathology.

History and Physical


Peripheral vertigo is described as dizziness or a spinning sensation. Other symptoms
associated with peripheral vertigo include:

 Loss of hearing in one ear


 Ringing in one or both ears
 Difficulty focusing vision
 Loss of balance

Evaluation
The diagnosis and workup consist of taking a very accurate and detailed history along
with symptomatic/physical findings. Peripheral vertigo is typically episodic and
acute/severe. Alternatively, central vertigo typically is over a longer duration of time,
and “most” of the time, less severe symptoms occur. Peripheral vertigo usually can be
made worse with head movements and typically has been associated with
horizontal/rotary nystagmus, which is fatigable and unidirectional.

Central vertigo can have nystagmus in any direction is not fatigable and typically multi-
directional.

The Dix Hallpike test can help aid in the diagnosis of peripheral vertigo, typically
making symptoms worse and nystagmus more obvious.

Other specialized tests include:

 Electro/videonystagmography (ENG)
 Computerized dynamic posturography (CDP)
 The rotating-chair test also known as sinusoidal harmonic acceleration (SHA)
 Vestibular-evoked myogenic potentials

Treatment / Management
Treatment usually involves giving the body time to heal and treatment of the underlying
process. There is some data to suggest, antihistamines, benzodiazepines,
corticosteroids, antiemetics, and anticholinergic’s may be of use depending on the
etiology of peripheral vertigo. Vestibular rehabilitation therapy (VRT) may also offer
relief to some patients. Vestibular rehabilitation therapy is a form of physical therapy
that takes advantage of the plasticity of the brain using specialized exercises and head
movements to help gaze and gait stabilization.[5][6]

Differential Diagnosis
The differential diagnosis of peripheral vertigo can be vast and will not be discussed in
depth here; however, it is important always to consider stroke, infection, and other
potentially treatable etiologies.

Prognosis
The prognosis for peripheral vertigo is typically quite favorable. It may lead to some
morbidity; however, following correct identification of the etiology is correctly identified,
symptoms can usually be quite tolerable if not completely resolved

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