SIGNS AND SYMPTOMS 
History
- Vertigo:
- Peripheral vertigo
- Sudden onset
- Associated with movement, head position
- Sensation of room spinning or off balance
- Nausea and vomiting
- Episodes of hearing impairment:
- Unilateral or bilateral
- Mild or profound
- Tinnitus (consider Ménière disease)
- Otorrhea (consider otitis media, tympanic membrane [TM] perforation)
- Otalgia (consider otitis media, mastoiditis, cholesteatoma)
- Associated with recent infections or sick contacts
- Predisposing factors include ear surgery, diabetes mellitus, stroke, migraine, and trauma
- Head/cervical spine trauma is a direct causal agent, as it dislodges inner ear particles
- Associated with family history of hearing loss or ear diseases
Physical Exam
- Complete head and neck exam
- Inspect external ear (erythema, swelling, evidence of surgery), ear canal (otorrhea, vesicles), and TM and middle ear (perforation, cholesteatoma, middle ear effusion, or otitis media)
- Mastoid tenderness (mastoiditis)
- Ocular exam, including range of movements, pupillary response, and fundoscopy, to assess for papilledema
- Nystagmus:
- Augmented by head movement or rapid head shaking
- Positional
- Horizontal, frequently with rotational component
- Direction is constant
- Attenuates with fixation
- Fatigable
- Complete neurologic and cardiac exams:
- Assess for other causes of symptoms
- Cranial nerves, Romberg test, tandem gait, cerebellar function
- Orthostatic vitals, carotid and vertebral bruits
- May be associated with facial weakness or asymmetry (consider stroke or Ramsay Hunt syndrome), neck pain or stiffness (consider meningitis), and visual changes (consider central cause of vertigo)
- Caloric testing:
- Irrigate external ear canal with cold water for 20 sec (1st inspect to confirm absence of TM perforation).
- Normal response causes horizontal nystagmus with the fast phase away from the irrigated ear
- Labyrinthitis produces partial or complete loss of response
- Dix–Hallpike maneuver:
- Tests for evidence of BPPV
ESSENTIAL WORKUP
- Careful neurologic exam to exclude central cause of vertigo
- Exclude underlying infections:
- Acute otitis media, meningitis, mastoiditis, Ramsay Hunt syndrome (herpetic lesions on the TM)
- Orthostatics
- Auditory evaluation
DIAGNOSIS TESTS & INTERPRETATION
- Indicated only if evaluating patients for central vertigo or more unusual etiologies of peripheral vertigo
- Chemistry panel and electrolytes if significant or refractory nausea and vomiting
- Lumbar puncture if clinical suspicion for meningitis or subarachnoid hemorrhage
Lab
- Finger-stick glucose
- Syphilis screening
- Rheumatoid factor
- Chemistry panel and electrolytes
Imaging
- Indications:
- Findings suggestive of central vertigo:
- Acute or gradual onset
- Not positional but may be exacerbated by head movements
- Pure direction—vertical, horizontal, or torsional
- Direction may change
- Nonfatigable
- High cardiovascular risk factors
- Focal neurologic findings
- Head CT:
- Fine cuts through the cerebellum
- MRI and MRA:
- Evaluate the posterior fossa, the 8th cranial nerve, and the vertebrobasilar circulation
- Imaging study of choice in patients suspected of central vertigo
ALERT
Consider brain imaging in patients > 45 yr, children, and patients with cardiovascular risk factors.
Diagnostic Procedures/Surgery
- Electronystagmography: May help in diagnosing difficult cases
- Infrared nystagmography: Torsional eye movement can be demonstrated directly
DIFFERENTIAL DIAGNOSIS
- Peripheral vertigo:
- Otitis media
- Vestibular neuritis
- Acoustic neuroma
- Autoimmune inner ear disease
- BPPV
- Cholesteatoma
- Ménière disease (associated tinnitus, "fullness," or hearing loss)
- Otosyphilis
- Ototoxic drugs (loop diuretics, aminoglycosides, streptomycin, salicylates, ethanol)
- Herpes zoster (Ramsey Hunt syndrome)
- Perforated TM
- Perilymphatic fistula (symptoms accentuated with Valsalva)
- Post-traumatic vestibular concussion
- Suppurative labyrinthitis (toxic appearance)
- Temporal bone fracture
- Central vertigo—often presents with symptoms indistinguishable from peripheral vertigo because the labyrinth has a monosynaptic connection to the brainstem:
- Cardiac arrhythmia (presyncopal symptoms)
- Hypoglycemia (gradual onset, not positional)
- Hypotension (exacerbated with standing)
- Cervicogenic disease (onset with rotational neck movement)
- Hypothyroidism
- Alcohol or drug induced
[Outline]
PRE-HOSPITAL
- Cardiac monitor for arrhythmia
- Finger-stick glucose to exclude hypoglycemia
- Acute stroke assessment
- Antiemetics for nausea and vomiting
- IV fluids for dehydration
- Fall precautions
INITIAL STABILIZATION/THERAPY
- Bed rest and hydration
- Fall precautions
ED TREATMENT/PROCEDURES
- Medications are minimally beneficial for BPPV
- Avoid chronic use (up to 48 hr) to encourage development of vestibular compensation
- Medications for symptomatic relief:
- Vestibular suppressants: Diazepam, meclizine, scopolamine
- Antiemetics: Ondansetron, prochlorperazine, promethazine
- Corticosteroids: Poor evidence for efficacy
- Debris repositioning is primary therapy for BPPV. Effective relief in 50–80% of patients:
- Vestibular enhancement exercises
- Surgery for failed medical and physical therapy:
- Posterior canal plugging to occlude canal
- Nerve section
MEDICATION
- Diazepam (benzodiazepine): 2–10 mg IV; 5–10 mg (0.1–0.3 mg/kg/24 h) PO q6–12h
- Dimenhydrinate: 5 mg/kg/24 h PO, IM, IV, or PR
- Meclizine (antihistamine): 25 mg (50 mg/24 h for patient > 12 yr) PO q6h
- Lorazepam: 0.5–2 mg IV, IM, or PO q6h (peds: 0.05 mg/kg IV/PO q4–8h)
- Ondansetron: 4–8 mg IV, IM, or PO q8h (peds: 1 mo–12 yr and < 40 kg: 0.1 mg/kg IV; > 12 yr and > 40 kg: 4 mg IV)
- Prochlorperazine: 5–10 mg (peds: 0.3 mg/kg/24 h IM or PO for patient > 2 yr old) IV, IM, or PO q6–8h
- Promethazine: 12.5–25 mg (peds: 1.5–2 mg/kg/24 h) IV or PO q4–6h
- Scopolamine (anticholinergic, not approved in pediatrics): 0.4 mg PO q4–6h; 1.5-mg transdermal patch q3d
Pediatric Considerations
Bacterial labyrinthitis:
- Antibiotics IV
- Surgical debridement
Pregnancy Considerations
- Class D medication: Diazepam, lorazepam
- Class C medication: Prochlorperazine
- Class B medication: Famciclovir
- Class B medication: Corticosteroids
First Line
Second Line
- Diazepam or lorazepam
- Prochlorperazine or promethazine (beware dystonic or dysphoric reactions)
[Outline]
DISPOSITION
Admission Criteria
- Symptoms concerning for an acute stroke or central etiology of vertigo
- Intractable nausea and vomiting
- Severe dehydration
- Unsteady gait
Discharge Criteria
- Tolerate oral fluids
- Steady gait
- Normal neurologic exam
- Avoid driving, heights, and operating dangerous equipment
- Fall precautions
- Arrange neurology or otolaryngology follow-up
Issues for Referral
- Recurrent symptoms
- Concern for cholesteatoma
- Possible severe underlying conditions such as vertebrobasilar ischemia or brainstem tumor will need consultation from neurologist or neurosurgeon
FOLLOW-UP RECOMMENDATIONS
- Vestibular rehabilitation for patients with persistent vestibular symptoms and chronic vertigo due to peripheral vestibular etiology
- Auditory brainstem response test is indicated in younger children.
- Surgical therapy in the form of labyrinthectomy/posterior canal occlusion/vestibular nerve section, etc., can be considered in cases of refractory vertigo and unsuccessful canalith repositioning procedure.
[Outline]
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See Also (Topic, Algorithm, Electronic Media Element)