Ear, Nose & Throat
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Question 19 of 45
A 44 year old man presents to ED complaining of feeling like the room is 'spinning' associated with nausea and vomiting. You suspect vertigo and are assessing the patient to determine the likely cause. Which of the following clinical features is suggestive of a central cause of vertigo?
Answer:
Features suggestive of central or peripheral causes of vertigo are shown below:| Central vertigo | Peripheral vertigo |
|---|---|
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Vertigo
Ear, Nose & Throat
Last Updated: 12th February 2021
Vertigo refers to the perception of spinning or rotation of the person or their surroundings in the absence of any actual physical movement; it is a symptom, not a diagnosis. In contrast, dizziness is a perception of disturbed or impaired spatial orientation, but there is no false sense of motion.
Vertigo can be disabling, affecting an individual’s ability to work or to drive; it is associated with an increased risk of depression.
Assessment of vertigo
When assessing a patient complaining of vertigo, it is important to differentiate peripheral from central vertigo.
Examination of a patient complaining of vertigo should include:
- Examination of the ear for signs of infection, discharge, vesicular eruptions, or signs of cholesteatoma
- Examination of the eye for nystagmus
- Fundoscopy
- Testing of the cranial nerves and cerebellar function
- Testing for signs of peripheral neuropathy
- Checking for facial asymmetry suggestive of peripheral facial nerve involvement or a cerebrovascular event
- Examining the person's gait, coordination and their ability to stand unaided
- Special tests
- Romberg’s test
- Ask the person to stand up straight with their feet together (or at a distance at which they are steady), and then shut their eyes. If the person cannot maintain their balance when their eyes are closed, the test is positive.
- A positive test suggests a problem with proprioception or vestibular function. It is therefore useful in identifying instability associated with vertigo, but not in distinguishing between peripheral and central causes of vertigo.
- Hallpike manoeuvre (to help make a diagnosis of BPPV)
- See separate article on BPPV
- Head impulse test (to help differentiate between a central and peripheral cause)
- Advise the person to sit upright and to fix their gaze on the examiner. Then rapidly turn the head 10–20 degrees to one side and watch the person's eyes. Repeat several times to the same or opposite side, randomly and unpredictably, until satisfied as to the consistent presence or absence of the corrective saccade.
- In a normal response (indicating a normal peripheral vestibular system), the eyes stay fixed on the examiner. If the eyes are dragged off target by the head turn, a corrective abnormal movement (saccade) occurs as the eyes move back to fix on the examiner. A corrective saccade represents a positive test (disrupted vestibulo-ocular reflex) and implies moderate to severe loss of function of the horizontal semicircular canal on the side to which the test is positive.
- Unterberger’s test (to identify damage to one of the labyrinths)
- Ask the person to march on the spot with their eyes closed and observe them for lateral rotation.
- If there is labyrinthine damage, the person will rotate to the side of the affected labyrinth.
- Alternate cover test
- Ask the person to look at the examiner's nose, then alternately cover their right eye and left eye a number of times. Do this for several cycles, focusing on one eye at a time, watching for vertical correction when the covered eye is uncovered (upward on one side, downward on the other side).
- No vertical correction indicates a normal response, but in a person with skew deviation there will be vertical correction which increases suspicion of stroke in a person with acute vestibular syndrome.
- Romberg’s test
Peripheral vertigo
Peripheral vertigo is caused by disturbance of the vestibular system in the inner ear; the difference in activity between the two ears leads to a difference in sensory inputs to the vestibular nuclei, from which the brain detects a sensation of movement.
Common causes include:
- Benign paroxysmal positional vertigo
- Vestibular neuritis or labyrinthitis
- Meniere’s disease
Uncommon causes include perilymphatic fistula, labyrinthine concussion, vestibular ototoxicity (for example drug-related damage), semicircular canal dehiscence syndrome and syphilis.
| Diagnosis | Benign paroxysmal positional vertigo (BPPV) | Vestibular neuritis | Meniere's disease |
|---|---|---|---|
| Epidemiology | Can affect people of any age but commonly presents between 50 - 70 years. F > M. | Onset occurs most commonly at 30 – 60 years of age. F = M. | Diagnosis most commonly made in people aged 30 - 60 years. F > M. |
| Aetiology | Usually idiopathic. Can be precipitated by head injury, a prolonged recumbent position, ear surgery or following an episode of inner ear pathology. | Often follows a viral infection e.g. URTI. | Unknown. |
| Pathophysiology | Loose calcium carbonate debris moving in the semicircular canals causing motion of the fluid in the inner ear. | Inflammation of the vestibular nerve. | Thought to be caused by endolymphatic hypertension in the inner ear. |
| Vertigo | Transient attacks typically lasting less than 1 minute induced by moving the head. | Spontaneous and sudden onset, lasts days, gradually improves with time. | Spontaneous episodic attacks lasting 20 minutes - 12 hours, can occur in clusters with remission periods. |
| Associated features | Nausea and vomiting, lightheadedness, imbalance. | Nausea and vomiting, malaise, pallor, sweating, unsteadiness. | Tinnitus, fluctuating sensorineural hearing loss, aural fullness. |
| Examination findings | Normal at rest. Dix-Hallpike manoeuvre demonstrates torsional (rotatory) upbeating nystagmus. | Positive head impulse test. Spontaneous fine horizontal nystagmus. | ENT exam findings typically normal. Romberg's test may be positive. Unterberger's test may be positive. |
Central vertigo
Central vertigo is caused by a disturbance to the visual-vestibular interaction centres in the brainstem and cerebellum, or to sensory pathways to and from the thalamus.
Central causes include:
- Migraine (most common cause of central recurrent attacks of vertigo)
- Stroke
- Transient ischemic attack (TIA)
- Cerebellar tumour
- Acoustic neuroma
- Multiple sclerosis
Features suggestive of central or peripheral causes of vertigo are shown below:
| Central vertigo | Peripheral vertigo |
|---|---|
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
