Red Flags: Focal neuro signs, severe headache, inability to walk, direction-changing nystagmus - consider stroke!
Assessment and differential diagnosis of spinning sensation
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.
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:
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:
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 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:
| Central vertigo | Peripheral vertigo |
|---|---|
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