Rosen & Barkin's 5-Minute Emergency Medicine Consult (413 page)

• 3 most common causes of peripheral vertigo include, benign paroxysmal positional vertigo (BPPV), Ménière disease, and labyrinthitis
  
• Labyrinthitis:
  
  • Serous: Viral or bacterial
    
  • Suppurative: Bacterial
    
  • Autoimmune: Wegener or polyarteritis nodosa
    
  • Vascular ischemia
    
  • Head injury or ear trauma
    
  • Medications:
    
    • Aminoglycosides, loop diuretics, antiepileptics (phenytoin)
      
  • Allergies
    
  • Chronic
    
• BPPV:
  
  • Dislodgement of otoconia debris:
    
    • Idiopathic: 49%
      
    • Post-traumatic: 18%
      
    • Sequela of labyrinthitis: 15%
      
    • Sequela of ischemic insult
      

• Suppurative and serous labyrinthitis:
  
  • Usually secondary to acute otitis media, mastoiditis, or meningitis
    
• BPPV:
  
  • Onset 1–5 yr of age
    
  • Symptoms: Abrupt onset of crying, nystagmus, diaphoresis, emesis, ataxia
    
  • Recurrences for up to 3 yr
    
  • Migraine–BPPV complex is the most common etiology of pediatric vertigo
    
• Ménière disease:
  
  • Rare before 10 yr of age
    

DIAGNOSIS

• 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
  

• 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
    

• 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
  

• 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
  

• Finger-stick glucose
  
• Syphilis screening
  
• Rheumatoid factor
  
• Chemistry panel and electrolytes
  

• 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
    

• Electronystagmography: May help in diagnosing difficult cases
  
• Infrared nystagmography: Torsional eye movement can be demonstrated directly
  

• 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:
  
  • Brainstem ischemia
    
  • Cerebellar hemorrhage
    
  • Inferior cerebellar ischemia
    
  • CNS lesions (tumors)
    
  • Chiari malformation
    
  • Multiple sclerosis (paresthesia, optic neuritis)
    
  • Partial seizures of temporal lobe
    
  • Vestibular–masseter syndrome (associated masseter muscle weakness)
    
  • Vestibular migraine (30% have vertigo independent of headaches)
    
  • Wallenberg syndrome (associated Horner's syndrome, crossed sensory signs)
    
• 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
  

TREATMENT

• Cardiac monitor for arrhythmia
  
• Finger-stick glucose to exclude hypoglycemia
  
• Acute stroke assessment
  
• Antiemetics for nausea and vomiting
  
• IV fluids for dehydration
  
• Fall precautions
  

• Bed rest and hydration
  
• Fall precautions
  

• 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:
  
  • Epley maneuver
    
• Vestibular enhancement exercises
  
• Surgery for failed medical and physical therapy:
  
  • Posterior canal plugging to occlude canal
    
  • Nerve section
    

• 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
  

Bacterial labyrinthitis:

• Antibiotics IV
  
• Surgical debridement
  

• Class D medication: Diazepam, lorazepam
  
• Class C medication: Prochlorperazine
  
• Class B medication: Famciclovir
  
• Class B medication: Corticosteroids
  

• Meclizine
  
• Ondansetron for nausea/vomiting
  

• Diazepam or lorazepam
  
• Prochlorperazine or promethazine (beware dystonic or dysphoric reactions)
  

FOLLOW-UP