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ESSENTIALS OF DIAGNOSIS
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Either a sensation of motion when there is no motion or an exaggerated sense of motion in response to a given bodily movement Duration of discrete vertiginous events is key to diagnosis Must differentiate peripheral from central etiologies of vestibular dysfunction Peripheral: Onset is sudden; often associated with tinnitus and hearing loss; horizontal nystagmus may be present Central: Onset is gradual; no associated auditory symptoms Evaluation includes audiogram and electronystagmography (ENG) or videonystagmography (VNG)
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Clinical Findings
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A Symptoms and Signs
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Vertigo is the cardinal symptom of vestibular disease It is either a sensation of motion when there is no motion or an
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CHAPTER 8 B Laboratory Findings
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Laboratory investigations such as audiologic evaluation, caloric stimulation, ENG or VNG, and MRI are indicated in patients with persistent vertigo or when central nervous system disease is suspected These studies will help distinguish between central and peripheral lesions and to identify causes requiring specific therapy ENG consists of objective recording of the nystagmus induced by head and body movements, gaze, and caloric stimulation It is helpful in quantifying the degree of vestibular hypofunction and may help with the differentiation between peripheral and central lesions Computer-driven rotatory chairs and posturography platforms offer additional diagnostic modalities from specialized centers
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Brandt T et al General vestibular testing Clin Neurophysiol 2005 Feb;116(2):406 26 [PMID: 15661119] Guilemany JM et al Clinical and epidemiological study of vertigo at an outpatient clinic Acta Otolaryngol 2004 Jan;124(1):49 52 [PMID: 14977078] Lempert T et al Episodic vertigo Curr Opin Neurol 2005 Feb;18(1):5 9 [PMID: 15655395]
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exaggerated sense of motion in response to a given bodily movement While vertigo is typically experienced as a distinct spinning sensation, it may also present as a sense of tumbling or of falling forward or backward It should be distinguished from imbalance, light-headedness, and syncope, all of which are nonvestibular in origin The vertigo that results from peripheral vestibulopathy is usually of sudden onset, may be so severe that the patient is unable to walk or stand, and is frequently accompanied by nausea and vomiting Tinnitus and hearing loss may be associated and provide strong support for a peripheral (ie, otologic) origin A thorough history will often narrow down, if not confirm, the diagnosis Critical elements of the history include the duration of the discrete vertiginous episodes (seconds, minutes to hours, or days), and associated symptoms Triggers should also be sought, including diet (eg, high salt in the case of Meniere s disease), stress, fatigue, and bright lights The physical examination of the patient with vertigo includes evaluation of the ears, eye motion in response to head turning and observation for nystagmus, cranial nerve examination, and Romberg testing In acute peripheral lesions, nystagmus is usually horizontal with a rotatory component; the fast phase usually beats away from the diseased side Visual fixation tends to inhibit nystagmus except in very acute peripheral lesions or with central nervous system disease Dix-Hallpike testing (quickly lowering the patient to the supine position with the head extending over the edge and placed 30 degrees lower than the body, turned either to the left or right) will elicit a delayed onset (~15 sec) of fatigable nystagmus in cases of benign positioning vertigo Nonfatigable nystagmus in this position indicates a central etiology for the dizziness Since visual fixation often suppresses observed nystagmus, many of these maneuvers are performed with Fresnel goggles, which prevent visual fixation and often bring out subtle forms of nystagmus The Fukuda test, in which the patient consistently rotates when walking in place with eyes closed, can also demonstrate vestibular asymmetry In contrast to peripheral forms of vertigo, dizziness arising from central lesions tends to develop gradually and then become progressively more severe and debilitating Nystagmus is not always present but can occur in any direction and may be dissociated in the two eyes The associated nystagmus is often nonfatigable, vertical rather than horizontal in orientation, without latency, and unsuppressed by visual fixation ENG is useful in documenting these characteristics The evaluation of central audiovestibular dysfunction usually requires imaging of the brain with MRI Episodic vertigo can occur in patients with diplopia from external ophthalmoplegia and is maximal when the patient looks in the direction where the separation of images is greatest Cerebral lesions involving the temporal cortex may also produce vertigo, which is sometimes the initial symptom of a seizure Finally, vertigo may be a feature of a number of systemic disorders and can occur as a side effect of certain anticonvulsant, antibiotic, hypnotic, analgesic, and tranquilizing drugs or of alcohol
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