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Published by Kreshnik HAJDARI

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Published by: Kreshnik HAJDARI on Apr 08, 2010
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Initial Evaluation of Vertigo
Benign paroxysmal positional vertigo, acute vestibular neuronitis, and Ménière's disease cause most casesof vertigo; however, family physicians must consider other causes including cerebrovascular disease,migraine, psychological disease, perilymphatic fistulas, multiple sclerosis, and intracranial neoplasms. Onceit is determined that a patient has vertigo, the next task is to determine whether the patient has a peripheralor central cause of vertigo. Knowing the typical clinical presentations of the various causes of vertigo aids inmaking this distinction. The history (i.e., timing and duration of symptoms, provoking factors, associatedsigns and symptoms) and physical examination (especially of the head and neck and neurologic systems, aswell as special tests such as the Dix-Hallpike maneuver) provide important clues to the diagnosis.Associated neurologic signs and symptoms, such as nystagmus that does not lessen when the patientfocuses, point to central (and often more serious) causes of vertigo, which require further work-up withselected laboratory and radiologic studies such as magnetic resonance imaging. (Am Fam Physician2006;73:244-51, 25 Copyright © 2006 American Academy of Family Physicians.)
ne of the most common and frustrating complaints patients bring to their familyphysicians is dizziness. There are four types of dizziness: vertigo, lightheadedness,presyncope, and dysequilibrium. 
The most prevalent type is vertigo (i.e., false sense of motion), which accounts for 54 percent of reports of dizziness in primary care.
Thedifferential diagnosis of vertigo
(Table 1
includes peripheral vestibular causes (i.e., those originating inthe peripheral nervous system), central vestibular causes (i.e., those originating in the central nervoussystem), and other conditions. Ninety-three percent of primary care patients with vertigo have benignparoxysmal positional vertigo (BPPV), acute vestibular neuronitis, or Ménière's disease.
Other causesinclude drugs (e.g., alcohol, aminoglycosides, anticonvulsants [phenytoin (Dilantin)], antidepressants,antihypertensives, barbiturates, cocaine, diuretics [furosemide (Lasix)], nitroglycerin, quinine, salicylates,sedatives/hypnotics),
cerebrovascular disease, migraine, acute labyrinthitis, multiple sclerosis, andintracranial neoplasms. Much confusion surrounds the nomenclature of acute vestibular neuronitisbecause the term "labyrinthitis" often is used interchangeably with it. Labyrinthitis (i.e., inflammation of the labyrinthine organs caused by infection) is distinct from acute vestibular neuronitis (i.e., inflammationof the vestibular nerve), and the terms are not interchangable.
Clinical recommendationsEvidencerating Referenc esComments
Use the Dix-Hallpike maneuver to diagnoseBPPV.C7, 10The Dix-Hallpike maneuver has apositive predictive value of 83 percentand negative predictive value of 52percent for the diagnosis of BPPV.Do not use laboratory tests to initially identifythe etiology of dizziness.C10Laboratory tests identify the etiology overtigo in less than 1 percent of patients with dizziness.Consider radiologic studies in patients withneurologic signs and symptoms, risk factorsfor cerebrovascular disease, or progressiveunilateral hearing loss.C19-Use MRI for diagnosing vertigo when C26MRI is superior to computed
neuroimaging is needed.tomography for the diagnosis overtigo because of its superior abilityto visualize the posterior fossa.
BPPV = benign paroxysmal positional vertigo, MRI = magnetic resonance imaging. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C =consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidencerating system, see page 196 or http://www.aafp.org/afpsort.xml.
Because patients with dizziness often have difficulty describing their symptoms, determining the causecan be challenging. An evidence-based approach using knowledge of key historic, physical examination,and radiologic findings for the causes of vertigo can help family physicians establish a diagnosis andconsider appropriate treatments in most cases
(Figure 1)
Differential Diagnosis of Vertigo
Peripheral causes
Acute labyrinthitisInflammation of the labyrinthine organs caused by viral obacterial infectionAcute vestibular neuronitis(vestibular neuritis)*Inflammation of the vestibular nerve, usually caused by viral infectionBenign positional paroxysmalvertigo (benign positional vertigo)Transient episodes of vertigo caused by stimulation of vestibular senseorgans by canalith; affects middle-age and older patients; affects twice asmany women as menCholesteatomaCyst-like lesion filled with keratin debris, most often involving the middle eaand mastoidHerpes zoster oticus (Ramsay Huntsyndrome)Vesicular eruption affecting the ear; caused by reactivation of the varicella-zoster virusMénière's disease (Ménière'ssyndrome, endolymphatichydrops)Recurrent episodes of vertigo, hearing loss, tinnitus, or auralfullness caused by increased volume of endolymph in the semicircular canalsOtosclerosisAbnormal growth of bone in the middle ear, leading to immobilization of thebones of conduction and a conductive hearing loss[corrected]Perilymphatic fistulaBreach between middle and inner ear often caused by trauma or excessivestraining
Central causes
Cerebellopontine angletumor Vestibular schwannoma (i.e., acoustic neuroma) as well as infratentorialependymoma, brainstem glioma, medulloblastoma, or neurofibromatosisCerebrovascular diseasesuch as transient ischemic attackor strokeArterial occlusion causing cerebral ischemia or infarction, especially if affecting the vertebrobasilar systemMigraineEpisodic headaches, usually unilateral, with throbbing accompanied byother symptoms such as nausea, vomiting, photophobia, or phonophobia;may be preceded by auraMultiple sclerosisDemyelinization of white matter in the central nervous system
Other causes
Cervical vertigoVertigo triggered by somatosensory input from head and neck movementsDrug-induced vertigoAdverse reaction to medicationsPsychologicalMood, anxiety, somatization, personality, or alcohol abuse disorders
*-Acute vestibular neuronitis often is erroneously called acute or viral labyrinthitis.Information from references 1 through 6.
Diagnosing Vertigo
FIGURE 1. Algorithm for an initial approach for diagnosing the cause of vertigo. (MRI = magneticresonance imaging.)
History alone reveals the diagnosis in roughly three out of four patients complaining of dizziness,although the proportion in patients specifically complaining of vertigo is unknown.
When collecting a

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