Differential diagnosis of vertigo and tinnitus/PGS (VPL)

Vertigo
Vertigo is a feeling of disturbed balance. It is a very common symptom in practice, in patients older than 75 years it occurs in 45%. The etiology is diverse. Patients also describe various forms of nausea as "dizziness", so a careful medical history is required.

Diagnostics
Dizziness resolution:


 * systematic - with a component of direction (there is probably a vestibular cause) - feeling of loss of balance, riding in an elevator, twisting, tendency to fall to one side;
 * unsystematic - without directional component (various etiologies) - uncertainty, feeling intoxicated, wandering and staggering, darkness before the eyes, like drunk.

Anamnesis
We determine the duration, recurrence, dependence on position (orthostatic dizziness), benign paroxysmal dizziness when changing position, with loss of consciousness (diff.dg. Syncope), transient ischemic attack, reversible ischemic neurological deficit, dizziness during exercise or walking up stairs (susp. heart failure ), headache (migraine), trauma, tumor, cervicogenic dizziness, dizziness after food (postprandial hypotension), concomitant illness (cardiac, hypertension, pacemaker failure), with dependence on head movements, e.g. looking up (vertebrobasilar insufficiency, benign paroxysmal positional dizziness), together with tinnitus and hearing impairment (in Meniere's disease ), with ear pain, ev. with ear discharge (atchronic otitis media ), or in mastoiditis, cold-worsening dizziness (eg, eardrum perforation, st.p. ear surgery), due to alcohol, drugs, harmful substances, st.p. head injuries, the effect of closing the eyes (if it disappears when closing the eyes - eye etiol.).

Physical exam

 * Internal (blood pressure measurement, arrhythmias, cardiac edema, carotid murmurs, anemia, orthostatic dysregulation: Schellong's test).
 * Neurological (examination of cerebellar symptomatology, sensitive polyneuropathy with loss of position perception, lesions of the cranial nerves - nervus trigeminus or nervus facialis, indicating a process in the bridge of the cerebrospinal cord):
 * examination of gait - falls to one side (fall to the affected side - for vestibular causes, to the healthy side - for cerebellar causes), walking with a broad base (side-neutral tendency to fall - cerebellar or sensitive ataxia );
 * Romberg test - positive (in proprioceptive and sensitive ataxia ), negative (in cerebellar dizziness);
 * Unterberger gait test - positive (for cerebellar and vestibular injuries ).
 * Nystagmus ( vestibular - in one direction, exhausted, never vertical; central - complex, changing direction, direction and vertical, not exhausted).
 * Examination of the ear with an otoscope ( herpes zoster oticus, otitis media , perforation), examination of the hearing (unilateral deafness, usually of vestibular etiology).

Additional diagnostics

 * ECG - ev. Holter examination (suspected arrhythmias);
 * laboratory tests - blood count, glycemia, creatinine, liver tests, event. basal TSH (it is not necessary to test all this in a targeted examination);
 * event. send to an ENT specialist, neurologist, ophthalmologist, orthopedist.

Differential diagnosis of vertigo

 * 1) Internal causes:
 * 2) * decreased cardiac output (in cases of cardiac arrhythmias, heart failure, coronary heart disease , cardiomyopathies , mechanical obstruction in the bloodstream, such as aortic stenosis , loss of circulating volume, diarrhea or bleeding);
 * 3) * hypertension or hypotension (e.g. in orthostatic dysregulation);
 * 4) * cerebral circulatory disorder ( dehydration, increased blood viscosity (with microcirculatory disorder), hypoxemia (e.g. due to hyperventilation syndrome), anemia );
 * 5) * metabolic disorders (hypoglycaemic or hyperglycaemic precomatose, thyrotoxic crisis, uremia );
 * 6) * infection ( chřipkovitá disease, scarlet fever , rubella , measles , mumps , febrile infection).
 * 7) Otological etiology:
 * 8) * vestibular neuritis (unilateral vestibular deficit with acute rotational dizziness, with vegetative accompaniment - vomiting, increased tendency to fall, rotating spontaneous nystagmus and feeling sick, lasts for weeks and slowly subsides, there is no hearing impairment at all) - Therapy is necessary only in severe nausea due to irritation for vomiting we prescribe antivertiginosis (such as dimenhydrinate supp. 100 mg 1-2 times a day (in the Czech Republic rather thiethylperazine supp.), from the 3rd day positioning exercises (so-called "gymnastics of the labyrinth")
 * 9) * benign paroxysmal positional dizziness (acute, persistent attacks of rotational vertigo provoked, which are caused by a certain posture of the head, nystagmus leads to the lower ear, otherwise there is a neurological finding without deviations) - It is caused by cupulolithiasis (idiopathic or posttraumatic). - Therapy consists of position training. - Spontaneous remission occurs after a few months, positioning exercises accelerate remission.
 * 10) * Ménier's disease (repeated attacks of dizziness for several hours, which are always accompanied by tinnitus, pressure in the ear, hearing loss due to the inner ear (at the beginning of the attack, later also during it), usually with vomiting, spontaneous nystagmus and a tendency to fall in a certain direction) - Diff.dg. distinguish mere hearing loss (without dizziness). - Therapy: to ensure rest in bed during the attack, from pharmaceuticals antivertiginosis (dimenhydrinate supp. 100 mg 1-2 times a day, in the Czech Republic only in tabular form, ie rather thiethylperazine supp.) And in the meantime betahistine 1. – 3. week 3 × 16 mg and then 2-6 months 3 × 8 mg.
 * 11) * Kinetosis Therapy: dimenhydrinate, event. scopolamine (considered inappropriate in the Czech Republic).
 * 12) * Ototoxic substances (aminoglycosides, atropine, barbiturates, quinidine, salicylates, alcohol, CO in very heavy smokers, metals such as arsenic, lead, mercury, silver, iodine, benzene, toluene, hydrogen sulfide, toxic substances in meat and fungal poisoning).
 * 13) Neurological etiology:
 * 14) * posterior spinal cord lesions ;
 * 15) * brainstem or cerebellar damage ( CMP, brain tumor, etc.);
 * 16) * auricular horn syndrome in neurinoma acoustics (benign slow-growing tumor from Schwann vaginal nerve VIII cells, occurring mainly in the 4th-5th decade) - Tinnitus with progressive hearing loss and balance disorders is present, disorders of the innervation of the trigeminal nerve (decreased corneal reflex) and paresis of the facial nerve, later pyramidal symptoms and signs of intracranial hypertension are added. - Therapy - surgery on neurosurgery! - CAVE: this may be a partial manifestation of a generalized form of neurofibromatosis (Recklinghausen's disease);
 * 17) * multiple sclerosis (synonym = multiple sclerosis );
 * 18) * epileptic seizures - aura character of the seizure.
 * 19) Ophthalmological etiology:
 * 20) * refractive errors (dizziness from the beginning of the use of new glasses, with a refractive difference> 3 diopters, after unilateral cataract surgery);
 * 21) * after alcohol consumption, st.p. craniocerebral trauma , fatigue , latent acuity ;
 * 22) * eye muscle disorders (nerve nerves III, IV, VI) - in the elderly, eg in circulatory disorders, in diabetes mellitus, in hypertensive patients, myasthenia gravis, in multiple sclerosis (internuclear ophthalmoplegia), in tumors, in increased intracranial pressure;
 * 23) * acute attack of glaucoma - severe pain + hard eyeball + red eye.
 * 24) Reflector origin (susp.):
 * 25) * in pseudoradicular C-spine syndrome ;
 * 26) * in C-spine blockade.
 * 27) Psychogenic dizziness :
 * 28) * is a very common - up to 30% - "loss of support, as at the edge of the abyss";
 * 29) * overlaps with a functional disorder of blood pressure regulation.

Therapy - principles
Initiation of causal therapy according to the underlying disease. In dizziness (etiol. Hypoperfusion of the brain) during dehydration - increase fluid intake (rehydrate). During orthostatic dysregulation - morning cold shower (stimulate blood circulation), classic Kneipp treatment (physiotherapy - special hydrotherapy, exercise therapy, phytotherapy, ... to strengthen the body), sports, morning coffee before getting up, possibly also medicines - e.g. etilephrine 1 × 25 mg daily (not registered in the Czech Republic - rather use eg Gutron )

Positional gymnastics
It is a release maneuver (so-called Semont's maneuver) in case of vertigo. Benign paroxysmal positional dizziness (from the vestibular apparatus) manifests itself below the image of a dizziness lasting a few seconds or minutes after lying down, lying down or changing position. A professional ENT examination and therapy with position training will be performed. The prognosis is favorable - spontaneous remission, when exercising without avoiding movement, remission is accelerated. Right-hand: turn the head to the left by 45 ° and, while sitting in the middle of the bed (legs suspended) - place on the side (on both sides) as quickly as possible, maintaining the inclination of the head. The released otoliths get inertia out of the location where they irritated the vestibular apparatus.

Meniere's disease
Endolymphatic hydrops leading to a mixture of perilymph and endolymph - with consequent loss of vestibular function - balance and hearing. It is manifested by an attack of dizziness with hearing loss and tinnitus (typical Triassic) lasting several minutes to hours. Usually present spontaneous nystagmus to the patient ear and frequently vomiting.

Send to the ENT specialist and further according to him:


 * bed rest, antiemetics, antivertiginosis.
 * In case of severe vomiting infusion and try betahistidine ;
 * in case of numerous seizures and resistance to therapy, surgery is recommended : saculotomy, labyrinthine short circuit event. vestibular nerve neurectomy).

Prevention with a diet limited by salt and fluids, avoid triggers - stress, alcohol and nicotine, and preventively we give betahistidine 3 times a day tbl. after

See Ménière's disease for more information .

Tinnitus
[✎ edit embedded article]

Inclusion
It is one of the diseases of the inner ear.


 * Division of inner ear diseases :
 * Cochlear hearing loss;
 * sudden hearing loss;
 * presbyacusis ;
 * noise damage (acoustic trauma);
 * tinnitus (tinnitus).
 * Vestibular apparatus :
 * vestibular neuropathy;
 * benign paroxysmal positional dizziness ;
 * Meniere's disease.
 * Inflammation of the inner ear - labyrinthitis.
 * Toxic damage to the inner ear.
 * Inner ear injury:
 * labyrinth commotion ;
 * round window membrane rupture.

Clinical picture
The clinical picture is individual and very variable.

We describe tinnitus


 * by type (such as rustling, hissing, growling, cracking, whistling, ringing),
 * according to duration (as constant or seizure) and
 * according to character (as uniform or pulsating).

Diagnostics
After determining the basic diagnosis of tinnitus, we will send an ENT specialist.

Differential diagnostics

 * Secretory otitis.
 * Sudden hearing loss.
 * Meniere's disease.
 * Neurinoma acoustics - schwannom n.VIII.
 * Vertebrocochlear syndrome.
 * Angioma.
 * Anemia.

Therapy

 * Therapy according to the underlying disease.
 * In idiopathic tinnitus and therapeutic resistance, we still indicate the patient to cognitive-behavioral therapy after 6 months from the start of treatment.
 * Phytotherapy - Ginkgo biloba preparations.

related articles

 * Vertigo
 * Vertigo / PGS / diagnostics
 * Vertigo / PGS (VPL)
 * Tinnitus
 * Tinnitus / PGS (VPL)