I. Meniere’s syndrome
The incidence of Meniere’s syndrome has been reported to vary widely, accounting for 9.7% to 30% of patients with vertigo. It is characterized by recurrent episodes of vertigo, with sudden onset, mostly rotational, lasting from a few minutes to a few hours, followed by a slight feeling of instability for a few days, followed by a remission period of variable duration and no symptoms. Because the lesion is located in the peripheral labyrinth, vertigo is often accompanied by tinnitus, initially low and later high pitch deafness, with deafness, nystagmus, nausea and vomiting. The patient prefers to lie on his side with the diseased side facing upwards, with the eyes looking to the affected side, otherwise the nystagmus and vertigo are easily aggravated. The nystagmus is mostly subtle, horizontal and rotational, and is more pronounced when looking to the healthy side. It occurs mostly in young adults, 20 to 40 years old, but is rare in the elderly and rare in children and under 20 years old. The tinnitus gradually decreases with age and the duration of the disease, and the hearing is gradually lost. Vertigo and nystagmus gradually decrease due to the long-term compensatory effect of the center. Common causes are allergic reactions, viral infections, metabolic disorders, blood circulation disorders, and vegetative dysfunction.
II. Vestibular neuronitis
Vestibular neuronitis may be a viral infection. 73% of patients have an acute onset, 85% of them have true vertigo, with falls in severe cases and later postural vertigo. 68% of patients have spontaneous nystagmus within a few weeks of onset, mostly horizontal or horizontal rotational and often dorsal to the side of the lesion. The age of onset ranges from 20 to 60 (mean 39) years. Vestibular function is unilaterally reduced or lost in 67% and 13% of cases, respectively. The disease is generally benign and self-limiting, with signs and symptoms disappearing within a few weeks and months of onset, respectively, or as short as a few days have been reported. Cochlear symptoms are not usually present, but it has been reported that approximately 30% of cases are associated with cochlear symptoms. The common cochlear symptoms are tinnitus (40%), swelling and pressure in the ear (16%). There is usually no hearing impairment, and spontaneous hearing loss is even less common.
The disease has been divided into two types: acute and chronic, and it is believed that the chronic type is actually the beginning of Meniere’s syndrome. The disease is generally nonrecurrent and can be differentiated from Meniere’s syndrome.
Benign, episodic, postural vertigo
This disease is extremely common, accounting for 18% of patients with vertigo. It has been reported that 80% of patients with postural nystagmus detected by the open-eye postural test are suffering from this disease. It is more common in women than in men, and often occurs in women between 50 and 60 years of age. The vertigo has a peripheral, postural character. The nystagmus is rotational or horizontal and is easily fatigable. If the patient is placed in a position that induces vertigo, the nystagmus usually appears after 3 to 6 s. This incubation period is characteristic for this disease. The disease has a benign, self-limiting course, usually weeks or months, but can recur. In some patients, the only abnormal sign is a positive postural test; therefore, it has been suggested that all patients suspected of having this disease should have a postural test to avoid missing the diagnosis.
Head trauma, ear disease, old age, noise injury, and the application of aminoglycoside antibiotics can degenerate the otoliths of the ellipsoidal sac. The degenerated otoliths are displaced by gravity, and benign, episodic, and postural vertigo and nystagmus occur.
IV. Cervical vertigo
It is vertigo caused by neck diseases. Nine percent of patients in neurosurgery due to cervical pathology complain of vertigo. It is characterized by the manifestation of both cervical disease and vestibular-cochlear system involvement, and the variable temperature test is usually normal in patients of this department. The cause may be cervical spondylosis, cervical trauma, foramen magnum malformation, or posterior cervical sympathetic nerve syndrome.
V. Auditory neuroma
It accounts for 8% to 10% of all brain tumor patients and 10% of those with vestibular nerve involvement as the first symptom of instability. Vertigo is often mild and intermittent (lasting weeks or months). A few may present as isolated episodes with normal intervals. Later on, there is often treble tone deafness without deafness, a sense of instability, abnormal response to the variable temperature test, other cerebral nerve palsy (V, VI, VII, X), ipsilateral limb ataxia, headache, and other signs common to cerebellopontocerebellar horn tumors.
Care should be taken to differentiate from other diseases causing vertigo. However, the diagnosis is facilitated by a slowly developing history, multiple, careful audiological examinations, the presence of other signs in the pontocerebellar horn of the cerebellum, cerebrospinal fluid pressure and protein tests, and internal auditory tract x-ray. In suspicious cases, isotope brain scan, CT, or even MRI should be performed. Those who still cannot be excluded should be closely followed up and observed.
VI. Post-traumatic head injury vertigo
About 10%-15% of patients with head trauma who have temporal bone fracture have vertigo. If there is a longitudinal fracture of the temporal bone (i.e., the direction of the fracture line is parallel to the long axis of the rock), there may be mild to moderate mixed deafness and vertigo; if there is a transverse fracture, there may be severe neurological deafness, vertigo, and loss of vestibular function. In some patients with mild or moderate head trauma, the only positive test is a nystagmus electrooculogram, which shows nystagmus when the eyes are closed.
VII. Cortical vertigo-epilepsy
Abnormal discharges in the cortical balance representative areas of the temporal and parietal lobes can cause vertigo. It has been reported that 90 cases out of 505 epileptic patients have vertigo. In a few cases, vertigo can be used as an aura of epilepsy. In individual cases, vertigo can be the only clinical manifestation of their temporal lobe epilepsy. The lesion is mostly located on the posterior lateral aspect of the temporal lobe, or the subparietal lobule of the proximal lateral fissure. Patients may present with a sensation of movement of the limb contralateral to the lesion, or a sensation of movement of objects around it in the opposite direction, acute vertigo, a sensation of rotation, or sometimes just a sense of instability, and may be without nystagmus. When the abnormal discharge spreads to the olfactory cortex, it may cause olfactory hallucinations, and to the cortical motor area, it may cause other manifestations of epilepsy such as convulsive seizures. Occasionally, vertigo may provide a stimulus for “reflex epilepsy,” and rotational and variable temperature tests may precipitate seizures.
EEG, especially with pterygoid electrodes, can detect focal spike foci in the temporal region. However, 10% to 15% of patients with temporal lobe epilepsy have a normal EEG.
VIII. Posterior circulation ischemia
The sudden onset of vertigo in patients over 50 years of age with hypertensive atherosclerosis should be the first consideration for this condition. If there are signs of involvement of other brainstem structures, the diagnosis is almost confirmed. A cranial CT examination will be more useful to confirm the diagnosis.
Sudden collapse disorder is an episodic fall without aura and without loss of consciousness. Some patients start with vertigo and 1/3 of them are precipitated by neck activity. The mechanism is a transient quadriplegia due to ischemia in the conus cruciatus region.
Labyrinthine stroke is a thrombosis of the internal auditory artery or its vestibular branch and presents with acute vertigo, nausea, vomiting, and emaciation.
IX. Other cerebrovascular accidents
A high prevalence of vertigo has been reported in patients hospitalized for cerebrovascular accidents; approximately 5% of patients with subarachnoid hemorrhage and 2% of patients with dorsolateral medullary syndrome have vertigo as their first symptom.
X. Multiple sclerosis
Vertigo is the first symptom in 5% to 12% of patients, and 30% to 0% of patients have vertigo. Therefore, patients with vertigo should have a careful medical history, detailed neurological examination, lumbar puncture if necessary, examination of cerebrospinal fluid immunoglobulin synthesis rate and IgG component bands, examination of (visual, brainstem and somatosensory) evoked potentials, cranial CT or even cranial and spinal MRI if necessary, and close observation of changes in the condition.
Eleven: Neurosis
If the vertigo attack is not accompanied by nystagmus, it is possible that it is non-organic. If the patient has overwork, insomnia and other triggers, and has other clinical manifestations of neurosis, the diagnosis of neurosis is favorable.
Psycho-psychological factors can affect the function of the vagal-vestibular system, and the plant nerve dysfunction induced by hyperventilation can cause spontaneous or postural nystagmus to appear or worsen.