Vertigo Cases
Case # 1
32 year old female brought in by paramedics. Complains of feeling dizzy. Dizzyness awoke her this
morning in bed. Most of the time feels fine and then every so often is struck by an attack of an intense
spinning sensation, especially when trying to move or get up. Each attack lasts about one minute. She
has had about 8 attacks so far today. Prefers to sit quietly. Between attacks feels nauseated and
anxious, but has no vertigo. Recently lost 50lbs on the Dr. Bernstein diet. No significant past medical
history. No medications or allergies. Not pregnant.
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What is your differential diagnosis?
What is the most likely diagnosis?
What are the usual presenting symptoms of this condition?
What diagnostic test is indicated?
What therapeutic manoeuvre is indicated if the diagnostic test is abnormal?
Case #1 answers
1. BPPV, orthostatic hypotension, vestibular neuronitis, cerebellar CVA, psychological, cardiac
dysrhythmia
2. BPPV
3. Paroxysmal short-duration attacks of profound vertigo related to head movement
4. The Dix- Hallpike test (and maybe also the supine head turning test)
5. The Epley manoeuvre
Case # 2
42 year old female presents with nausea, vomiting, and dizziness. Onset about one hour after eating
cheap take-out sushi with friends after yoga class. She was sitting on the couch when it started and lay
on the couch vomiting until EMS arrived, she is now brought on a stretcher into bed 20 at FMC. She
looks uncomfortable and mildly diaphoretic. Her JVP is normal but her mouth is dry. Heart rate is 110,
vitals signs otherwise unremarkable.
1. What is your differential diagnosis?
2. What is your leading diagnostic consideration?
3. What else do you want to look for on physical exam?
4. What diagnostic testing would you like?
Case #2 answers
1. Orthostatic hypotension secondary to vomiting from food poisoning, cerebellar infarct from
vertebral artery dissection (yoga), vestibulitis, Meniere’s (should not be this severe)
2. Cerebellar infarct
3. Full neuro exam: EOMs, CN 5 and 7, finger nose testing, heel-shin testing, gait. Motor power
in all four extremities. Speech- any dystharthria? Postural vitals. Response of symptoms to
fluid bolus and/or antiemetics.
4. CT head, CT angiogram head and neck
Case #3
50 year old male comes by EMS from Banff hospital on a beautiful July day. He was scuba diving in lake
Minnewanka when he had a sudden onset of vertigo. He has had continuous vertigo since with nausea,
ear pain and tinnitus.
What is the single most important piece of information you would like to know on history?
What is the differential diagnosis of vertigo in a scuba diver? Describe each entity and its management.
Case #3 answers
1. Timing of the onset of vertigo in relation to the dive... ie during descent, during ascent, after
ascent complete, how long after ascent, related to a Valsalva manoeuvre.
2. –Non diving related causes of vertigo
3. -Barotitis media- middle ear squeeze secondary to eustacian tube dysfunction during descent.
The tympanic membrane may rupture. The diver may experience vertigo, nausea, ear fullness,
pain. Hemotympanum or tympanic membrane rupture may be present.
-Inner ear barotrauma can also occur during rapid descent, sometimes triggered by a valsalva
manoeuvre intended to equalize middle ear pressures. Pressure is transmitted through the
vestibular and cochlear structures and may rupture the oval window, cause a fistula, etc. May
have tinnitus, sensorineural hearing loss, nausea and vomiting. Consult ENT.
-CVA secondary to air embolism from Pulmonary overpressurization syndrome. This occurs
during ascent or up to 10 minutes after ascent. Often abruptly fatal or with multiple neurologic
deficits, but could have less significant deficits or isolated vertigo depending on the vascular
territory affected. Involve stroke team... ?catheter retrieval of air embolism? Supportive
treatment?
-Decompression sickness can range from joint aches and skin pain and mottling, to multiple
neurological deficits including vague paresthesias, ataxia, motor findings. Multifocal within
brain and spinal cord so symptoms are odd. Vestibular decompression sickness can mimic inner
ear barotrauma. Onset 1-6 hours after surfacing, maybe up to 48 hours. Tx with hyperbaric
chamber.
Case #4
25 year old healthy male presents with spinning sensation and difficulty walking. He had a sore
throat and rhinorrhea last week but thought he was better. Today he started to feel dizzy while
drinking his morning coffee before leaving for work, then he lost his balance and stumbled to
the right when he tried to stand up. He then managed to walk to the phone and call his brother
to come and get him. He is able to walk but needs to grab furniture for support at times, and
has fallen twice. He is otherwise healthy and has no stroke risk factors. There is no tinnitus, ear
pain or hearing loss.
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What is your differential diagnosis?
Your leading diagnosis?
What will you look for on physical exam?
Are there any diagnostic tests this patient requires?
What is your disposition?
What is the treatment?
Case #4 answers
1. Vestibular neuritis, cerebellar CVA, middle ear infection causing suppurative labyrinthitis,
orthostatic dizziness, BPPV.
2. Vestibular neuritis. Labyrinthitis also causes hearing deficits. Ramsay-Hunt syndrome is
zoster of cranial nerve 8, has zosteriform lesions on tympanic membrane, and may be
accompanied by LMN CN 7 weakness.
3. Full neuro exam and walk test. A bit of ataxia is okay, but the patient should be able to walk
unassisted. If the patient cannot walk, this is central vertigo until proven otherwise. Look for
other neuro deficits, cerebellar deficits. Orthostatic vitals and correlating symptoms. DixHallpike. Check tympanic membranes for signs of otitis media or Ramsay Hunt. Percuss the
mastoids for tenderness. Of course get vital signs- suppurative labyrinthitis will be sick and
febrile. Check for nystagmus and suppression with fixation.
4. Consider CT/CTA if any doubt about diagnosis. Differentiating vestibular neuritis from
cerebellar CVA is difficult.
5. If certain of diagnosis... discharge, outpatient ENT or family medicine follow up. If uncertain,
get help from stroke team or neurology.
6. Tx= Serc prn for symptoms, steroid taper.
Case #5
A 55 year old female presents with dizziness. She describes a dull ache and plugged sensation in
her right ear which have been present for about a week. She hears a swishing sound in her right
ear. Two hours ago she started to feel unsteady, like the floor was rocking like the deck of a
boat. She feels a bit nauseated with this but has not vomited. This has happened twice in the
past six months with vertigo lasting 30 minutes to three hours each time. During the same
period of time certain sounds have seemed louder and irritating, such as talking on the phone.
She is otherwise healthy and takes no medications.
1. What is your differential diagnosis?
2. What is the most likely diagnosis?
3. What will you look for on physical exam?
4. What is hyperaucusis? What is its significance?
5. What is your management plan?
6. What is the typical natural course of this condition?
Case #5 Answers
1. Meniere’s, otitis media, middle ear effusion, eustacian tube dysfunction
2. Meniere’s
3. Examine the tympanic membrane- is there evidence of otitis media or middle ear effusion.
Check hearing acuity. Weber and Rhinne testing for sensorineural vs conductive hearing
loss.
4. Hyperaucusis is the perception that sounds are louder than they should be. It can be an early
sign of sensorineural hearing loss. While bothersome, as the hearing loss progresses it
abates.
5. ENT follow up and formal audiometry testing. Could offer Serc for now for disequilibrium
vertigo sensation.
6. Gradual sensorineural hearing loss over several years- then tinnitus improves once hearing
gone. Episodic vertigo of varying severity, lasting 30 minutes to several hours.
Case #6
18 female presents to ER following an HPTP appointment. She has been being treated for
pyelonephritis for 5 days with IV antibiotics and has been improving from that regard- her fever
has resolved, and her back pain has decreased. She now complains of dizziness- she has some
difficulty walking and feels very unsteady on her feet. This onset before bed last night and is
worse this morning. She is otherwise healthy and denies pregnancy.
1. What is your differential diagnosis?
2. What is your leading diagnostic consideration?
3. What laboratory test do you need to confirm your suspicion?
4. What is your management plan?
Case #6 Answers
1. Typical differential
2. Aminoglycoside toxicity (gentamycin)
3. Gentamycin level, renal function.
4. Stop gentamycin, test renal function and support with IV fluids, switch to ceftriaxone if IV
antibiotics are still required. Avoid other nephrotoxins. Some evidence for aspirin and/or
oral mucomyst. Could be followed through HPTP if you talk to ID doc. Once daily dosing of
aminoglycosides and minimizing the duration of total therapy to 7-10 days helps to reduce
risk.
Case #7
A 63 male presents complaining of dizziness. It has bothered him since yesterday, but is
much worse today. He finds that he feels very unsteady on his feet, and has been bumping
into furniture as he walks. By mid-morning he resigned himself to the couch and has only
been getting up with his wife’s assistance since. He also has some double vision, nausea,
and feels like his hands are “clumsy”. His wife notes that his speech is slightly slurred. His
past medical history is significant for well-controlled epilepsy (last seizure 10 years ago). He
has hypertension but no other stroke risk factors.
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What is your differential diagnosis?
What piece of history is missing?
What diagnostic testing would you like to order?
What is the treatment for this condition?
What is the predicted course once treated?
Case #7 answers:
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Dilantin toxicity, CVA(posterior circulation), vestibular neuritis, EtOH intoxication
Medications
Dilantin level (and albumin)
Stop dilantin, monitor levels. Look for reason for toxicity: increase in dilantin dose, intentional
overdose, recent addition of a CYP 450 inhibitor, recent EtOH binge, stopping chronic EtOH use.
5. He will improve as his dilantin level falls in the next 2-3 days.
Case #8
55 male presents for a laceration, but mentions to you while you are suturing that for the past year and
a half he frequently feels vaguely unsteady on his feet, and often has difficulty sleeping due to ringing in
his right ear. The ringing is better while he is busy during the day, but worse at night and while doing
deskwork in a quiet room. The unsteadiness is not really a spinning sensation, and he has never fallen or
had any other neurological complaints. When he sleeps with his left ear against the pillow, he does not
wake up to his alarm clock because he can’t hear it as well. You are the first physician he has mentioned
these symptoms to.
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What is your differential diagnosis?
What investigation should this patient undergo?
Why is his tinnitus worse at night? Is this common
What symptomatic treatment could you recommend for his sleeping difficulty secondary to
tinnitus?
Case #8 Answers
1- Acoustic neuroma (vestibular schwannoma), consider Menieres, perilymphatic fistula,
cryptogenic.
2- MRI brain
3- Tinnitus is worse when background noise is minimized so patients frequently notice it at bedtime.
This pattern is very common.
4- Suggest soft background music, “white noise”, or ocean wave spa music playing at bedtime. This
offers distraction so the patient does not fixate on the tinnitus while trying to sleep.