History
The patient should be asked exactly when and how the head or neck was injured and if a loss of consciousness occurred. If the patient was involved in a motor vehicle accident, the patient should be asked whether the airbag was deployed. One study found a significant incidence of vertigo and hearing disturbances after airbag deployment. [12] Available emergency room and hospital records should also be obtained.
Characterizing exactly what the patient means by "dizzy" is the most important step of the evaluation process. Vertigo is the illusion of movement in the absence of actual movement and is a specific symptom of a lesion of the inner ear, vestibular nuclei, or vestibular pathways. It is important to distinguish vertigo from disequilibrium, in which a feeling of unsteadiness exists without the discrete illusion of motion. Characterizing the vertigo is also necessary for a precise diagnosis.
The temporal relationship between the trauma and onset of symptoms is important. Duration of symptoms is important as well. Momentary vertigo associated with rapid head movements suggests benign paroxysmal positional vertigo (BPPV). Vertigo that begins in a delayed fashion and lasts between 20 minutes and 24 hours tends to occur in Ménière disease. Labyrinthine concussion involves vertigo that may persist for several days. Asking about associated symptoms such as hearing loss, tinnitus, nausea, and vomiting also helps to elucidate the diagnosis. Ménière disease classically presents with fluctuating symptoms, including hearing loss, tinnitus, and aural fullness.
Although the symptomatology of vestibular injuries associated with head trauma may vary, some injuries may present similarly. For example, brainstem concussion and labyrinthine concussion can both cause acute vertigo that results in constant unsteadiness and worsens with darkness, fatigue, and motion. Further testing is necessary to differentiate between these 2 pathologies. BPPV is easily recognized based on the pattern of dizziness that is elicited only when the head is placed in certain positions. Ménière syndrome typically produces episodic whirling vertigo, often associated with nausea and vomiting, as well as with fluctuating hearing loss, tinnitus, and aural fullness. Onset of the symptoms of Ménière syndrome varies from immediately following the trauma to one year later. In posttraumatic Ménière syndrome, the vestibular symptoms often predominate.
Patients with perilymphatic fistulas (PLFs) present with symptoms similar to those of patients with Ménière syndrome; however, those symptoms can be differentiated based on the temporal relationship to the injury. Patients with PLFs are usually symptomatic within 24-72 hours after injury, whereas traumatic Ménière syndrome typically takes months to years to manifest. Patients with cervical vertigo can also have symptoms of tinnitus, as well as hearing loss and neck pain or tenderness with palpation.
Physical
See the list below:
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A complete head and neck examination is necessary.
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An otologic inspection is necessary to rule out disease of the external and middle ear. The Weber test and Rinne test are used to document sensorineural or conductive hearing losses.
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A fistula test entails making a sensitive recording of eye movements while pressurizing each ear canal with a pneumatic otoscope and is almost always needed. A positive test (known as the Hennebert sign) is good grounds for surgical exploration. In window fistulae, very little nystagmus is produced, and a positive test may consist only of a slight nystagmus after pressurization. [13] In superior canal dehiscence, a strong nystagmus may be produced.
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Examine the patient for the presence of spontaneous gaze and positional nystagmus.
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Nasopharyngoscopy and indirect laryngoscopy are considered part of the neurotologic examination.
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A cranial nerve examination is essential.
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A vestibular and cerebellar assessment is made via past-pointing, rapid repetitive motion, Romberg, tandem walking, and cold-water caloric testing.
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Administer the Dix-Hallpike maneuver.
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Testing for smooth pursuits, saccades, and fixation suppression can be used to indicate the presence of a central lesion.
Causes
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Many mechanisms cause blunt trauma to the head. Motor vehicle accidents are responsible for half of all cases of mild head trauma, whereas assaults and falls account for the rest. [14]
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Posttraumatic vertigo. The Dix-Hallpike maneuver.
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Posttraumatic vertigo. The Epley maneuver.
