Snapshot A 26-year-old man presents to his primary care physician due to dizziness. He said his symptoms began 2 weeks prior to presentation, are recurrent, and last a few seconds. He notices that his symptoms worsen with head movement; however, he denies any ear ringing or hearing loss. The Dix-Hallpike maneuver was performed, which showed horizontal nystagmus that is delayed in onset and fatigable. (Benign paroxysmal positional vertigo) Introduction "Dizziness" is a term used by patients that can mean many things such as login to view 4 more bullets Vertigo login to view 6 more bullets Peripheral vertigo login to view 11 more bullets Central vertigo login to view 9 more bullets Physical exam maneuvers login to view 16 more bullets Summary of Peripheral Vs. Central Vertigo Vertigo Type Etiology Differential Symptoms Peripheral vertigo Lesion affecting the: vestibular apparatus (in the inner ear) cranial nerve VIII Benign paroxysmal positional vertigo (BPPV) Vestibular neuritis labrynthitis presents similarly but with otological findings (e.g., tinnitus or hearing loss) treat with steroids and meclizine for symptoms. Meniere's disease Acoustic neuroma Aminoglycoside toxicity Semicircular canal dehiscence syndrome Perilymphatic fistula Herpes zoster oticus (Ramsay Hunt syndrome) Intermittent and positional vertigo Can be associated with tinnitus as well as: hearing loss postural unsteadiness Nyastagmus is: delayed in onset rotatory or horizontal prominent if vertigo is present adaptive Vertigo stops with visual fixation Central vertigo Lesion affecting the brainstem nuclei cerebellum Vestibular migraine Brainstem stroke Multiple sclerosis Ischemic or hemorrhagic damage to the cerebellum high altitude cerebral edema (HACE) Non-positional vertigo May accompany other cranial nerve injuries such as: facial droop dysarthria Nystagmus is: immediate or delayed in onset rotatory, horizontal, or vertical not adaptive Vertigo does not stop with visual fixation