Treatment of BPPV is particularly rewarding, because particle repositioning procedures have been shown to be highly effective. Management of peripheral vertigo hinges on the facilitation of compensation through physical exercise regimens, such as the Cawthorne-Cooksey exercises and customized regimens, 97 together with appropriate psychological support for patients who develop the common sequelae of avoidance behavior, anxiety, and depression. Luxon, Doris-Eva Bamiou, in Neurology and Clinical Neuroscience, 2007 Vestibular Rehabilitation Magnetic resonance angiography can identify occlusive vascular disease most commonly involving the vertebral-basilar junction. MRI of the brain is usually normal because the vascular insufficiency is transient and function returns to normal between episodes. Vertebrobasilar insufficiency is usually caused by atherosclerosis of the subclavian, vertebral, and basilar arteries. Vertigo may be an isolated initial symptom of vertebrobasilar ischemia, but repeated episodes of vertigo without other symptoms should suggest another diagnosis. These symptoms occur in episodes either in combination with the vertigo or alone.
Associated symptoms resulting from ischemia in the remaining territory supplied by the posterior circulation include visual illusions and hallucinations, drop attacks and weakness, visceral sensations, visual field defects, diplopia, and headache. Vertigo with vertebrobasilar insufficiency is abrupt in onset, usually lasting several minutes, and is frequently associated with nausea and vomiting. Whether the vertigo originates from ischemia of the labyrinth, brain stem, or both structures is not always clear because the blood supplies to the labyrinth, eighth cranial nerve, and vestibular nuclei originate from the same source, the basilar vertebral circulation ( Chapter 378).
Vertebrobasilar insufficiency is a common cause of vertigo in older people. If the drug is discontinued early during the course of symptoms, the disorder may stabilize or improve. Caloric and rotational testing can confirm the vestibular loss. The diagnosis can be made at the bedside with a head-thrust test (bilateral corrective saccades see later). They then discover that they are unsteady on their feet and that the environment tends to jiggle in front of their eyes ( oscillopsia). Unfortunately, many patients being treated with ototoxic drugs are initially bedridden and unaware of the vestibular impairment until they recover from their acute illness and try to walk. More often, there is a progressive symmetrical loss of vestibular function leading to imbalance but not vertigo. The patient may suffer acute vertigo if the toxic effect is asymmetrical. The aminoglycosides streptomycin and gentamicin are remarkably selective for vestibular ototoxicity. About two thirds of patients have antibodies directed against heat shock protein 70. It can occur in isolation or with other systemic features of autoimmune disease. Autoimmune inner ear disease typically arises with episodic vertigo and fluctuating hearing levels similar to Meniere disease, but it is more fulminant with early bilateral involvement. Radiographic studies of the temporal bone readily identify these disorders. Vertigo can be associated with chronic bacterial otomastoiditis, either from direct invasion of the inner ear by the bacteria or by erosion of the labyrinth by a cholesteatoma. Lee Goldman MD, in Goldman-Cecil Medicine, 2020 Other Peripheral Causes of Vertigo