Compare conditions

Put any two — or three — conditions side by side, adult or pediatric, to spot the look-alike differences fast, row by row.

Vertigo (Dizziness and Spinning)

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In one line

·The false feeling that you or the room is spinning, usually from an inner-ear problem.

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Normal physiology

·Your inner ear sits deep inside your skull, right next to the hearing part of the ear. It has three tiny loops filled with fluid, called semicircular canals, that act like a carpenter's level—they tell your brain which way is up, which way you're tilting, and whether you're moving or still. Floating on top of the fluid are tiny crystals made of calcium, called otoliths, that sit on a patch of hair cells. When you move your head, the crystals shift and bend the hairs, sending a signal to the brain. Your eyes and the sensors in your muscles and joints also send position signals, and your brain compares all three streams to build one clear picture of where you are in space.

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What goes wrong

·A spinning sensation (Vertigo) happens when the signals from one ear don't match the signals from the other ear or from your eyes, so your brain gets confused and thinks you're spinning. The most common cause is tiny crystals breaking loose from their gel pad and floating into one of the fluid-filled loops—when you move your head, the crystals tumble and make the fluid swirl much more than it should, fooling the brain into sensing wild spinning that isn't real. A virus can also attack the vestibular nerve (balance nerve) and make it fire wrong signals, or fluid can build up in the inner ear and distort the messages. Less often, a stroke in the brainstem, a tumor pressing on the nerve, or a head injury can scramble the wiring.

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Hallmark signs

·The room feels like it is spinning or moving around you
·Feeling unsteady or like you might fall
·Nausea or throwing up
·Eyes that jerk or drift to one side on their own, called involuntary eye jerking (nystagmus)
·Dizziness that comes on suddenly when you move your head or change position
·Ringing, buzzing, or fullness in one or both ears (tinnitus or aural fullness)
·Sudden trouble speaking, slurred words, or drooping on one side of the face
·Double vision or sudden vision loss

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Red flags · escalate now

·Sudden trouble speaking, slurred words, trouble understanding speech, or drooping on one side of the face
·Double vision, sudden vision loss, or new trouble seeing to one side
·Sudden very severe headache — the worst you have ever had — especially if it came on like a thunderclap
·Weakness, numbness, tingling, or trouble moving one side of your body (arm, leg, or face)
·Trouble walking, loss of coordination, repeated falls, or inability to stand without help

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Workup

·MRI of the brain with diffusion-weighted imaging (DWI)
·Audiometry (formal hearing test in a soundproof booth)
·Videonystagmography (VNG) or electronystagmography (ENG)
·Complete blood count (CBC) with differential
·Basic metabolic panel (BMP) including glucose and electrolytes
·MRI of the internal auditory canals with gadolinium contrast

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Treatment

·Epley maneuver (canalith repositioning) — a series of four head positions, each held for 30 seconds, that guide the loose ear crystals out of the semicircular canal and back into the part of the inner ear where they belong
·Meclizine 25 mg by mouth every 6–8 hours as needed (or dimenhydrinate 50 mg, or promethazine 25 mg) — these are vestibular suppressants that calm the inner-ear signals and reduce the sensation of spinning
·Vestibular rehabilitation therapy (VRT) — supervised exercises (gaze stabilization, balance training, habituation tasks) done with a physical therapist 1–2 times per week for 4–8 weeks
·Oral corticosteroids (e.g. prednisone 60 mg daily, tapered over 2–3 weeks, started within 3 days of symptom onset) — sometimes combined with antiviral medication (e.g. valacyclovir 1 g three times daily for 7 days)
·Diuretics (e.g. hydrochlorothiazide 25 mg daily or acetazolamide 250 mg twice daily) plus low-sodium diet (< 2 g/day) for Meniere disease
·Acute stroke treatment — IV alteplase (tPA) within 3–4.5 hours, or endovascular thrombectomy (threading a wire through the blood vessels to pull out a clot) within 6–24 hours (depending on imaging), for blood-starved (ischemic) stroke in the posterior circulation (cerebellum or brainstem)
·Antiemetics by IV or IM (e.g. ondansetron 4 mg IV, metoclopramide 10 mg IV, or promethazine 12.5–25 mg IV/IM) in the emergency department for severe nausea and vomiting

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NCLEX trap

·Most a spinning sensation (vertigo) comes from the inner ear — the labyrinth, which holds your balance sensors — not the brain. Peripheral a spinning sensation (inner ear) is far more common than central a spinning sensation (brainstem or cerebellum). Look at the pattern first: Does the room spin when they move their head? Do they have hearing loss or ringing in the ears? Can they still walk? These clues usually point to the inner ear. You only worry about stroke if the patient has other brainstem signs like double vision, trouble swallowing, slurred speech, or one-sided weakness, or if the a spinning sensation never stops and they cannot stand at all. Start with the Dix-Hallpike test — a bedside move where you quickly lay the patient back with their head turned and hanging slightly off the table to trigger spinning — to check for BPPV, the most common cause.
·Not all dizziness is a spinning sensation (vertigo). Ask exactly what they feel. A spinning sensation means the room is spinning around them, like they just got off a merry-go-round. Lightheadedness (feeling faint, like they might pass out) points to the heart or blood pressure dropping. Unsteadiness (feeling off-balance but no spinning) can be nerve damage, muscle weakness, or medicine side effects. A floating or foggy feeling may be anxiety or a reaction to drugs. The word they use changes your whole plan. Always clarify: 'Does the room spin, or do you feel like you might faint?'
·BPPV is caused by tiny calcium crystals — otoliths — that have fallen into the wrong part of the semicircular canals in the inner ear. The cure is physical: you move the patient's head through a series of positions called the Epley maneuver to roll the crystals back where they belong in the utricle, a chamber in the inner ear. This works immediately in about 80% of people. Meclizine only masks the spinning feeling for a little while; it does not move the crystals. Use meclizine short-term (a few days maximum) only if the spinning is so severe the patient cannot tolerate the maneuver, but the real treatment is repositioning. Teach the patient they can repeat the Epley at home if it comes back.
·BPPV is the most common cause in older adults, but stroke in the cerebellum (the balance control center at the back of the brain) or brainstem (the stalk connecting brain to spinal cord) can also cause sudden a spinning sensation (vertigo) in this age group. Red flags for stroke include a spinning sensation that does not go away, severe trouble walking or standing (they fall every time they try), double vision, slurred speech, numbness or weakness on one side of the body, or very bad headache. If any of these are present, think stroke first and get a CT or MRI and neurology involved right away. Also ask about new medicines, because some — like gentamicin, an antibiotic — can poison the inner ear and cause permanent dizziness. Always do a full neuro check, test coordination with finger-to-nose, and watch them walk.
·Ménière's disease is a problem of too much fluid pressure in the endolymph (the fluid inside the inner ear's balance and hearing tubes). It causes episodes of a spinning sensation (vertigo) that last hours (not seconds like BPPV), fluctuating hearing loss (hearing gets worse during attacks and may not fully come back), ringing in the ears (tinnitus) (ringing or roaring in the ear), and a feeling of fullness or pressure in the ear. Over time, the hearing loss can become permanent. So you must monitor their hearing with regular audiology exams and protect what's left. Treatment includes a very low-salt diet (under 1500 to 2000 mg of sodium per day) and sometimes a diuretic like hydrochlorothiazide (a water pill) to reduce inner-ear fluid pressure. During an attack, give meclizine or a benzodiazepine like diazepam to calm the a spinning sensation and nausea. Refer to an ENT specialist (ear, nose, and throat doctor) for long-term care, possible steroid injections into the ear, or even surgery if attacks are disabling and nothing else works.

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