الفهرس 
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Abstract
Vertigo is defined as false illusions of circular motion. Although vertigo is the second commonest complaint in medical practice, diagnosis is difficult due to vague description by the patient; many different systems included e.g. CNS, ENT, Ophthalmology, Cardiovascular, Hematology, psychiatry, etc.
The prevalence of vertigo is approximately 20% to 30% and it reaches 40% in patients older than 40 years. The incidence of falling is 25% in subjects older than 65 years, two to three times higher in women than in men. It accounts for about 2-3 % of emergency department visits.
Vertigo is classified into either peripheral or central depending on the location of the dysfunction of the vestibular pathway.
Central vertigo arises from disturbances in the balance centers of the brain. It usually has accompanying neurologic deficits, such as slurred speech, double vision or pathologic nystagmus. A number of conditions that involve the central nervous system may lead to vertigo including: migraine headaches, lateral medullary syndrome, multiple sclerosis, and cerebellar infarction.
Pripheral Vertigo caused by problems within the inner ear ”otogenic” or the veatebular nerve. The most common cause is benign paroxysmal positional vertigo (BPPV) but other causes include Ménière’s disease, superior canal dehiscence syndrome, labyrinthine fistulae, and vestibular neuritis. Also, chemical insults (e.g., aminoglycosides) or physical trauma (e.g., skull fractures) may cause vertigo.
Benign paroxysmal positional vertigo (BPPV) is brief periods of vertigo (less than one minute) which occur with change in position. It is the most common cause of vertigo. It is due to a mechanical malfunction of the inner ear. BPPV is normally diagnosed with the Dix-Hallpike test and Tests of vestibular system (balance) function. BPPV can be effectively treated with repositioning movements as Epley and Semont maneuvers .
Ménière’s disease frequently presents with vertigo in combination with tinnitus, a feeling of ear pressure or fullness, severe nausea or vomiting, and hearing loss. As the disease worsens, hearing loss will progress. It is diagnosed by audiometry and computerized tomography (C.T). Ménière’s disease is treated by vestibular suppressants, corticosteroids and surgical treatment as intratympanic steroid injection in some cases .
Vestibular migraine is a common cause of vertigo and the most common cause of spontaneous episodic vertigo. It affects approximately 10% of patients with migraine. Symptoms include spontaneous and positional vertigo, head motion vertigo/dizziness and ataxia, all of variable duration, ranging from seconds to days, and independent of migraine associated headache. Photophobia, phonophobia, or aura may be diagnostic symptoms. Management is similar to the recommended treatment of migraine headaches, and includes dietary and lifestyle modifications, and prophylactic therapies (beta blockers, calcium channel blockers, and tricyclic antidepressants).
Vestibular neuritis presents with severe vertigo. It is believed to be caused by a viral infection of the inner ear. Persisting balance problems may remain in 30% of people affected. Vestibular neuritis is treated by steroids and antiviral drugs.
Regarding the diagnosis of vertigo, proper diagnosis depends on careful history taking. A thorough history is crucial in evaluating the cause of vertigo. Several areas must be addressed in detail in taking the history, complete analysis of the complaint, family history, past history, etc. History-taking also seeks to specify how and when the vertigo happens:
How and when it first happened
How often and for how long it typically lasts
Its severity and whether it affects activities (e.g. whether it is possible to walk during an episode).
If there is a trigger for the vertigo or anything that makes it worse (e.g. head movement to a particular side).
If anything improves the symptoms.
Once a good history has been obtained, a complete General physical examination, Gait and balance examination, Examination of cerebeller function, Vestibule-ocular reflex, Hearing, full ophthalmologic examination and cranial nerves testing should be performed. Investigations may include vestibular, audiological assessment, imaging and laboratory tests .
In the field of treatment, treatment of various vertiginous diseases is challenging. The objective for the treatment of a vertiginous disease is to eliminate the underlying pathology either with surgical or non surgical maneuvers. It is not always possible to treat the underlying disease. The choice of treatment of vertigo should be guided by the symptoms, the supposed etiological factors and the age of the subject. Surgical solutions should be proposed for cases of chronic incapacitating vertigo that are refractory to non surgical treatment (pharmacotherapy and vestibular rehabilitation).
Common medical treatment options for vertigo may include the following:
Anticholinergics such as scopolamine.
Anticonvulsants such as topiramate or valproic acid for vestibular migraines.
Antihistamines such as betahistine or meclizine, which may also have antiemetic properties.
Beta blockers such as metoprolol for vestibular migraine.
Corticosteroids such as methylprednisolone for inflammatory conditions such as vestibular neuritis or dexamethasone as a second-line agent for Ménière’s disease.
Vestibular rehabilitation, also called vestibular rehabilitation training or VRT, is a form of ”brain retraining”. It involves carrying out a special programme of exercises that encourage the brain to adapt to the abnormal messages sent from the ears. During VRT, patient keeps moving despite feelings of dizziness and vertigo. The brain should eventually learn to rely on the signals coming from the rest of the body, such as eyes and legs, rather than the confusing signals coming from the inner ear. By relying on other signals, brain minimizes any dizziness and helps to maintain balance .
The surgical procedures possible today target etiological factors or attempt to ablate the peripheral vestibular organ . Symptomatic surgical treatment doesn’t treat the cause but destroys all or part of the labyrinth, or disconnects it from the vestibular centers thus prevent the dizziness sensation. Depending upon hearing level, the choices range from selective vestibular neurectomy for serviceable hearing to labyrinthectomy for non serviceable hearing. Etiological surgical treatment aims to correct the cause of vertigo and may be in the form of endolymphatic decompression or Repair or grafting of fistulae.