Post-Traumatic Vertigo

Timothy C. Hain, MD

Updated 10/2012

What is Post-Traumatic Vertigo?

Head injuries are sustained by 5% of the population annually. Post-traumatic vertigo refers to dizziness that follows a neck or head injury. While injuries to other parts of the body might, in theory, be associated with dizziness, in practice this is almost never the case. Because of the high incidence of litigation associated with post-traumatic vertigo, most clinicians are extremely cautious in making this diagnosis.

What Causes Post-Traumatic Vertigo?

There are many potential causes of post-traumatic vertigo:

Otoconia After a head injury, otoconia may be displaced from the utricle and migrate into other parts of the ear, causing dizziness.

Positional vertigo, and particularly Benign Paroxysmal Positional Vertigo (BPPV) . This is the most common type of severe dizziness, and it is also common after head injury. It is easily recognized by the pattern of dizziness that is brought only when the head is placed in certain positions. There are several good treatments for BPPV and the prognosis for this syndrome, in the proper hands, is excellent. It is also possible to have rarer causes of positional vertigo including mainly utricular injury , vestibular atelectasis, and various forms of central vertigo caused by cerebellar or brainstem disturbances (see Figure 1).

Normal membranous labyrinthDilated membranous labyrinth in Meniere’s disease. After a head injury, scarring of the drainage pathways may cause fluid to build up.

Post-traumatic Meniere’s disease, also sometimes called hydrops. Episodes of dizziness accompanied by noises in the ear, fullness, or hearing changes. The mechanism is thought to be bleeding into the inner ear, followed by disturbance of fluid transport (see Figure 2). The onset of symptoms may vary from immediate to as long as one year later. There are frequently legal implications to this diagnosis. The probability of Meniere’s disease being reasonably attributed to post-traumatic mechanisms is a function of the severity of injury (severe makes it more likely), the latency from the injury (longer is less likely), the presence of a pre-existing condition, and the presence of secondary gain. Persons with the Large Vestibular Aqueduct syndrome are felt to be more likely to develop these symptoms.

Labyrinthine “concussion.” A a non-persistent hearing or labyrinthine disturbance which follows a head injury, not caused by another mechanism. A hearing loss or a nystagmus must be present to make this diagnosis with a reasonable degree of medical certainty. While the name implicates an inner ear disturbance, this symptom complex may be impossible to differentiate from other entities.

Post-traumatic migraine. Dizziness combined with migraine headaches. Headaches and vertigo are common after head injuries. The main difficulty in this situation is to determine whether they are related or coincidental.

Cervical vertigo. Imbalance following a severe neck injury. While nearly all dizziness specialists agree that cervical vertigo does exist, there is controversy regarding the frequency with which it occurs (Brandt T, 2001).

TboneLongitudinal temporal bone fracture TbobeOblique temporal bone fracture

Temporal bone fracture. In this situation there is severe dizziness after an injury, and a skull or temporal bone CT scan indicating a fracture. Often accompanied by hearing loss or peripheral facial weakness (Bell’s palsy). Temporal bone fractures, especially the oblique variety (see above), may impair hearing and cause dizziness. There often is blood seen behind the eardrum (hemotympanum). Either a conductive or sensorineural hearing loss may be present. Vestibular deficits are also common, especially in the oblique variety. Bilateral vestibular problems are exceedingly rare. Treatment is conservative. Prophylactic antibiotics are given, usually for four weeks. Myringotomy and insertion of a ventilating tube may be indicated, especially for serious otitis that persists after one month.

Window Rupture Round window fistula. A membrane “blows out” between the inner and middle ear, causing dizziness and possibly also hearing loss.

Perilymph fistula. Usually symptoms of imbalance and dizziness provoked by straining or blowing the nose (see Figure 3). People with fistula may also get dizzy with loud noises (called Tullio’s phenomenon). The frequency to which this syndrome occurs is controversial, but general opinion holds that it is rare.

Factitious vertigo. This refers to complaints of vertigo related to psychological causes such as depression, anxiety, or an attempt to obtain compensation (also known as “malingering”). Anxiety and depression may result from traumatic brain injury that creates a self-perpetuating psychological reaction (Alexander, 1998).

Epileptic vertigo. Vertigo due to brain injury, typically the part of the temporal lobe that processes vestibular signals. Loss of consciousness usually occurs at the time of injury. The typical symptom is “quick spins,” although this symptom has other potential causes (BPPV, vestibular neuritis). Treatment is with anticonvulsants.

Diffuse axonal injury (DAI). Pure deceleration forces can produce diffuse axonal injury (Gennarelli et al, 1982). In some individuals who come to autopsy after a twisting type injury of the head on neck, small areas of bleeding (petechial hemorrhage), and interruption of neuronal circuits (axonal damage) can be found. Complaints of dizziness attributed to brainstem injuries which cannot be imaged with a good MRI. This is an autopsy diagnosis — it cannot be made with certainty prior to death. Historically, significant DAI is not felt to occur in awake humans who do not report loss of consciousness. A 30- minute loss seems likely to be needed for a significant DAI (Alexander, 1998).

Post-concussion syndrome. A combination of headache, dizziness, and mental disturbance which follows a head injury, without an identifiable etiology (cause). If an etiology can be determined for symptoms, a more specific diagnosis should be used. Post-concussion syndrome is often attributed to Traumatic Brain Injury(TBI), which is a general term for a head injury affecting the brain. While dizziness and nausea symptoms usually resolve over six weeks, cognitive symptoms and headaches may be persist longer. Occasionally symptoms are permanent. As noted above, in many cases, chronic symptoms are psychological in origin.

Whiplash injury syndrome. Very similar to post-concussion syndrome, but with the addition of neck complaints. Possibly related to cervical vertigo, dizziness occurs 20 to 60% of the time. This syndrome can persist for years; however, about 75% of patients are recovered by one year (Radanov et al, 1994).

In one small retrospective study of 16 patients, five had perilymphatic fistulas and two were diagnosed with Meniere’s disease. Eleven patients were unable to return to work at all, and three returned to full work capacity (Marzo, 2004).

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How is Post-Traumatic Vertigo Diagnosed?

First, the doctor will want to know exactly when and how the head or neck was injured, and the character of the dizziness (for example. is there spinning. unsteadiness, confusion?). The doctor will also want to know if you were unconscious and, if so, the duration of time. All available records from the emergency room or hospital where you were seen after the injury should be obtained if possible.

Next, a specialized examination for dizziness will be performed. Balance will be measured. A search for nystagmus will be made, related to head and/or neck position or to vibration of the neck. You will be checked for pressure sensitivity with the fistula test.

Laboratory tests will be ordered. In most instances these will include an audiogram, electronystagmography (ENG), possibly an MRI scan or CT scan of the inner ear. An EEG may be obtained. In patients with hearing disturbance, an electrocochleography (ECOG) may be done. Moving platform posturography and psychological testing is sometimes done in persons who have entirely normal test results. They can document subtle imbalance and cognitive difficulties.

How is Post-Traumatic Vertigo Treated?

Treatment is individualized to the diagnosis. Treatment usually includes a combination of medication, changes in life style, and possibly physical therapy. Occasionally, surgery may be recommended.

Research Studies in Post-Traumatic Vertigo

At the American Hearing Research Foundation (AHRF), we have funded basic research on related conditions in the past. Click here if you would you would like more information about contributing to the AHRF’s efforts.

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Acknowledgments

Graphics are courtesy of Northwestern University

References

  • Alexander MP. In the pursuit of proof of brain damage after whiplash injury. Neurology 1998:51:336-340
  • Berrettini, S., E. Neri, et al. (2001). “Large Vestibular Aqueduct in distal renal tubular acidosis. High- resolution MR in three cases.” Acta Radiol 42(3): 320-322.
  • Brandt T, Bronstein AM. Cervical Vertigo. J Neuurol Neurosurg Psychiatry. 2011 Jul;71(1):8-12.
  • Feneley, M. R. and P. Murthy (1994). “Acute bilateral vestibulo-cochlear dysfunction following occipital fracture.” J Laryngol Otol 108(1): 54-6.
  • Genarelli and others. Diffuse axonal injury and traumatic coma in the primate. Ann Neurol 1982:12:564-574.
  • Marzo SJ, Leonetti JP et al. Diagnosis and management of post-traumatic vertigo. Laryngoscope. 114(10):1720-3, 2004.
  • Pulec JL, DeGuine C. Hemotympanum from trauma. ENT journal, 2001,Vol80, 486
  • Radanov BP, Surzenegger M, Schnidrig A. Relation between … Br. J. Rheum 1994:33:442-448
  • Rubin AM. Dizziness associated with head-and-neck trauma. AudioDigest Vol 30, #22, 1997
  • Tusa RJ, Kaplan PW, Hain TC, Naidu S: Ipsiversive eye deviation and epileptic nystagmus. Neurology. 1990.