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CONDITIONS PRODUCING VERTIGO 379
widely advocated, but it is an unpleasant regime which should be reserved
for cases uncontrolled by the methods described. One way and another,
medical therapy adequately controls the condition in 80 per cent of cases.
During the acute attack sedation is essential, and vomiting may neces-
sitate intramuscular administration. Among the drugs commonly used are
promethazine theoclate (Avomine), prochlorperazine maleate (Stemetil),
chlorpromazine hydrochloride (Largactil) and promethazine hydrochloride
(Phenergan), while phenobarbitone and hyoscine are effective alternatives.
If circumstances are favourable stellate ganglion block may be effective in
In unilateral cases, when medical treatment has failed, surgical destruc-
tion of the affected labyrinth is the most certain method of controlling the
symptoms, but it results, of course, in loss of hearing in that side. It is indi-
cated where the hearing is already poor, and if the patient is having difficulty
in maintaining a useful working and social life. If the hearing is still useful
selective destruction of the vestibular labyrinth may be achieved by using
ultrasound to the affected horizontal (lateral) semicircular canal. This
method may also be used in bilateral cases. Alternative operations are
decompression of the endolymphatic sac, division of the vestibular nerve
in the internal auditory meatus and stellate ganglionectomy.
Meniere-like symptoms may be produced by a variety of conditions which
should be considered in any differential diagnosis. They include: a plug of
wax; Eustachian tubal obstruction; otitis media, catarrhal or suppurative;
circumscribed labyrinthitis; purulent labyrinthitis; labyrinthine haemor-
rhage in leukaemia, haemophilia, etc.; spasm of the internal auditory artery;
toxic neuritis from excess of alcohol or tobacco, or following a septic infec-
tion in the teeth, tonsils, sinuses or the genito-urinary tract; drug toxicity,
e.g. from salicylates, quinine, ototoxic antibiotics, etc.; syphilitic disease of
the ear; allergy with urticaria, angioneurotic oedema, etc.; tumour of the
eighth nerve or of the cerebellopontine angle; anaemia of the brain from
haemorrhage; endocrine disorders; vascular spasm in cerebral arterioscler-
osis; localized meningitis in the posterior fossa; thrombosis of the arteries
supplying the pons medulla or cerebellum; syphilis of the midbrain or gumma
of the cranial base; functional disturbance of the medullary nuclei or cortical
centres allied to migraine, epilepsy or asthma; and cerebellar tumours.
From this list it is evident that the help of a neurologist may be frequently
necessary in arriving at a diagnosis.
Vestibular Neuronitis. This is characterized by severe vertigo of sudden
onset without deafness or tinnitus, and with no signs of neurological involve-
ment, but with abnormal caloric responses. It is frequently preceded by a
mild febrile illness and is usually thought to be of an infective, possibly virus,
origin. It is sometimes called epidemic vertigo. It may be slow to resolve but
symptomatic recovery is the rule, and treatment is merely symptomatic.
Positional Nystagmus. There are two types described. The benign paroxysmal
type which is associated with degenerative changes in the utricle and is
characterized by the occurrence of vertigo and nystagmus with the head
in a particular position. The condition has certain features—the nystagmus