Key words: Vertigo, otoneurology, etiopathogenesis, statistics "Vertigo" is a Latin word meaning “to turn” /1,2/. Dizziness is not a disease, but a symptom that can occur in the form of a sensation of self-rotation or environmental rotation in many different diseases /2,5,4/. Cases of dizziness and loss of balance make up 2.4% of hospital admissions /6/. Approximately 26% of emergency room visits are due to complaints of vertigo /6,17/. The vast majority of patients with balance disorders are in the middle-aged and elderly population groups /13,18/, while dizziness complaints are rarely encountered in childhood /12,15/. Among the population aged 60 and above, 20% report experiencing dizziness that significantly affects their daily lives /6,20/. Balance disorders can be grouped into four subcategories: • Vertigo (a spinning sensation) /15,16/ • Feeling of faintness (presyncope) • Imbalance (disequilibrium) /11/ • Lightheadedness Among these four categories, vertigo is most commonly seen in young people /12,15/, while presyncope is more common in the elderly /14,13/. The vestibular system consists of two parts: peripheral and central /26/. Peripheral vestibular pathologies play a primary role in the etiology of dizziness /5,11,23/. These include: Benign Paroxysmal Positional Vertigo (BPPV) /7,8,10/, Ménière’s disease /17,32/, vestibular neuritis, labyrinthitis, otosclerosis, perilymphatic fistula, vestibular migraine, and trauma /17/. In addition, neurological pathologies are also among the etiological causes /37,38/. These include: cerebrovascular diseases, multiple sclerosis, vestiginous migraine, epilepsy, cerebellar infarction, hemorrhage, and cerebellopontine tumors /33,36/. Other etiological causes of vertigo include systemic conditions such as syncope, psychogenic dizziness, side effects of medications, hypoperfusion states (e.g., shock, dehydration), and cardiovascular pathologies /18,19,20/. There are also some metabolic disorders, such as anemia, hypothyroidism, hyperthyroidism, and electrolyte imbalances, in which dizziness may also occur /19,20,35,32/. Research shows that the main cause of dizziness is related to inner ear pathologies. A study conducted between 01.01.2015 and 31.12.2015 on 174 patients (121 women and 53 men) investigated the causes of vertigo. It was found that the most common cause was Benign Paroxysmal Positional Vertigo (BPPV), which accounted for 28.2% of the cases. This was followed by vestibular migraine (28.2%), Ménière’s disease (13.8%), vascular problems (5.7%), vestibular neuritis (4%), and chronic subjective dizziness (4.6%) /40/. Another study on the etiology of vertigo was conducted between 2012–2015 among 5,348 patients. In this group, the following distributions were observed: • BPPV – 35.56% • Chronic subjective dizziness – 24.85% • Vestibular migraine – 11.67% • Ménière’s disease – 7.07% • Multisensory neuropathy – 4.32% • Vestibular paroxysmia – 3.31% • Vestibulopathy – 3.20% • Presyncope – 1.23% • Posterior circulation ischemia – 1.07% • Vestibular neuritis – 1.01% • Vertigo resulting in sudden deafness – 0.6% • Other causes – 1.27% • Unknown causes – 1.27% /39/. Pathophysiology of peripheral vertigo: The balance system has two primary functions /26/: 1. To stabilize the visual field during head movements 2. To control upright posture within the gravitational field /5/ These functions are managed by the visual system, vestibular system, and proprioceptive system. The central nervous system receives nerve impulses from peripheral organs, processes the information, and when necessary, integrates it to regulate balance through appropriate reflexes /24,26,27/. True vertigo is defined as a sensation where the patient feels either they are spinning or the environment around them is rotating /3,14,9/. In addition to this, patients may also describe blurred vision, unsteadiness, or lightheadedness as dizziness /1,3,4/. Clinically, the patient's history (anamnesis) and accompanying symptoms must be carefully evaluated for differential diagnosis, and if necessary, certain tests should be conducted in a dizziness (vertigo) laboratory. It is important to remember that physical examination and testing should not proceed without first clarifying the main complaint. For patients presenting with vertigo to an otolaryngologist, one of the most critical points is taking a detailed patient history. When collecting anamnesis, attention should be paid to: • The nature of the vertigo • Its intensity • Duration • Whether it is related to the ear • Accompanying symptoms • The position of the patient during vertigo • Family history • Predisposing factors /5,29,40/ When discussing the nature of vertigo, this refers to the patient’s perception of movement illusion, lightheadedness, loss of balance, oscillopsia, diplopia, and similar sensations. The intensity and duration of vertigo are also key aspects: • If vertigo lasts a few seconds, this suggests Benign Paroxysmal Positional Vertigo (BPPV) /6,7,24,9,8/ or postural hypotension • If it lasts minutes, it may indicate vascular syndromes • If it lasts hours, it could suggest Ménière’s disease • If it lasts days, vestibular neuritis or labyrinthitis • If it is persistent, spinocerebellar pathologies should be considered /36,37,38,39/ Certain triggers can provoke vertigo, such as: • Changes in position /22,6,9/ • Rapid head movements • Extension of the head • Loud noises (Tullio phenomenon) • Coughing and sneezing There are also important predisposing factors in the development of vertigo, including: • Migraine /30,39,33/ • Head trauma • Previous ear surgeries and other surgical procedures (e.g., rhinoplasty) • Infectious diseases • Metabolic disorders • Neoplasms • Ototoxic medications When taking anamnesis in patients with dizziness, family history must be carefully considered. It is important to determine whether conditions such as: • Otosclerosis • Syphilis • Allergies • Thyroid disorders • Diabetes • Hypoglycemia • Congenital deafness • Neurofibromatosis • Kidney diseases are present in the family /34,35,27/. When a patient presents to an otoneurologist with complaints of vertigo, a series of evaluations should be performed following anamnesis. These include: • General ENT (ear, nose, throat) examination • Neurological examination • Audio-vestibular tests • Bedside tests • Tests performed in the dizziness (vertigo) laboratory • Blood tests • Radiological imaging If no issues are detected during the general ENT exam, the most important symptom the otolaryngologist should focus on during the physical examination after anamnesis is nystagmus /21,19,17/. Nystagmus is an involuntary, rhythmic movement of the eyes. There are several types of nystagmus: • Congenital (present from birth) • Physiological (end-point, optokinetic, or induced by motion/physical stimuli) • Pathological (spontaneous, gaze-evoked, positional, horizontal, vertical, torsional) /34,33/ Based on gravitational response, nystagmus is also categorized as geotropic and ageotropic. It can further be classified by intensity /5/: • Grade 1: Only occurs when looking in the direction of the fast phase • Grade 2: Occurs when looking in the direction of the fast phase and in the central gaze • Grade 3: Present in central gaze as well as when looking to the right and left The clinician must determine whether the observed nystagmus is of peripheral or central origin /32,31/. To distinguish between them, several features must be evaluated: Characteristics of Peripheral Nystagmus: • Often horizontal or torsional /10,16/ • The eyes move synchronously /14,15/ • The direction does not change • Reduces with visual fixation • Shows fatigue with repetition • Has a latency period in the Dix-Hallpike test /7,8,9,18/ • According to Alexander’s Law, nystagmus intensity increases when looking in the direction of the fast phase and decreases in the opposite direction /7,6/ Characteristics of Central Nystagmus: • Can occur in any direction /6/ • Pure vertical nystagmus directly indicates a central nervous system pathology /32,33/ • The eyes may move independently • Direction may change • Does not decrease with gaze fixation • Does not fatigue with repetition • In the Dix-Hallpike test, onset is immediate /5,37,38/ If anamnesis is collected carefully, a final diagnosis can be made based on this information and additional examinations. During the analysis of nystagmus, the clinician must first identify whether vertigo is central or peripheral in origin, and then, if peripheral, which side is affected /6,28,30/. This is why a detailed history and examination are crucial for patient assessment. The coexistence of multiple symptoms may signal certain central or peripheral disorders /5,6/. For example: • If vertigo is accompanied by coordination problems and a feeling of imbalance, cerebellar pathway pathologies should be considered /40,41/ • If vertigo is accompanied by disturbed perception, visual issues (illusions), or hallucinations of taste and smell, a temporal lobe pathology might be suspected /36,35/ • If there are diplopia, dysarthria, drop attacks, limb weakness, or sensory loss, a brainstem disorder may be the cause /29/ • If vertigo is accompanied by hearing loss, tinnitus, facial weakness, sensory changes, or limb incoordination, cerebellopontine angle tumors should be considered • If there is postural control dysfunction, vestibulospinal tract pathology is possible /27,26/ • If there is eye movement disorder (e.g. diplopia), consider issues in the oculomotor centers • If vertigo presents along with hearing loss, tinnitus, ear fullness, or pain, a labyrinthine disorder is likely /24,23/ • If vertigo occurs with hearing loss, tinnitus, and facial nerve paralysis, internal auditory canal pathologies must be considered /25,21/ Thus, with carefully collected anamnesis and accompanying evaluations such as VNG, caloric testing, vHIT, cVEMP, oVEMP, EcoG, posturography, and audiological tests, an individualized treatment approach—be it conservative, surgical, or rehabilitative—can be implemented.