Dizziness

1
Dizziness

• Dr Madeline Rogers
• GP GPwSI in ENT
• Asplands Medical Centre
• Woburn Sands

2
Balance-input

• Eyes
• Somatosensors esp neck. Also joints/muscles/skin
• Labyrinth
• Brain stem vesicular nuclei
• Cerebellum
• Cortex

3
What do you mean by dizziness?

• Giddiness
• Lightheadedness
• Vertigo
• Unsteadiness
• Clumsiness
• faintness

4
Balance Impairment

• Eyes- Poor vision- balance worse in poor
  lighting. Poor propioceptive input loss of
  visual horizon
• Impaired somatosensors- elderly peripheral
  neuropathies
• Labyrinth- vertigo
• Brain stem- CVA tumours MS- initial attack may
  be difficult to differentiate from acute
  vestibulitis. Patient may complain of
  lightheadedness, being clumsy and /or vertigo.
  The vertigo tends to be persistent
  non-positional
• Cerebellum- clumsiness Move to side of lesion.
  Symptoms are progressive.
• Cortex- syncope
• Anxiety- hyperventilation etc

5
Balance Impairment

• Light-headedness- syncope-
• positional- postural hypotension
  autonomic neuropathy (DM)
  anaemia hypovolaemia
• Non positional - hypoglycaemia cardiac e.g.
  arrhythmias gastrointestinal e.g.
  dumping
• Functional- anxiety / hyperventilation
• Unsteadiness- periperal neuropathies
• e.g. neuropathic feet in DM alcohol small cell
  lung Ca B12 deficiency Drugs eg
  allopurinol,INAH,nitrofurantoin heavy metals
• Clumsiness- stagger to side of lesion
• past-pointing
  loss of fine movementhypotonia
• Vertigo- peripheral central
• Mixed- MS CVA

6
Vertigo

• Hallucination of movement
• Is it vertigo? Is it dizziness?
• did you feel light-headed or did the world spin
  as if you had just got off a playground
  roundabout
• Establishing vertigo narrows the diagnosis to
  disorders of labyrinth or its central
  connections.
• Peripheral - Middle ear disease
• Benign Paroxysmal
  Positional Vertigo
• Acute vestibular
  Neuronitis-labyrithitis/acute vestibular failure
• Menieres
• Head injury-fracture of
  temporal bone/surgery
• Drugs- aminoglycosides/
  furosemide
• Central- Vestibular migraine
• Cerebellar or brainstem
  stroke
• MS
• Tumour

7
Middle ear disease

• Acute AOM-
• Chronic suppurative otitis media- cholesteatoma
  eroding into inner ear labyrinth- suspect with
  vertigo and discharging ear
• Trauma after stapedectomy for otosclerosis due to
  perilymph leak.

8
Acute Vestibular Failure

• Aka- acute labyrinthitis/ acute vestibular
  neuronitis
• Probably viral . Acute vertigo with vomiting
  Usually lasts 1-7 days but takes weeks for
  compensation to occur.
• Seasonal outbreaks
• Central compensation can be delayed but use of
  vestibular sedatives eg prochlorperazine. Ok for
  short use in acute phase as inj/ supp/s/l
• BPPV may follow because calcium deposits break
  off damaged otoconia. Thus prolonging symptoms.
• Central compensation may be very delayed or
  incomplete in elderly

9
Benign Paroxysmal Positional Vertigo

• May follow acute vestibular failure or head
  injury.
• Episodic
• Positional- provoked by turning to affected side.
• Lasts seconds minutes. Often when turns in bed
• Effect fatigues eg in repeated testing
• Otoconial debris usually in posterior canal
• Dix-Hallpike test- vertigo provoked with
  torsional nystagmus short duration
  fatiguability
• Vestibular sedatives no therapeutic advantage.
• Positional manoeuvres exercises to treat eg
  Epley Daroff-Brandt

10
Menieres Disease

• Triad of symptoms Rotational vertigo
• Loss of
  hearing
• Tinnitus
• Affects young- middle aged
• Lasts 1-24 hrs
• Prodromal phase- feeling of fullness in ear
• No vertgo between attacks
• Hearing loss- low frequency progressive with
  attacks
• Can be unilateral or progress to bilateral
• Management initially medical. Stop smoking
  reduce salt caffeine.
• diuretics
• vestibular sedatives

11
Menieres Disease

• If medical fails
• Surgical referral
• Grommets
• Chemical ablation
  of labyrinth with gentamycin
  instilled transtympanically or
  directly to round window niche.
• Surgical
  labyrinthectomy
• Neurosurgical
  division of vestibular nerve
• Hearing loss

12
Examination

• Good history essential examination may be normal
• Observe
• CVS- pulse / BP /carotids
• Ears- tympanic membrane tuning fork testing
• Romberg- perform standing on thick foam. Removes
  proprioception via long tracts. Isolates
  vestibular mechanism
• Unterberger- turns to hypoactive side. Problem if
  other muscle /joint disorders
• Neuro-otological exam- Cranials . Cerebellar
  function
• Head Thrust- Vestibulo- ocular reflex
• Dix- Hallpike test

13
Investigations

• Audiometry- asymmetrical snhl-
• MRI to exclude acoustic neuroma or any
  cerebello-pontine angle tumour

14
Red Flags

• Refer-
• Severe progressive symptoms
• Balance disorder associated with hearing loss
• Vertigo with unilateral snhl or unilateral
  tinnitus
• Any assoc neurological symptoms suggestive of
  brainstem CVA
• Vertigo with chronic suppurative otitis
  media-chloesteatoma eroding into inner ear

15
Dizziness in The Elderly

• Multisystem failure
• Polypharmacy
• Poor eyesight
• Cardiac problems
• Cerebrovascular disease
• BPPV
• Burnt out menieres
• Vestibular failure
• Incomplete central compensation
• Peripheral neuropathies
• Muscle weakness
• Arthritic joints