Dizziness

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Dizziness

• A Patient Complaint That Can Make the Doctors
  Head Spin.

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What Is Dizziness ?

• A non-specific term used to describe a number of
  signs and symptoms
• Unsteadiness
• Giddiness
• Light-headed
• Disequilibrium
• Vertigo

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Focus of Diagnostic Workup

• Vertigo auditory and Vestibular system
• Near-faint dizziness cardiovascular system
• Psychophysiological dizziness - psychiatric
• Hypoglycemic dizziness- metabolic assessment
• Disequilibrium peripheral nerves, spinal cord,
  inner ear, vision, CNS

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Vertigo

• An illusion of movement in space
• Rotation (most common)
• Linear
• Tilt

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History of the Dizzy Patient

• Detailed description of dizziness
• Differentiate vertigo from non-vertigo
• Determine onset, length, and if recurrent
• Associated neurological or systemic signs
• Any hearing loss?
• Current medications
• Differentiate Peripheral vs. Central cause

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Peripheral or Central Cause?

• Peripheral
• Labyrinth or vestibular nerve dysfunction
• Recurrent
• Nystagmus-horizontal
• Position change
• Moderate to severe vertigo

• Central
• Cerebellum or brain stem dysfunction
• Continuous
• Nystagmus-vertical
• Mild vertigo
• Non-positional

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Peripheral Vestibular Disorders

• BPPV
• Labrynthitis
• Menieres disease
• Acoustic Neuroma
• Motion sickness
• Cervicogenic
• Perilymphatic fistula

• Vestibular neuronitis
• Semicircular canal infection
• Semicircular canal water penetration

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Central Vestibular Disorders

• Brain stem lesion
• Basilar artery migraine
• TIA
• Stroke
• MS
• Cerebellar lesions

• Metastatic Tumor
• Meningioma

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Anatomic and Physiologic Components of Balance

• Vestibular labyrinth, vestibular nuclei
• Visual CN III, IV, VI
• Proprioceptive upper cervical ms and joints

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Types of Vertigo

• Subjective vertigo
• The patient feels that they are spinning

• Objective vertigo
• The patient feels still but objects appear to be
  moving around them

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Causes of Vertigo

• Ear disease
• Toxic conditions (alcohol, food poisonings)
• Postural hypotension
• Infectious disease
• Cervicogenic
• Disease of the eye or brain
• Psychological

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Benign Paroxysmal Positional Vertigo (BPPV) 20

• Brief episodes recurrent
• Moderate to severe
• Associated with head position
• Gradually diminishes over a month or two
• No hearing loss
• Latency or delayed onset of S/S
• Positive Nylen-Barany maneuver
• Caused by otoconia (debris) floating in PSC

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Nylen-Barany AKA Dix-Hallpike

• Patient seated, head turned 45 degrees
• Patient quickly lays supine
• Latency period, then horizontal or rotational
  nystagmus
• Nystagmus decreases after 10-20 seconds
• Affected ear is the side head is turned toward
  when nystagmus and vertigo occurs

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Nylen-Barany Maneuver
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Treatment Options for BPPV

• Epleys
• Sermonts
• Habituation exercises (Brandt-Daroff)
• Cervical adjusting

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Modified Epleys Maneuver

• Patient placed supine with head turned 45 degrees
  toward the affected ear (30 sec.)
• Dr. turns head 90 degrees so affected ear is up.
  (30 sec.)
• Patient rolls on to side, head looking toward the
  floor (30 sec.)
• Patient is lifted into sitting position
• Procedure is repeated until no nystagmus

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Modified Epley Maneuver
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Sermonts Maneuver

• Patient can be instructed to do this at home.
• Patient turns head 45 degrees away from the
  affected side
• Quickly lays down maintaining head position (4
  minutes)
• Brought up and placed on other side with same
  head position. (4 min) Sit up normal

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Sermonts Maneuver
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Post Maneuver Instructions

• Patient waits 10 min. before leaving office.
• Other person drives them home.
• Sleep half-reclined 2-3 days.
• Avoid laying on bad side.
• Avoid extreme head extension for 2-3 days

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Cervicogenic Vertigo

• Hx of neck trauma, muscle spasm
• Limited cervical ROM
• Positive chair rotation test (Fitz-Ritson)
• Patients may complain of dysequilibrium (tilt)
  more than rotational vertigo
• Overstimulation of upper cervical proprioceptors
• May overlap BPPV or Menieres disease

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Vertebrobasilar Insufficiency TIAs

• Vertigo with associated Neurological signs
• Diplopia
• Ataxia
• Drop attacks
• Dysarthria
• Paralysis/weakness/Numbness
• Headache
• Risk factors (HTN, Diabetes, Coronary Disease)

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Menieres Disease

• Sudden and recurrent (paroxysmal) attack of
  severe vertigo (4th leading cause)
• Low-tone hearing loss
• Low-tone tinnitis
• Sense of fullness in the ear
• Vertigo lasts for hours to a day then burn out
• Hearing loss may progress

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Cause of Menieres

• Overproduction or retention of endolymph
• Possible autoimmune etiology
• Head trauma
• Previous infection
• Pregnant females are more prone

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Management of Menieres

• Salt-restriction diet
• Diuretic therapy
• Cervical adjusting (overlaps with cervicogenic
  vertigo

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Perilymphatic Fistula

• Hx of barometric pressure changes (airplane or
  weight lifting)
• Opening develops between middle and inner ear
  (oval window rupture)
• Rare cause of vertigo
• Bearing down reproduces s/s
• Tx - surgical

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Labyrinthitis

• Sudden severe vertigo that last days to weeks
• Maybe nausea and vomiting
• Viral infection - no hearing loss
• Bacterial infection hearing loss

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Acoustic Neuroma

• Mild but constant hearing loss
• Dizziness with possible tinnitis
• Gradual onset
• Benign schwannoma of 8th CN
• Other CN findings as tumor grows
• Surgical excision

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Cerebral Hemorrhage

• Sudden vertigo and nausea
• Vomiting associated with a headache
• Inability to stand
• Nystagmus, nuchal rigidity, facial paralysis,
  ataxia, dysrythmia, small reactive pupils
• Hx of HTN in 2/3 of patients

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When to refer to a specialist

• Serious vertigo that is disabling
• Ataxia out of proportion to vertigo
• Vertigo longer than 4 weeks
• Changes in hearing
• Vertical nystagmus
• Focal neurological signs
• Systemic disease or psychological origin