A practical approach to dizziness

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A practical approach todizziness

• Michael Gilchrist, MD MPH
• 8/17/09

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Case

• 71 year old female with hypertension present to
  clinic with dizziness.
• What questions would you ask?

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Dizziness

• Common primary care complaint
• Vertigo, presyncope, disequilibrium, other

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Outline

• Presyncope
• Vertigo
• Causes
• Characteristics of different causes
• History and physical
• Warning signs
• How to approach the patient?

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Im dizzy

• Non-specific term
• Vertigo and psychiatric causes make up the
  majority of cases seen in clinic setting (55-70)
• Multicausal, presyncope, unknown, hyperventilation

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Presyncope

• Prodromal symptom of fainting
• Usually occurs when patient is standing or
  upright, not supine
• Orthostatic hypotension, cardiac arrhythmias,
  vasovagal attacks most common

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Other causes

• Parkinsons disease
• Peripheral neuropathy
• Hyperventilation
• Medications
• Hypoglycemia
• Psychiatric disorders

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Vertigo vs. presyncope

• Positional vertigo and postural presyncope often
  confused
• Both can occur when someone goes from sitting to
  standing
• Vertigo (especially BPPV) can be provoked with
  maneuvers that move the head without changing BP

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Vertigo

• Dysfunction of vestibular system (central vs.
  peripheral)

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Vertigo

• Illusion of motion
• Self-motion
• Motion of the surrouding environment
• spinning, tilting, moving
• All vertigo is made worse by moving the head.

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The history

• Patient description (spinning sensation,
  however is non-specific)
• Time course
• Vertigo is rarely described as continuous.
• Hearing loss? If so, duration and progression,
  unilateral vs. bilateral, tinnitus, sx of otitis

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Causes of Vertigo

• Peripheral
• Benign positional vertigo
• Vestibular neuritis
• Herpes zoster oticus
• Menieres disease
• Labyrinthine concussion
• Cogans syndrome
• Acoustic neuroma
• Aminoglycoside toxicity
• Otitis media

• Central
• Migrainous vertigo
• Brainstem
• TIA
• Wallenbergs syndrome
• Cerebellar infarcation or hemorrhage
• Chiari malformation
• MS

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BPV

• Most commonly recognized form of vertigo
• Attributed to calcium debris within the
  semicircular canal (canalithiasis)
• I feel like the room is spinning when I turn my
  head
• Lasts seconds, but pt may feel destabilized for
  hours after an attack
• No ear pain, tinnitus, or hearing loss

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BPV (cont.)

• Diagnosis usually made by history
• Dix Hallpike maneuver
• Positive in 50-80 of patients
• Canalith repositioning maneuvers
• Medical therapy usually not helpful due to
  transient symptoms

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Vestibular neuritis

• Viral or postviral inflammatory disorder
• Rapid onset of severe persistent vertigo with
  nausea, vomiting, ataxia
• Sometimes combined with unilateral hearing loss
  (labyrinthitis)
• Steroid taper.
• Dramamine, meclizine (H1 blockers),
  benzodiazapines

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Herpes zoster oticus

• AKA Ramsay Hunt syndrome
• Activation of latent herpes zoster infection
• Vertigo hearing loss, ipsilateral facial
  paralysis, ear pain, vesicles
• Antiviral therapy

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Menieres disease

• Excess endolymphatic fluid pressure
• Episodic, acute vertigo, lasts minutes to hours
• Unilateral tinnitus, hearing loss, ear fullness
• Treatment
• Salt, caffeine, tobacco restriction
• Diuretics
• Surgical

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Labryinthine concussion

• Traumatic vestibular injury following head trauma
• Transverse fractures of the temporal bone

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Cogans syndrome

• Autoimmune
• Similar to Menieres veritgo, ataxia, nausea,
  vomiting, tinnitus, hearing loss
• oscillopsia perception of objects jiggling
  after abruptly turning the head

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Acoustic neuroma

• Slow growing tumor
• Patients often experience mild vertigo or no
  vertiginous symptoms at all
• Unilateral tinnitus and hearing loss
• MRI brain

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Otitis media

• Fever, hearing loss, nausea, vomiting
• If pt has pain with tragal stimulation, consider
  CT scan of face to evaluate for labryinthine
  fistula in the temporal bone

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Peripheral causes

• Benign positional vertigo - most common, no
  hearing loss
• Vestibular neuritis - sometimes hearing loss
• Herpes zoster oticus (Ramsay-Hunt)
• Menieres disease - unilateral hearing loss
• Labyrinthine concussion
• Cogans syndrome - autoimmune
• Acoustic neuroma - often minimal vertigo
• Aminoglycoside toxicity
• Otitis media

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Central causes
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Migrainous vertigo

• Can have central and peripheral manifestations
• Diagnosis made by history (aura, headache
• Sometimes associated with migraine headaches

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Brainstem ischemia

• Vertebrobasilar arterial system
• Rarely the sole manifestion, however
• MRI brain

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Wallenbergs syndrome

• Lateral medullary infarction
• Posterior inferior cerebellar artery
• Oftentimes concurrent
• Ocular movements
• Ipsilateral Horners syndrome
• Ipsilateral limb ataxia
• Sensory loss
• Hoarseness, dyphagia (CN IX)

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Cerebellar infarction/hemorrhage

• Sudden intense persistent vertigo with nausea and
  vomiting. Pronounced gait abnormalities
• Pt falls toward the side of the lesion
• Typically older pts (gt60 y/o) with CV risk factors

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Warning signs

• Suggestions of central vestibular disease or
  brainstem lesions
• Persistent vertigo
• Ataxia
• Nausea/vomiting
• Headache
• Vision loss, diplopia
• Slurred speech

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Vertigo, physical exam findings

• Nystagmus
• Hallpike maneuver
• Move patient rapidly from sitting to lying
  position, head tilted downward of facing you

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The Dix-Hallpike Test of a Patient with Benign
Paroxysmal Positional Vertigo Affecting the Right
Ear
Furman J and Cass S. N Engl J Med
19993411590-1596
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Central vs. Peripheral Vertigo

• Peripheral
• Nystagmus unidirectional, horizontal with a
  torsional component
• Other neurologic signs absent
• Deafness or tinnitus may be present
• Central
• Nystagmus can be in any direction
• Other neurological signs often present
• Gait instability
• Deafness or tinnitus typically absent
• Often less severe
• More likely to be chronic, not episodic

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High yield historical questions

• Subjective description, avoid leading questions
• Duration/frequency of symptoms
• Triggering factors
• Associated nausea/vomiting?
• Hearing loss or tinnitus?
• Any other neurological complaints
• Recent viral illness, fever, systemic symptoms?
• New medications?

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Physical exam

• Neurological exam
• Check for nystagmus with and without Dix-Hallpike
• Ear exam
• Gait
• Cardiovascular exam