1. 1 Evaluation of Dizziness Daniel Giuglianotti, D.O. PGY-2 UMDNJ-SOM Family Medicine Contributor: Deborah Simcox

2. 2 Presentation Overview Pathophysiology and Clinical Presentation Differential Diagnosis Workup Symptomatic Therapy and Patient Education

3. 3 Introduction- Dizziness Very common complaint Overall Incidence = 5-10% Incidence = 40% patients over 40 years old 2.5% of ER visits in 1995-2004

4. 4 Pathophysiology and Clinical Presentation Wide variety of causes and organ systems  Vestibular dysfunction  Cardiac insufficiency  Psychiatric  Metabolic  Multiple Sensory deficits  Cerebellar disease

5. 5 Pathophysiology and Clinical Presentation Vestibular Disease = True Vertigo  Abnormal movement or abnormal movement of the environment:  NO DISTINCTION between the two  ie. “spinning”, “weaving”, “seasickness”, “rocking”

6. 6 Pathophysiology and Clinical Presentation Vestibular Disease  Peripheral Lesions  Benign Positional Vertigo (BPV)  Ménière's Disease  Acute Labrynthitis (Vestibular Neuritis)  Ototoxins  Acoustic Neuroma

7. 7 Pathophysiology and Clinical Presentation Vestibular Disease  Central Lesions  Multiple Sclerosis  Vertebrobasilar Insufficiency  Migraine-Associated Vertigo  Drugs

8. 8 Pathophysiology and Clinical Presentation Cardiovascular Disease  “light-headedness” or “faintness”  Postural changes in BP and pulse  Causes:  Dysrhythmias  Low EF  Volume depletion  Decreased vascular tone

9. 9 Pathophysiology and Clinical Presentation Multiple Sensory Deficits  Elderly, symptoms worsen when you take away a sense Cerebellar Disease  gait ataxia, unsteadiness  alcohol, ischemic injuries, paraneoplastic syndrome

10. 10 Pathophysiology and Clinical Presentation Psychiatric illness  Ill defined “I just feel dizzy”  constant “lightheadedness”  Etiology unknown Metabolic Disturbances  change in CNS homeostasis  hypoxia, hypo/hypercarbia, hypoglycemia

11. 11 Differential Diagnosis

12. 12 Workup History  Central versus Peripheral Disease  Distinguishing among Peripheral Causes  Drug History  aminoglycosides, diuretics, antihypertensive, antidepressants

13. 13 Workup History  Central versus Peripheral Disease  Central = brainstem symptoms  ie. weakenss, facial numbness, diplopia, hemiplegia, dysphasia  Peripheral ==> cochlear from retrocochlear (acoustic neuroma)  BPV- occurs with change in positions, lasts a few seconds  Vestibular neuritis- sudden, severe vertigo after viral illness  Acute labyrinthitis- inner ear infection  Meniere’s disease- episodic vertigo, tinnitus, temporary hearing loss

14. 14 Workup Physical Exam Keys:  Vitals: BP, Pulse: supine/standing  General appearance  Skin: pallor  Eyes: nystagmus  Ears: TM lesions, hearing acuity tests  Heart: murmurs, carotid arteries  Neuro: Keys are CN V, VIII, X  Sensory, vision, gait, cerebellar testing

15. 15 Workup - Physical Examination Provocative Maneuvers  Anxious- hyperventilate  Cardiac- Standing up  Multiple sensory deficits, cerebellar or Vestibular - walking and turning  Fukuda step test- march with eyes closed

16. 16 Workup - Physical Examination Provocative Maneuvers/ Vestibular Stimulation  The Dix–Hallpike (Báránay) Maneuver

17. 17 Workup - Dix-Hallpike  Peripheral lesion  nystagmus = same side as hearing loss  “spinning” away from hearing loss  Rhomberg test + patient sways towards side of hearing loss  Central Lesion  Absence of any of the 3 above  immediate nystagmus/symptoms  failure to resolve/adapt

18. 18 Workup - Physical Examination Provocative Maneuvers/Vestibular Stimulation  Maneuvers Alleviating Symptoms  Testing of Hearing on Physical Exam

19. 19 Workup - Laboratory Studies Electronystagmography and/or Audiologic Testing  Formal hearing testing  Brainstem auditory evoked response: choclear vs non. Imaging Studies  MRI for retrocochlear lesion  Schwannoma  MRI for basilar TIA

20. 20 Symptomatic Therapy and Patient Education Peripheral Vestibular Disease  Benign Positional Vertigo Epley Maneuvers 80% success rate Dislodges debris into vestibule http://www.neurology.org/content/vol63/issue1/images/data/150/DC1/video1.mpg http://www.neurology.org/content/vol63/issue1/images/data/150/DC1/video2.mpg Vestibular exercises Pharmacologic Therapy Vestibular suppressant - refractory ¢Meclizine or promethazine http://www.neurology.org/content/vol63/issue1/images/data/150/DC1/video1.mpg http://www.neurology.org/content/vol63/issue1/images/data/150/DC1/video2.mpg

21. 21 Symptomatic Therapy and Patient Education Peripheral Vestibular Disease  Vestibular Neuronitis  acyclovir not proven  meclizine for short course  Possible glucocorticoids  Ménière's Disease  Salt restriction - 1 gm per day for 6 months  Diuretics: HCTZ or acetazolamide twice daily  Avoid caffeine and alcohol

22. 22 Symptomatic Therapy and Patient Education Central Vestibular Disease  More chronic  Ativan 1 to 2mg BID  Gait training  Vestibular exercises Cardiovascular Faintness  hydration  Standing slowly  Discontinuing offending medications

23. 23 Symptomatic Therapy and Patient Education Psychogenic Light-Headedness  rebreathing into paperbag  anxiolytic  antidepressant Multiple Sensory Deficits, Geriatric Dizziness, Cerebellar Dysfunction  “add senses” or remove offending agent  attention to all contributing factors  Supportive care

24. 24 Osteopathic Considerations Labyrinthitis - 2 minute treatment  Periauricular drainage technique  Muncie Technique  Coding  ICD-9 = 739.0  E&M = 99213.25  CPT=98925 = $26.82 If did 3 body regions = 98926 = $37.01

25. 25 References Goroll: Primary Care Medicine, 6th ed., 2009 The 5-Minute Osteopathic Manipulative Medicine Consult, Millicent Channell D.O., David C. Mason, D.O. http://www.neurology.org/content/vol63/issue1/ima ges/data/150/DC1/video1.mpg http://www.neurology.org/content/vol63/issue1/ima ges/data/150/DC1/video1.mpg http://www.neurology.org/content/vol63/issue1/ima ges/data/150/DC1/video2.mpg http://www.neurology.org/content/vol63/issue1/ima ges/data/150/DC1/video2.mpg