1. Dizziness
L. Jay Turkewitz MD

2. Dizziness One of the most common complaints in all practice
Affects 20-30% of the population
I have been hospitalized twice in my life with severe vertigo and uncontrolled vomiting

3. Dizziness Makes up a tremendous number of ER and Urgent Care visits.
True persistent dizziness can lead to falls, and subsequent injuries and substantial day to day dysfunction of daily activities.
Balance related falls leads to death in the elderly—i.e. hip fracture and subsequent blood clots and pulmonary embolus or subdurals but rarely are these falls due to VERTIGO

4. Dizziness Nonspecific when the patient walks in and says I am dizzy
Your job is to figure out what the patient means by dizziness
The key issue is whether the patient has true Vertigo a sense of rotation.

5. Dizziness There is a specific “Dizziness” clinic at Mayo’s
Classic paper by Daniel Drachman on the % of patients with various symptoms who complain of dizziness
True Neurological vertigo is RARE

6. Dizziness Vertigo Neurologic Presyncope NON Neurologic
Disequilibrium Often Neurologic
Lightheadedness Rarely Neurologic

8. VERTIGO
VERTIGO

9. Dizziness
Vertigo, The illusion or sense of a spinning rotation of the room BUT it may be the patient who feels they are doing the spinning BUT there is a sense of rotation!
Peripheral vs Central
Peripheral is a reflection of disorders of the semicircular canals, utricle –the Vestibular End Organs or the 8th Nerve (ENT Docs say 8th nerve vertigo is central!)
Central Vertigo implies dysfunction of the Vestibular Nuclear Connections or Cerebellum (less likely)
The book is misleading on this point

12. Dizziness Peripheral Vertigo Prominent Nausea and Vomiting
Unidirectional Nystagumus
Sudden Onset
Auditory Issues such as Hearing Loss or Tinnitus
May be positional
Very Disabling
Delay anf fatigue

13. Dizziness Central Vertigo Nystagmus is variable
Less prominent nausea and vomiting
May not be disabling
Variable onset
No hearing issues
Other brainstem findings

14. Dizziness Presyncope The sensation that one is about to faint
“feel faint”
Nausea
Dimming of Vision
Sweating
Tremor
Cardiovascular, Metabolic or much less likely Hematologic in nature

15. Disequilibrium The sense one is about to fall
Motor weakness may cause this
Loss of sensory input from neuropathy may cause this
Balance and gait are the issues!

16. Dizziness Lightheadedness Non specific Hyperventilation is the classic
Psych issues
Meds
Altered Sensorium
My 8th grade auditorium

17. Dizziness
Vertigo
Central Vertigo always requires immediate evaluation including neuro imaging
Must eliminate the possibility of a posterior fossa mass pressing on the brainstem or primary brainstem pathology.

18. Dizziness Peripheral Vertigo Sudden Brief Attacks Fall to the ground
Spells of Tumarken
No pre-syncope
No seizure stigmata
Nausea, vomiting and uni-directional nystagmus
Peripheral Nystagmus (Horizontal with a Rotatory Component) Dampens with Fixation!

19. Dizziness Central Vertigo Often a more gradual onset
They may not be able to walk but this may reflect other issues including hemiparesis
Vertical Nystagmus is always of central origin
Unlike peripheral nystagmus central nystagmus may persist beyond 48 hours.
Peripheral Vertigo always compensates over time

21. Dizziness Brainstem Lesions Which Cause Vertigo
Always involves other tracts, motor, sensory or other cranial nerve nuclei so look for signs of other deficits on Neuro exam
Wallenberg’s Syndrome in the distribution of the Posterior Inferior Cerebellar Artery BUT usually due to vertebral occlusive disease is the classic brainstem syndrome causing vertigo

23. Dizziness Wallenberg’s Infarction of Vestibular Nuclei
Ipsilateral Horner’s Sundrome
Ipsilateral Facial Numbness
Contralateral Limb Numbness
Dyphagia
Dysarthria
Diplopia

27. Dizziness Cerebellar Lesions Causing Vertigo
Cerebellar Infarcts (Medical Emergency)—Swell and compress the brainstem (posterior Fossa Herniation Syndrome)
Cerebellar signs- Past pointing, dysmetria, dysdiadokinesis (rapid alternating movements)

28. Dizziness Vertigo associated with transient Brainstem Ischemia
Vertebrobasilar Insufficiency---diplopia, transient homonomous visual defects, dyarthria
Drop Attacks VBI but patient does not lose consciousness

29. Dizziness Brainstem Stroke has a myriad of features!
Any stroke’s findings is a reflection of the affected artery and it’s collateral blood flow
Opthalmoplegia
Hearing Loss
Visual Field Defects
Sensory Loss
Ataxia
MONOCULAR BLINDNESS IS ANTERIOR CIRCULATION

30. Dizziness Cerebellar Bleeds Headache Nausea Vomiting Nystagmus
Ataxia of Gait
Depressed Level of Consciousness
EMERGENCY SURGERY!
Prevent Herniation of Cerebellum into the Brainstem

31. Dizziness
Multiple Sclerosis

32. Dizziness
Peripheral Causes of Vertigo Much More Common than Central Causes…Statistically whenever you see someone with severe Vertigo is usually peripheral.

33. Dizziness BPPV (Benign Paroxysmal Positional Vertigo)
Most common cause of vertigo
Usually elderly
Positional One side or the other DOWN on the Pillow
Latency
Fatigue with repetitive episodes, Lasts 60 seconds per episode
Cupulolitiasis----Debris from the Utricle flowing freely in the semi-circular canals endolymph
This acts as a plug like a plunger causing a push and pull effect on the cupula creating asymetric neural impulses from the ears WHICH IS THE MECHANISM of Peripheral Vertigo and Nystagmus!
Rolling Over in Bed much more often than LOOKING UP!

35. Dizziness Vestibular Neuronitis
Probably akin to the same mechanism as Bell’s Palsy (reactivation of latent Herpes Virus BUT affecting the vestibular portion of the 8th nerve)
Often after a viral infection
May be a viral infection of the vestibular apparatus this is not like the book says NUCLEAR this is PERIPHERAL NOT CENTRAL
Lasts weeks but the acute vertigo is over after about 48 hours and the patient then feels disequilibrium for about 6-8 weeks. The vertigo can be recurrent during that time frame.

36. Dizziness Labyrinthitis
By definition there is a decrease in hearing unlike vestibular neuronitis
The Labyrinthe is affected
Can be viral or bacterial or spirochetal
The end organ of hearing is involved by definition
Otitis Media bacterial spread through a ruptured membrane or a perilymph fistula

37. Dizziness
These patients with labyrinthitis usually appear quite ill and have fever.
Unlike vestibular neuronitis where fever is uncommon
If you have Labyrinthitis there must be hearing loss and usually vertigo with nausea vomiting a peripheral pattern of nystagmus
ENT Emergency

38. Dizziness Ramsay Hunt Syndrome Varicella Zoster Virus reactivation
Affects Cranial Nerves 7 and 8
Facial Paresis
Tinnitus
Hearing Loss and Vertigo

39. Dizziness Meniere’s Disease Very Overdiagnosed..Occurs as attacks
Low Frequency Sensory Neural Hearing Loss is the HALLMARK Hearing Loss may fluctuate
Increase in the volume of Endolymph which has led to various therapeutic interventions
Distension of the Endolymphatic System
Severe Vertigo Nausea Vomiting with a peripheral pattern of Nystagmus
Attacks last minutes to hours, Ear fullness or pain
Abrupt Spells of Tumarkan Fall to the Floor!
Usually unilateral but may be bilateral

40. Dizziness Acoustic Neuroma Slow Unilateral Hearing Loss and Tinnitus
Schwanoma of the acoustic nerve
Begins on vestibular portion but affects hearing first
Slow growth is the reason vertigo rarely develops
Cranial nerves 5 and 7 This is the classic cerebello-pontine angle lesion

41. Evaluation
MRI 41

42. Pre-Syncope Simple Faint
Usually Needs to be differentiated from a seizure
Post Episode Confusion Rare
No tongue biting
No incontinence
No shaking

43. Disequibirium
Patient feels unsteady, they feel like they are going to fall.
Usually after a sudden change in position particularly when they have lost visual cues.
Loss of sensory input
Motor weakness subtle affecting balance
Extrapyramidal Disease Parkinsons!
Visual Impairment with Neuropathy
Arthritis when it is severe
Long standing Diabetes or HIV

44. Lightheadedness Vague Difficult to characterize
Most common in a dizziness clinic
Most important issue is that this is usually non neurologic and usually not a sign of severe significant disease
Floating sensation
Depersonalization a psych issue (anxiety,depression)
Hyperventilation

45. Evaluation Patient may be uncooperative due to illness
Vital Signs Orthostatic BP Changes supine and standing and look for a change in pulse
Complete HEENT and Neuro Exams
Nystagmus
EOM’s
Pupils
Fundus exclude Papiledema
Tympanic Membranes are CRUCIAL! (Scars,Fluid,Pus)
Weber Rinne after Gross Hearing

46. Evaluation Cardiac Exam Emboli Carotid Bruits Emboli Neuro Exam
Gait Romberg is key
If you can’t stand with your feet together with eyes open it is a cerebellar issue if it is only with eyes closed there is a sensory input issue.

47. Evauation Dix-Hallpike Maneuver Diagnose BPPV
Turn Head 45 degrees to the side being tested
Rapidy lower head to a position hanging below the examing table
Eyes open (nustagmus and Vertigo)
After a short latency a positive test is denoted by the eyes having a burst of nystagmus with the eyes beating towards the ground (fast phase component of nystagmus)
Lasts a minute or so
Posterior Canal Variant of BPPV

48. Dizziness Always hyperventilate the patient if need be to dx
Reproducing the syomtoms is the key to understanding whats wrong in non obvious cases

49. Evaluation Labs Not Helpful Diagnosing Vertigo CBC (anemia)
Chem Profile (eletrolytes)(dehydration BUN)
Thyroid Tests
Glucose Tolerance Test (hypoglycemia)
EKG afib or arrythmia of other type ???echo

50. Evaluation Electronystagmography
Records eye movements to look for nystagmus
In response to vestibular,visual, cervical,caloric, rotational,positional stimulations to assess vestibular function
Audiogram KEY Meniere’s Low Frequency Sensorineural Hearing Loss

51. Evaluation
ENG

52. Evaluation
Audiogram

53. Evaluation
ENG

54. Evaluation
ENG

55. Evaluation
MRI