1. A practical approach to dizziness
Michael Gilchrist, MD MPH
8/17/09

2. Case
71 year old female with hypertension present to clinic with “dizziness”.
What questions would you ask?

3. Dizziness Common primary care complaint
Vertigo, presyncope, disequilibrium, other

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

5. “I’m dizzy” Non-specific term
Vertigo and psychiatric causes make up the majority of cases seen in clinic setting (55-70%)
Multicausal, presyncope, unknown, hyperventilation

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

7. Other causes Parkinson’s disease Peripheral neuropathy
Hyperventilation
Medications
Hypoglycemia
Psychiatric disorders

8. 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

9. Vertigo
Dysfunction of vestibular system (central vs. peripheral)

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

12. 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

13. Causes of Vertigo Peripheral Central Migrainous vertigo Brainstem
Benign positional vertigo
Vestibular neuritis
Herpes zoster oticus
Meniere’s disease
Labyrinthine concussion
Cogan’s syndrome
Acoustic neuroma
Aminoglycoside toxicity
Otitis media
Central
Migrainous vertigo
Brainstem
TIA
Wallenberg’s syndrome
Cerebellar infarcation or hemorrhage
Chiari malformation MS

14. 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

15. 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

16. 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

17. Herpes zoster oticus AKA Ramsay Hunt syndrome
Activation of latent herpes zoster infection
Vertigo + hearing loss, ipsilateral facial paralysis, ear pain, vesicles
Antiviral therapy

19. Meniere’s 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

20. Labryinthine concussion
Traumatic vestibular injury following head trauma
Transverse fractures of the temporal bone

21. Cogan’s syndrome Autoimmune
Similar to Meniere’s: veritgo, ataxia, nausea, vomiting, tinnitus, hearing loss
“oscillopsia”: perception of objects jiggling after abruptly turning the head

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

23. 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

24. Peripheral causes
Benign positional vertigo - most common, no hearing loss
Vestibular neuritis - sometimes hearing loss
Herpes zoster oticus (Ramsay-Hunt)
Meniere’s disease - unilateral hearing loss
Labyrinthine concussion
Cogan’s syndrome - autoimmune
Acoustic neuroma - often minimal vertigo
Aminoglycoside toxicity
Otitis media

25. Central causes…

26. Migrainous vertigo Can have central and peripheral manifestations
Diagnosis made by history (aura, headache
Sometimes associated with migraine headaches

27. Brainstem ischemia Vertebrobasilar arterial system
Rarely the sole manifestion, however
MRI brain

28. Wallenberg’s syndrome
Lateral medullary infarction
Posterior inferior cerebellar artery
Oftentimes concurrent
Ocular movements
Ipsilateral Horner’s syndrome
Ipsilateral limb ataxia
Sensory loss
Hoarseness, dyphagia (CN IX)

29. 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 (>60 y/o) with CV risk factors

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

31. Vertigo, physical exam findings
Nystagmus
Hallpike maneuver
Move patient rapidly from sitting to lying position, head tilted downward of facing you

32. The Dix-Hallpike Test of a Patient with Benign Paroxysmal Positional Vertigo Affecting the Right Ear
Figure 2. The Dix-Hallpike Test of a Patient with Benign Paroxysmal Positional Vertigo Affecting the Right Ear. In Panel A, the examiner stands at the patient's right side and rotates the patient's head 45 degrees to the right to align the right posterior semicircular canal with the sagittal plane of the body. In Panel B, the examiner moves the patient, whose eyes are open, from the seated to the supine right-ear-down position and then extends the patient's neck slightly so that the chin is pointed slightly upward. The latency, duration, and direction of nystagmus, if present, and the latency and duration of vertigo, if present, should be noted. The red arrows in the inset depict the direction of nystagmus in patients with typical benign paroxysmal positional vertigo. The presumed location in the labyrinth of the free-floating debris thought to cause the disorder is also shown.
Furman J and Cass S. N Engl J Med 1999;341:

33. Central vs. Peripheral Vertigo
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

34. 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?

35. Physical exam Neurological exam
Check for nystagmus with and without Dix-Hallpike
Ear exam
Gait
Cardiovascular exam