Medical Approach to Dizzy Patients

1. Medical Approach to Dizzy Patients Bastaninejad, Shahin, MD, Otolaryngologist & Head and Neck Surgeon

2. Presentation Outlines • Introduction • History • Physical Examination • Para-clinical issues • Differential Diagnosis • Non-systematized Dizziness • Vertigo • Peripheral • Central

3. Introduction • Dizziness is the third most common complaint among all outpatients. • The single most common complaint among patients older than 75 yrs. • Encompasses: weakness, presyncope, neurologic impairment, vertigo, visual disturbance, and psychologic illness.

5. Presentation Outlines • Introduction • History • Physical Examination • Para-clinical issues • Differential Diagnosis • Non-systematized Dizziness • Vertigo • Peripheral • Central

6. History • Does the patient experience a spinning sensation? This sensation is classic for true vertigo (vestibular end organs, vestibular nerve, vestibular nuclei). • Is the patient experiencing nausea and vomiting? (usually have labyrinthine disease) • Are any associated auditory symptoms present?

7. What is the timing of the dizziness? Does it completely resolve between attacks? • Are any neurologic symptoms associated with the dizziness? (also visual) • Drug history. • Past medical, surgical, family, psychiatric history and social history. • Vascular problems, such as coronary artery disease or carotid artery disease, suggest certain causes of dizziness. • Headaches may suggest migraine-associated dizziness…

8. Central Vs. Peripheral Vertigo: • Vertigo, which is peripheral in origin, often presents as severe, intense attacks that last several seconds to minutes. • A central etiology is more concerning in patients who describe mild symptoms that are gradual in onset and last several weeks to months.

12. Presentation Outlines • Introduction • History • Physical Examination • Para-clinical issues • Differential Diagnosis • Non-systematized Dizziness • Vertigo • Peripheral • Central

13. Physical Examination • Blood pressure (check for orthostatic) & PR and Heart Rhythm (ECG). • Ear  otoscopy, audiogram. • Eye  fundoscopy, iris reactivity, motion, Saccadic and persuade examination. • Complete cranial nerve (CN) evaluation. • Auscultate the heart and carotids.

14. Evaluate the balance function: • Head-thrust and head-shake tests • Dix-Hallpike maneuver (A positive result is suggestiveBPPV) • Fistula test (perilymph fistulas) • Cerebellar function should be assessed (finger-to-nose and heel-to-shin, Gait should be observed) • Romberg test (proprioceptive)

15. Dix-HallpikeManeuver:

16. Head thrust test

18. Presentation Outlines • Introduction • History • Physical Examination • Para-clinical issues • Differential Diagnosis • Non-systematized Dizziness • Vertigo • Peripheral • Central

19. Para-clinical Issues • hemoglobin and hematocrit levels. • thyroid function tests (T4 and TSH). • antinuclear antibodies. • fasting glucose. • cholesterol levels. • rheumatoid factor. • tests for syphilis (FTA-ABS and VDRL).

20. Radiographic imaging: • in patients with suspected retrocochlear abnormalities • in patientswho demonstrate equivocal results in other studies • all patients who have new-onset vertigo or neurologic findings (although not indicated in younger patientswho have a clear peripheral cause) MRI +/- Gd, Brain CT,…

21. Audiometery: in all patients. • Electronystagmography (پاستور نو) • It’s standard of objective assessment of vestibular function. • ENG provides the examiner withinformation regarding the site of the lesion • If the patient’s nystagmus is worsened by fixation, a central focus of a pathologic condition shouldbe suspected. ENG

22. Although direction-fixed positional nystagmusis nonlocalizing, it is morelikely to represent peripheral vestibular disease than central vestibular disease. • Direction-changing positional nystagmusis nonlocalizing; it can presentwith either central disease or peripheral disease • Electronystagmography does, however, have limitations. It fails to assessthe vestibulospinal tracts .

23. Rotational testing • The rotary chair is large and expensive, making it impractical for many otolaryngologists. • Computerized dynamic posturography: • this is primarily a test of functional abilities rather than a test to determine site of lesion. • Can be done in the clinic with the Romberg test.

25. Presentation Outlines • Introduction • History • Physical Examination • Para-clinical issues • Differential Diagnosis • Non-systematized Dizziness • Vertigo • Peripheral • Central

26. Differential Diagnosis • Nonsystematized dizziness • Vertigo • Peripheral • Central Vertigo: …Sense of motion. Thesesymptoms are generally brought on by disturbance to the vestibular endorgans and the retrocochlear pathways

28. Presentation Outlines • Introduction • History • Physical Examination • Para-clinical issues • Differential Diagnosis • Non-systematized Dizziness • Vertigo • Peripheral • Central

29. Nonsystematized dizziness • Proprioceptive system abnormalities • Pt. May have Ataxia too • chronic alcoholism • Vitamin deficiencies due to malnutrition • Pernicious anemia • Syphilis (tabesdorsalis)

30. Eye abnormalities • If visual compromise is suspected, tests for visual acuity should be performed • Complaints of diplopia should be investigated • In glaucoma often complain of dizziness is secondary to visual change

31. Cerebral anoxia • complain of lightheadedness (not while sitting or lying down) • Anemia • Arteriosclerosis • Orthostatic hypotension: • Shy-Drager syndrome (which classically has associatedautonomic changes). • Drug induced (e.g., atenolol).

32. Infection • meningitis or encephalitis also syphilis • Tumors: • Tumors affecting the cochlea and retrocochlear pathways may present with whirling symptoms (vertigo) • Tumors in other parts of the CNS often present with nonspecific dizziness

33. Trauma • Labyrinthine concussion • Blasts • Barotrauma • Metabolic abnormalities • thyroid dysfunction • pregnancy • Menstruation • Exogenous hormones • Hypoglycemia

34. Migraines • Often, migraine headaches are associated with auras of dizziness or also vertigo. • Acetazolamide has been particularly effective in prophylactic treatment of the patients who have vestibular symptoms associated with migraine. • Epilepsy • Generalized absence seizures

35. Psychogenic (chronic anxiety): • Complaints are often vague, numerous, and out of proportion to the physical findings. • In other patients, panic attacks manifest as sudden intense fear or discomfort and reach a crescendo within 10 minutes. • They are frequently associated with brief episodes of dizziness, nausea, shortness of breath, chest tightness, paresthesias, and diaphoresis. • Physical examination findings in patients who have psychogenic disorders are often dramatic.

37. Presentation Outlines • Introduction • History • Physical Examination • Para-clinical issues • Differential Diagnosis • Non-systematized Dizziness • Vertigo • Peripheral • Central

38. Peripheral Vertigo • Foreign bodies and cerumen in the external ear • Otitis media with effusion • Acute suppurativeotitis media • These patients are at risk for hearing loss (Toxic Labyrinthitis) • Eustachian tube dysfunction • Cholesteatoma

39. Benign paroxysmal positional vertigo (BPPV) • patients report attacks caused by turning in bed or watching traffic while sitting in a car. • This condition is fatigable. generally have a positive Hallpike maneuver . • Antihistamines tend to decreasethe symptoms but should be used minimally because they delay the processof fatigue.

40. Epleymaneuver – 90% successful

41. Vestibular neuritis • a complication of an upper respiratory tract infection. • The virus is postulated to affect the vestibular nuclei and causes sudden and severe vertigo, nausea, and vomiting. • The attacks are sudden and generally resolve after a couple of weeks. Auditory symptoms are absent. • treatment centers around bedrest andpharmacologic suppression of the vestibular symptoms and Cotricosteroids.

42. Vascular causes (inner ear)  Anterior Vestibular artery and/or Common Cochlear artery. • sudden, debilitating vertigo. • Vascular occlusion or hemorrhage is often accompanied by tinnitus and sudden hearing loss. • Endolymphatichydrops • The most common form of endolymphatichydrops is Meniere’s disease. Meniere’s

43. Classic triad of tinnitus, fluctuant sensorineural hearing loss, and vertigo. Aural fullness is another classic complaint in these patients. • Most of these patients initially have vertigo; the other symptoms may develop later. • The vertigo attacks may progress over the course of minutesto an hour and may persist for up to several hours. • The associated sensorineural hearing loss generally demonstrates a lowfrequencydeficit on audiometry, which is characteristic for this condition.

44. Although the disease starts unilaterally, up to 40% of patients may develope bilateral auditory symptoms. • Medical Treatment:Greater than 90% of patients with Meniere’s disease respond wellto medical management: • restrict daily salt intake to 1.5 g/d • Avoid Smoking and caffeine • Diuretics • Vestibular suppressants (dimenhyrinate,…) • Acute attacks: Hospitalization, Promethazine, Diazepam, Antiemetics, rehydration.

45. most common causes of otogentic vertigo

47. Presentation Outlines • Introduction • History • Physical Examination • Para-clinical issues • Differential Diagnosis • Non-systematized Dizziness • Vertigo • Peripheral • Central

48. Central Vertigo • Cerebellar hemorrhage: • hemorrhage in posterior fossa can lead to rapid compression and compromise of vital medullary functions, obstructive hydrocephalus, or herniation of the medullary tonsils. • Brainstem ischemia: • AICA: lateral cerebellum, the pons, and the labyrinth • PICA: cerebellumand the dorsolateral medulla  Wallenberg’s Syndrome

49. Vertebrobasilar insufficiency: • most commonly visualdisturbance, drop attacks, unsteadiness, or weakness and also central vertigo. • Management of Vertigo (algorithm): Algorithm