A practical approach to dizziness

1. A practical approach todizziness 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 • 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. Peripheral 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 Causes of Vertigo

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 Furman J and Cass S. N Engl J Med 1999;341:1590-1596

33. 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

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