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Dizziness

Dizziness. Pete Kang NYU School of Medicine Class of 2001. Dizziness: epidemiology. 1.5% of all hospital admissions 26% of all ED pts stated that they had experienced “dizziness” Most common non-pain-related complaint in the ED Account for 8 million outpatient visits per year in the U.S.

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Dizziness

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  1. Dizziness Pete Kang NYU School of Medicine Class of 2001

  2. Dizziness: epidemiology • 1.5% of all hospital admissions • 26% of all ED pts stated that they had experienced “dizziness” • Most common non-pain-related complaint in the ED • Account for 8 million outpatient visits per year in the U.S. • Adult > Pediatric

  3. Dizziness: differential diagnosisbroad categories of diseases • Vertigo • Near-faint or Presyncope dizziness • Psychophysiologic dizziness • Hypoglycemic dizziness • Disequilibrium • Drug-induced dizziness

  4. Vertigo: subclasses • Acute spontaneous attack • Recurrent spontaneous attacks • Recurrent episodes of positional vertigo

  5. Acute spontaneous attack of vertigo • Unilateral loss of vestibular function • Clinical presentation: • Intense sense of rotation aggravated by head motion • World turns slowly toward intact side, then quickly toward affected side • Prefers to sit upright w/ head still or to lie w/ intact side undermost • Difficulty in standing/walking; may fall toward affected side • May have nausea/vomiting, malaise, pallor, diarrhea

  6. Peripheral Severe nausea/vomiting Mild imbalance Hearing loss common Mild oscillopsia No focal signs Rapid compensation Central Mod. nausea/vomiting Severe imbalance Hearing loss rare Severe oscillopsia Focal signs Slow compensation Peripheral vs. Central lesions

  7. Viral neurolabyrinthitis • Most common; >90% of cases in younger age group w/o major vascular risk factors • Subacute onset; URI ~2 weeks prior • Unilateral caloric paresis, +/- hearing loss • No other focal signs • Symptomatic management, vestibular rehabilitation

  8. Bacterial otomastoiditis w/ labyrinth involvement • Prior infection; bony erosion seen in CT • Possible cholesteatoma • Possible complication of bacterial meningitis • Antibiotics • Surgical debridement

  9. Cerebellar infarct/hemorrhage • Elderly, w/ vascular risk factors • Other focal neurological signs present usually

  10. Multiple sclerosis • Vertigo is the presenting symptom in 5% of patients w/ MS • Multifocal neurologic symptoms/signs • Characteristic T2-intense lesions in white matter on MRI

  11. Recurrent, spontaneous attacks of vertigo • Sudden, temporary, and large reversible impairment of resting neural activity in one labyrinth or its central connections • Lasts from minutes to hours • Restoration of normal neural activity, rather than compensation

  12. Meniere’s disease • Characteristic fluctuating low-frequency hearing loss • Episodic vertigo • Roaring tinnitus • Ear pressure

  13. Autoimmune inner ear disease • May mimic Meniere’s disease • Signs/symptoms of systemic involvement • Elevated ESR, positive ANA’s/rheumatoid factor • Immunosuppression

  14. Syphilitic labyrinthitis • Similar to Meniere’s disease in signs/symptoms • Positive VDRL and/or FTA-ABS • Penicillin, steroids

  15. Migraine • Vertigo occurs in approximately 25% of migraine patients • Hearing loss infrequent • Headaches that meet International Headache Society criteria for migraine • Treat migraine

  16. Vertebrobasilar TIA • Common cause in older patients w/ risk factors • Subclavian steal syndrome • Abrupt, last several minutes • Other sx’s of posterior circulation • Antiplatelet drugs, anticoagulation

  17. Recurrent, positional vertigo • Transient excitation within the vestibular pathways triggered by change in position • Central vs. Peripheral lesions

  18. Peripheral Torsional/horizontal Latency Brief Fatigability Debris moving in semicircular canal Central Pure vertical No latency Persistent No fatigability Damage to central vestibulo-ocular pathways Brainstem or cerebellum Recurrent, positional vertigo: peripheral vs. central

  19. Benign positional vertigo (BPV) Dix-Hallpike test • 2-10 sec latency • Torsional/horizontal nystagmus • Lasts < 30 sec (fatigability) • Any deviation from this must raise suspicion for a central lesion

  20. Recurrent, positional vertigo: central lesions • Multiple sclerosis • Cerebellar tumors • Medulloblastomas • Cerebellar atrophy • Chiari type I malformation

  21. Near-faint dizziness or presyncope • “Light-headedness” before losing consciousness or fainting • Reduced blood flow to the entire brain • Causes • Vasovagal • Orthostatic hypotension • Volume depletion • Cardiac arrhythmias, cardiomyopathy, constrictive pericarditis, aortic stenosis

  22. Psychophysiologic dizziness • Associated with panic disorder (lifetime prevalence of 1.6%) • Hyperventilation  reduce pCO2  cerebral vasoconstriction  decreased cerebral blood flow • Onset with specific situations (such as public places, driving in highways, etc.)

  23. Hypoglycemic dizziness • Complication of insulin/sulfonylurea treatment • Insulinoma • Fasting • Postprandial phenomenon (functional hypoglycemia)

  24. Disequilibrium • Sensation of losing one’s balance without feeling of illusionary movement or impending LOC • Unsteadiness standing, walking • Disruption in integration between sensory inputs and motor outputs • Associated with aging

  25. Drug-induced dizziness • Aminoglycosides, cisplatin • Vertigo, disequilibrium • Damage to vestibular hair cells • Antiepileptic • Carbamazepine, pheytoin, primidone • Disequilibrium, intoxication • Tranquilizers • Barbiturates, benzodiazepines, tricyclics • Intoxication

  26. Drug-induced dizziness • Antihypertensives/diuretics • presyncope • Alcohol • Intoxication  CNS depression • Disequilibrium  cerebellar toxicity • Positional vertigo  change in cupula specific gravity

  27. Treatment: medical • Best therapy: treating the underlying disease • Indication for symptomatic therapy: • Illness is not readily treatable • Treatment must be continued for a long period before improvement • Severe and prolonged vertigo

  28. Treatment: medical • Acute severe vertigo • Promethazine (antihistamine): sedative (++), antiemetic (++) • Diazepam: sedative (+++), antiemetic (+) • Nausea & vomiting • Prochlorperazine (phenothiazine) • Metoclopramide (benzamide) • Chronic recurrent vertigo • Meclizine (antihistamine) • Dimenhydrinate (antihistamine)

  29. Treatment: surgical • Conservative surgery • Shunt surgery (decompress endolymphatic sac) • Effective in ~75% of cases • Selective section of vestibular division of CN VIII • Effective in >90% of cases • <10% significant hearing loss • Abnormal vascular loop at the brainstem insertion of CN VIII

  30. Treatment: surgical • Destructive surgery • Labyrinthectomy • Complete destruction of the end organ • Extremely high cure rate • Cost: destruction of all hearing in the involved ear

  31. Vestibular rehabilitation • Process of compensation • Requires: • Intact vision & depth perception • Normal proprioception • Intact sensation in lower limbs • Graded increase in demand for central compensation of vestibular input

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