Chapter 7: Dizziness, Vertigo, and Syncope

Question 1

Dizziness Examples

Answer 1

Vertigo (perceived movement (rotation, may be linear))
Light-headedness: Feeling faint (presyncope)
Dysequilibrium: Sensation of imbalance or unsteadiness, felt more in legs than in the head.
Ill-defined Dizziness: Can be anxiety

Question 2

Causes of vertigo

Answer 2

Must be acute unilateral damage to the vestibular function.

Symmetric bilateral damage (ototoxic drugs) or slow unilateral loss (acoustic neuroma) do not cause vertigo

Question 3

Determining etiology of vertigo

Answer 3

Periodicity
Duration
Positional or Spontaneous

Question 4

Peripheral vertigo

Answer 4

Tinnitus or hearing loss
N/V
Unidirectional nystagmus may arise from either central or peripheral dysfunction

Question 5

Central Vertigo

Answer 5

Diplopia, dysarthria, dysphagia or other symptoms of brainstem dysfunction
Decreased ability to walk or maintain posture
Vertical and direction-changing gaze-evoked nystagmus
Pure vertical or pure torsional
Brainstem ischemia never causes isolated vertigo

Question 6

Vestibular neuronitis

Answer 6

Acute unilateral (complete or incomplete) peripheral vestibulopathy
Sudden and spontaneous onset of vertigo, N/V
Onset over minutes to hours, symptoms peak within 24 hrs and improve over several days or weeks
Nystagmus is strictly unilateral

Question 7

Labyrinthine concussion

Answer 7

From head trauma

Vertigo, hearing loss, and tinnitus possible

Question 8

Infarction of the labyrinth

Answer 8

Infarction of inner ear presents with sudden onset deafness, vertigo, or both. Inner ear supply is Internal Auditory Artery
Central and Peripheral vestibular apparatus a

Question 9

Infarction of Brainstem or cerebellum

Answer 9

Most important DDx for suspected acute vestibular neuronitis

Look for central type nystagmus, CN signs, weakness, ataxia, or other signs of central process

Question 10

Meniere disease

Answer 10

Episodic vertigo with nausea and vomiting
Fluctuating, but progressive hearing loss
Tinnitus
Sensation of fullness or pressure in the ear
Caused by intermittent increase in endolympathic volume

Question 11

Perilymph Fistula

Answer 11

Disruption of the lining of the endolymphatic system

Caused by straining (sneezing, coughing, heard as a pop) followed by abrupt onset of vertigo

Question 12

Benign Paroxysmal Positional Vertigo

Answer 12

Changes in position
Seconds to minutes
Patient reclining in bed or upon awakening
N/V
Fluctuating frequency over months to years
Dix-Hallpike: Downbeating and torsional nystagmus

Question 13

Syncope causes

Answer 13

Hypotension due to cardiac causes, low intravascular volume, excessive vasodilation.
Think asystole, heart block (3rd degree), valvular disease, myocardial infarction, dehydration, blood loss, or Addison disease. Excessive vasodilation is usually neurologic.

Question 14

Neurogenic syncope

Answer 14

Inappropriate activation of a cardioinhibitory and vasodepressor reflex. Afferent impulses via the vagus nerve lead to cardioinhibition and vasodepression leading to hypotension and bradycardia. Micturition, deglutition, carotid sinus compression, heightened vagal tone.

Question 15

Autonomic failure

Answer 15

Central or peripheral causes, but the hallmark is the failure to release Norepinephrine upon standing

Question 16

Holter monitor

Answer 16

For prolonged cardiac monitoring

Question 17

Presyncope symptoms

Answer 17

Light-headedness, HA, neck pain, blurred vision, cognitive slowing, buckling knees

Question 18

Meds that cause orthostasis

Answer 18

Diuretics, antihypertensives, vasodilators, antidepressants

Question 19

Treating orthostasis

Answer 19

Slowly standup.

Midodrine, fludrocortisone, beta blockers.