Dizzines and Vertigo

Question 1

Dizziness vs Vertigo

Answer 1

Dizziness
Common primary care complaint
Sensation of unsteadiness
Feeling of movement within the head
Vertigo
Sensation of rotation or movement
Patient
Patient’s surroundings

Question 2

4 Categories of “Dizziness”

Answer 2

True Vertigo (50%)
Pre-syncope
Disequilibrium
Vague lightheadedness

Question 3

Pre-Syncope

Answer 3

Transient sensation that a faint is about to occur

May present as nausea ,weakness, SOB or change in vision

Question 4

Disequilibrium

Answer 4

A sensation of imbalance when standing or walking

No sense of faintness

Question 5

Vague Lightheadedness

Answer 5

Holds the remainder of symptoms of dizziness (which can’t fit to the other categories)
Psychiatric disorders,
Hyperventilation syndrome
Encephalopathies

Question 6

True Vertigo

Answer 6

Illusion or Hallucination of movement
Both vertigo and disequilibrium imply a loss of balance, but vertigo involves a sense of motion - either person is spinning or objects/room around them is spinning

Question 7

Equilibrium System

Answer 7

Eyes - vision, focal, peripheral
Inner Ear - vestibular system
Neck - proprioception
Joints - proprioception
Sole of Feet - Sensation

Question 8

High Yeild Historical Questions

Answer 8

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?

Question 9

PE

Answer 9

Neurologic - CNs, hearing, nystagmus
Head & Neck - TMs for vesicles, pushing on tragus, pneumatic otoscopy, valsalva maneuver
Cardiovascular - orthostatics (drop of 20 or more SBP), carotid sinus stimulation should never be performed

Question 10

Dix-Hallpike Maneuver

Answer 10

may be most helpful test to perform on patients with vertigo
positive predictive value of 83 percent and a negative predictive value of 52 percent for the diagnosis of BPPV After initial test, the intensity of induced symptoms typically wanes with repeated maneuvers in peripheral vertigo but does so less often in central vertigo.

Question 11

Labs

Answer 11

Identifies etiology in <1%
Appropriate of s/s suggest other causative conditions
Audiometry helps establish Meniere’s

Question 12

Radiology

Answer 12

If neurologic s/s present
Risk factors for cerebrovascular disease
Progressive unilateral hearing loss
R/O extensive bacterial infections, neoplasms, or developmental abn 
Suspect cervical vertigo
MRI better than CT for dx

Question 13

Referral

Answer 13

Not all need to be referred
Consider referral
Subspecialist needed (otolaryngologist, head & neck surgeon, neurologist, neurosurgeon)
If diagnosis of vertigo unclear
If patient has a medical problem requiring further subspecialty care

Question 14

Peripheral Causes of Vertigo

Answer 14

Benign positional vertigo
Vestibular neuritis
Herpes zoster oticus
Meniere’s disease
Labyrinthine concussion
Cogan’s syndrome
Acoustic neuroma
Aminoglycoside toxicity
Otitis media

Question 15

Central Causes of Vertigo

Answer 15

Migrainous vertigo
Brainstem 
TIA
Wallenberg’s syndrome
Cerebellar infarcation or hemorrhage
Chiari malformation
MS

Question 16

Benign Paroxismal Positional Vertigo (BPPV)

Answer 16

Most common disorder of inner ear’s vestibular system
Age 60- 70 (F:M - 2:1)
Head trauma
Characteristic story:
Turn head
After a few seconds delay, vertigo occurs
Resolves within 1 minute if you don’t move
If you turn your head back, vertigo recurs in the opposite direction
Episodic, not persistent (helpful in differentials)
An illusion of motion
“The room is spinning”
Other descriptions
Rocking
Tilting
Somersaulting
Descending in an elevator

Question 17

Benign Paroxysmal Positional Vertigo (BPPV) Pathophysiology

Answer 17

Otoliths become detached from hair cells in utricle

Inappropriately enter the posterior semicircular canal

Question 18

BPPV Tx

Answer 18

Head maneuvers
Vestibular rehabilitation home exercises
Surgery intractable and incapacitating symptoms
No support for routine use of medication
Coping strategies during this wait-and-see phase can involve modifying daily activities to help minimize symptoms
Motion sickness meds can be helpful

Question 19

Vestibular Neuritis and Labrynthitis

Answer 19

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

Question 20

Perilymphatic Fistula

Answer 20

Due to a traumatic “fistula” at the round or oval window.
After forceful cough, sneeze, scuba diving or direct blow to the ear.
Recurrence of vertigo with pneumo-otoscopy (Hennebert’s sign)
may induce hearing loss, tinnitus, aural fullness, vertigo, disequilibrium, or a combination of these symptoms
Self-limiting

Question 21

Meniere’s Dz

Answer 21

Excess endolymphatic fluid pressure
Episodic, acute vertigo, lasts minutes to hours
Unilateral tinnitus, hearing loss, ear fullness
Treatment
Salt, caffeine, tobacco restriction
Diuretics
Surgical

Question 22

Herpes Zoster Oticus

Answer 22

AKA Ramsay Hunt syndrome, when assoc. w/facial paralysis
Activation of latent herpes zoster infection
Vertigo + hearing loss, ipsilateral facial paralysis, ear pain, vesicles
Antiviral therapy

Question 23

Red Flags

Answer 23

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