Dizzines and Vertigo Flashcards
Also see PPT for charts and algorithms
Dizziness vs Vertigo
Dizziness Common primary care complaint Sensation of unsteadiness Feeling of movement within the head Vertigo Sensation of rotation or movement Patient Patient’s surroundings
4 Categories of “Dizziness”
True Vertigo (50%)
Pre-syncope
Disequilibrium
Vague lightheadedness
Pre-Syncope
Transient sensation that a faint is about to occur
May present as nausea ,weakness, SOB or change in vision
Disequilibrium
A sensation of imbalance when standing or walking
No sense of faintness
Vague Lightheadedness
Holds the remainder of symptoms of dizziness (which can’t fit to the other categories)
Psychiatric disorders,
Hyperventilation syndrome
Encephalopathies
True Vertigo
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
Equilibrium System
Eyes - vision, focal, peripheral Inner Ear - vestibular system Neck - proprioception Joints - proprioception Sole of Feet - Sensation
High Yeild 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?
PE
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
Dix-Hallpike Maneuver
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.
Labs
Identifies etiology in <1%
Appropriate of s/s suggest other causative conditions
Audiometry helps establish Meniere’s
Radiology
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
Referral
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
Peripheral Causes of Vertigo
Benign positional vertigo Vestibular neuritis Herpes zoster oticus Meniere’s disease Labyrinthine concussion Cogan’s syndrome Acoustic neuroma Aminoglycoside toxicity Otitis media
Central Causes of Vertigo
Migrainous vertigo Brainstem TIA Wallenberg’s syndrome Cerebellar infarcation or hemorrhage Chiari malformation MS
Benign Paroxismal Positional Vertigo (BPPV)
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
Benign Paroxysmal Positional Vertigo (BPPV) Pathophysiology
Otoliths become detached from hair cells in utricle
Inappropriately enter the posterior semicircular canal
BPPV Tx
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
Vestibular Neuritis and Labrynthitis
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
Perilymphatic Fistula
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
Meniere’s Dz
Excess endolymphatic fluid pressure
Episodic, acute vertigo, lasts minutes to hours
Unilateral tinnitus, hearing loss, ear fullness
Treatment
Salt, caffeine, tobacco restriction
Diuretics
Surgical
Herpes Zoster Oticus
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
Red Flags
Suggestions of central vestibular disease or brainstem lesions Persistent vertigo Ataxia Nausea/vomiting Headache Vision loss, diplopia Slurred speech
