Dizziness Flashcards
What symptoms may a patient experience which they call dizziness (4)
Vertigo
Lightheadedness
Syncope
Imbalance
Most common causes of vertigo (3)
Migraine-related
BPPV
Meniere’s
Categories of etiology
Vestibular Neurological Cardiovascular Psychological Metabolic Autoimmune Drug related Trauma/surgical Infectious
Vestibular causes (7)
- Benign paroxysmal positional vertigo
- Meniere’s->episodic, fluct hearing loss, tinnitis, aural pressure/fullness
- Temporal bone fracture, hypothyroid (hydrops), syphillis
- Labrynthitis->URTI
- Superior semi-circular canal dishiscience
- Perilymphatic fistula
- Middle ear->OM, labrynthitis
Neurological causes
Migraine related->history of migraines Posterior fossa tumors->vestibular scwannomas, meningiomas Multiple sclerosis->prolonged, spontaneous Cerebellar stroke Vertebrobasilar stroke Wallenberg Hereditary ataxias BIH Normal pressure hydrocephalus
How does vertebrobassilar stroke present
episodic vertigo lasting 1 to 15 minutes, with diplopia, dysarthria, ataxia, drop attack, and clumsiness of the extremities.
Clinical features of BIH->pseudotumor cerebri
raised intracranial pressure that is not caused by a mass lesion (e.g., a tumour); associated with headache and transient poor vision. These patients are often obese and complain of clumsiness, imbalance, and dizziness rather than true vertigo.
How does normal pressure hydrocephalus present
Ataxia
Urinary incontinence
Cognitive dysfunction
Cardiovascular causes
Syncope
Presyncope
Orthostatic hypotension
Autonomic dysregulation
Psychological
Psychophysiological->after labrynthe disorder
Psychogenic->agoraphobia, personality, anxiety
Metabolic causes
Diabetes->hypoglycemia
Hypothyroidism->+in patient’s with meniere’s
Autoimmune causes
Rheumatoid arthritis
Systemic lupu erythromatosous
Wegener’s
Bechet’s
Medication induced
Ototoxic drugs: gentamycin, neomycin
Chemotherapeutic->cisplatin
Alcohol
AntiHTN, anesthetic, antiarrythmia
Risk factors for medication induced
age >60 years, high serum drug levels, previous sensorineural hearing loss, concomitant renal impairment, attendant noise exposure, duration of therapy >10 days, and simultaneous administration of other ototoxic agents, such as loop diuretics or aspirin
Trauma causes
Post head injury
Complication of middle-ear surgery
Infectious causes
Lyme disease Syphillis CMV HSV-1 HIV
Red flags
Red flags Meniere's disease Vestibular neuritis Syncope or presyncope Labyrinthitis Cholesteatoma Posterior fossa tumour Multiple sclerosis Cerebellar stroke Vertebrobasilar insufficiency Wallenberg's syndrome Paraneoplastic cerebellar degeneration Lyme disease Syphilis HIV
History- charactristics of current episode
Dizziness, vertigo or syncope
Vertigo better or worse with eyes closed/open (more central does not change)
Duration: seconds (BPPV), mins-hours (migraine, meniere’s, CV), hours-days (labrynthitis, neuritis, central)
Positional
Tinnitus or hearing loss: meniere’s, labrynthitis (sudden hearing loss, NV), MS, SLE, infections
How the episodes began: URTI, trauma, surgery
General symptoms
-chest pain, exertiona dyspnea
-aura, visual disturbance, photo/phonophobia, headache
-nausea
-gait, limb weakness, dysarthria
-diplopia, dysarthria, ataxia, drop
-ataxia, urinary, cognitive
-clumsy, imbalance, dizziness
Psychiatric
History- identification of a cause
Trauma/surgery Medical illness-> DM, thyroid, MS, migraines FHx of illness->migraine, ataxias Contact with infectious Medication and drugs CVD risk factors Neoplastic disease
Physical examination
- Ear examination
- Eye: nystagmus, movements (palsies in MS, ICL), neurological signs (central)
- Clinical balance tests
- Head impulse test->differentiates acute vestibular neuritis, cerebellar stroke
- Dix-hallpike - CNS
- Cranial nerves
- cerebellar
- Gait
- Rombergs
- Limbs
- Speech - Cardiovascular
What is the head impulse test
The examiner turns the patient’s head as rapidly as possible 15 degrees to one side and observes the patient’s ability to keep fixating on a distant target. With a peripheral vestibular lesion, a saccade occurs as the vestibulo-ocular reflex fails, the patient cannot keep focusing on the target, and a catch-up movement occurs. After a cerebellar stroke, no catch-up saccade occurs. The head-impulse test is negative (no saccadic adjustment of the eyes on sudden head twisting) in people with cerebellar stroke, ruling out acute vestibular neuritis or labyrinthitis.
Describe the dix-hallpike
The test is performed by sitting the patient upright on a bed; for the right side, the examiner stands on the patient’s right side, rotates the patient’s head 45° to the right, and then moves the patient, whose eyes are open, to the supine right-ear down position, and then extends the patient’s neck slightly so that the chin points slightly upwards. Patient’s symptoms are noted and any nystagmus is observed
Results in dix hallpike if central lesion
test causes nystagmus that is not fatigable, is down-beating, and is associated with minimal vertigo.
What is the supine roll test and when is it performed
If the Dix-Hallpike test is negative in a patient who has a history suggestive of BPPV
positioning the patient supine with the head in the neutral position, then quickly rotating the head 90° to one side –>?nystagmus.
The head is returned to the face up position, allowing all dizziness and nystagmus to subside; the head is then turned rapidly to the opposite side
Findings in wallenbergs (5)
occlusion of the ipsilateral vertebral artery that supplies the posterior inferior cerebellar artery) causes:
- prolonged vertigo,
- abnormal eye movements,
- ipsilateral Horner’s syndrome,
- ipsilateral limb ataxia, and
- loss of pain and temperature sensation of the ipsilateral face and contralateral trunk
Investigations and findings
- Audiogram
- CT->if suspect SSCD
- MRI->posterior fossa tumor, cerebellar stroke, MS, head injury
- ECG, echo, 24 hour holter, tilt-table
- Special blood tests depending on history: antibodies, thyroid glucose, drug levels
Medications that cause orthostatic hypotension
Antihypertensives
Antidepressants
Anticholinergics
