Dizziness Flashcards
This is a common presenting, non-specific complaint in the Primary Care office as well as the ER. It is often a source of frustration for medical providers as it encompasses many potential disease states.
Dizziness
Common disorders that are under the umbrella of “Dizziness”
- Vertigo
- Presyncope
- Disequilibrium
Other Common Terms for “Dizziness”
- Lightheaded
- Faint
- Swimmy headed
- Foggy headed
- Swooning
- Off Balance
- Woozy
This is the sensation of moving or spinning.
Vertigo
This is the sense of imbalance, usually while walking.
Disequilibrium
This is the sensation associated with near fainting. (Lightheaded, Feeling Foggy, Feeling Faint)
Presyncope
So how do we know if a dizziness complaint is vertigo, presyncope, or disequilibrium? What do we do?
History is important!
- Be sure to ask open ended questions
- Allow the patient to describe their “dizzy” sensation to you without any prompting
- Avoiding the patient with words like spinning or light headed.
- Be sure to extrapolate associated symptoms
T/F: Patients who complain of dizziness rarely can identify a distinct symptom of presyncope, dysequilibrium, or vertigo
False!
Majority can identify a symptom that would lead you elsewhere. By hx or Phys Ex
When getting the History on a patient complaining of “dizziness” what do you do?
- Ask them to describe it
- Give them adequate time to explain
- Look for words like spinning, faint, off balance, woozy
- Does it only occur upon rising from seated position, only while walking, only when turning the head?
- Assc Symptoms? Nausea, Vomiting, Hearing Loss, Tinnitus, Chest Pain, Palpitations, Dyspnea, Headache, Parasthesia, Ataxia
Important PMH to note
- DM
- Sz
- Migraines
- Arrhythmia
- MS
- TIA/CVA
- CAD
- Anemia
Important Medications to note
- Digoxin
- BB
- Some Abx
- Diuretics
- Antidepressants
Important Social Hx to note
- EtOH
- Drugs
Important Family Hx to note
- Arrhythmia
- CAD
- CVA
- Migraine
- DM
Things to Look out for on Physical Exam
- Vitals – including orthostatics
- Gen Survey
- HEENT – Focus on those ears!! OM can cause dizziness
- Neck – Carotid Bruits, elevated JVP
- Pulmonary – Wheezes, Basilar Rales, Tachypnea
- Cardiac – Irregular Rhythm, Murmur
- Neuro – Cerebellar findings, upper motor neuron signs, decreased
What additional tests should you order?
- Hearing Test
- Visual Acuity
- Dix Hallpike Maneuver
- Labs – CBC, BMP, D-Dimer, Cardiac Enzymes, Tox Screen
- MRI – If neoplasm or CVA suspected. Also order MRA if considering vascular phenomenon
- EKG – Arrhythmia, MI
- Electronstagmography – Eval of vestibular dysfunction if H&P aren’t enough
What is the most common cause of “dizziness?”
Vertigo
Vertigo is a symptom of vestibular disease (Central vs. Peripheral)
Okay?
T/F: Patients experience a false sense of movement that may be described as spinning, whirling, tilting or moving.
True
Causes of Peripheral Vertigo
- Benign Positional Vertigo
- Meniere’s Dz
- Vestibular Neuritis
- Medications (ototoxic)
- Acoustic Neuroma
Causes of Central Vertigo
- Multiple Sclerosis
- Vertebrobasilar Insufficiency
- Migraine assc. vertigo
Differences between Peripheral Vertigo and Central Vertigo with Nystagmus in terms of Direction
Peripheral: Unidirectional, fast phase toward normal ear
Central: Direction may change with gaze
Differences between Peripheral Vertigo and Central Vertigo with Nystagmus in terms of Type
Peripheral: Horizontal with a torsional component, never purely vertical or torsional
Central: Can be any direction. Pure vertical or torsional indicative of central lesion.
Differences between Peripheral Vertigo and Central Vertigo with Nystagmus in terms of Effect of Visual Fixation
Peripheral: Suppressed
Central: Not suppressed
Differences between Peripheral Vertigo and Central Vertigo with Nystagmus in terms of Duration
Peripheral: Short, resolves with resolution of vertigo.
Central: Long, persists after resolution of vertigo
Differences between Peripheral Vertigo and Central Vertigo with Other Neurologic Signs
Peripheral: Absent
Central: Often present (dysarthria, dysmetria, visual field loss)
Differences between Peripheral Vertigo and Central Vertigo with Postural Instability
Peripheral: Walking preserved, minor if any instability
Central: Severe instability, patient may fall when walking
Differences between Peripheral Vertigo and Central Vertigo with Deafness or Tinnitus
Peripheral: May be present
Central: Absent
This is the most commonly attributed to calcium debris within the posterior semicircular canal. It is often idiopathic but may follow head trauma.
Benign Positional Vertigo
Symptoms of Benign Positional Vertigo
- Occur with specific movements of the head and last one minute or less
- Recurs periodically for weeks to months without therapy
- No other neurologic complaints
Treatment of Benign Positional Vertigo
Particle Repositioning (Epley and Semont maneuvers)
This condition occurs in the age group of 20-40. It is commonly associated with endolymphatic hydrops with distortion and distention of the membranous, endolymph containing portions of the labrytinthe system. It may or may not be associated with underlying otologic disease.
Meniere’s Disease
Symptoms of Meniere’s Disease
- Episodic Vertigo
- Sensorineural Hearing Loss
- Tinnitus
Treatment of Meniere’s Disease
- Reduce Symptoms
- Treat Vertigo
- Reduce of Eliminate Hearing Loss
Definite Diagnosis of Meniere’s Disease
- Two spontaneous episodes of vertigo lasting at least 20 minutes
- Audiometric confirmation of sensorineural hearing loss
- Tinnitus and/or perception of aural fullness
This is a condition generally considered to be a viral or postviral inflammatory disorder affecting the vestibular portion of the 8th cranial nerve.
Vestibular Neuritis
Symptoms of Vestibular Neuritis
- Severe Vertigo
- Nausea
- Vomiting
- Gait Instability
- **Severe symptoms usually last 2 days - 2 weeks with residual dizziness/imbalance going on for several months.
Treatment of Vestibular Neuritis
Corticoidsteroids have been shown some promise in the acute phase
This is a condition where Schwann cell derived tumor that commonly arise from the vestibular portion of the 8th cranial nerve. Accounts for ~8% of intracranial tumors in adults. The median age at diagnosis is 50 years old.
Acoustic Neuroma (Vestibular Schwannoma)
Risk Factors for Acoustic Neuroma
- Exposure to loud noise
- Neurofibromatosis
- Childhood Exposure to low dose radiation
Symptoms of Acoustic Neuroma
- Asymmetric Hearing Loss
- Tinnitus
- Unsteady Gait
- Vertigo
- Facial Parasthesia
- Pain
Diagnosis of Acoustic Neuroma
MRI
Treatment for Acoustic Neuroma
- Surgery
- Radiation
- Observation
Ototoxic Medications
- Various Chemotherapeutic Agents
- Erythromycin
- Gentamicin **
- Neomycin
- Streptomycin
- Tobramycin
- Vancomycin (which potentiates ototoxicity of Gentamicin)
This is a condition defined as autoimmune inflammatory demyelinating disease of the CNS. Primarily seen in women of child bearing age.
Multiple Sclerosis
Symptoms of MS
- Sensory Disturbances in the Limbs
- Visual Changes
- Vertigo
- Balance Problems
Diagnosis of MS
- Clinical
- MRI
- LP
Treatment of MS
- IV Steroids
- Methotrexate
This is a condition where there is a posterior circulation problem usually due to atherosclerosis. This should be considered in anyone with stroke risk factors.
Vertebrobasilar Insufficiency
Symptoms of poor perfusion in the posterior circulation:
- Ataxia
- Dysmetria
This is the term used to describe episodic vertigo in patients with a history of migraine or other clinical features of migraine.
Migrainous Vertigo
T/F: Patients with migrainous vertigo typically have no other neurologic symptoms and may not even have headache with the vertigo.
True
Diagnosis of Migrainous Vertigo
Exclusion!
Treatment of Migrainous Vertigo
- Abortive therapy
- Prophylaxis
Presyncope/Lightheadedness
- Cardiac Arrhythmia
- Structural Cardiac Disease
- Hypotension
- Hypoglycemia or other metabolic disturbance
- Vasovagal Presyncope
- Carotid Sinus Hypersensitivty
- Anxiety
- Depression
- Medications
- May be a psychiatric phenomenon
This is often a problem of the elderly but may present in younger patients with a hx of head trauma, may also follow episodes of vertigo.
It may represent CNS diseases such as Parkinsons, Visual Disturbance, Disorders of the cerebellum, Polyneuropathy, MS.
Disequilibrium
Vertigo Summary
- Spinning
- Head movements may exacerbate problem
- May only last a few minutes
- Assc. nausea and/or vomiting
- Nystagmus
Presyncope Summary
- Lightheaded or feeling faint
- May be exacerbated by rising from a seated or supine position
- May have assc. palpitations, nausea, diaphoresis, parasthesia
- Anxiety reaction
Disequilibrium Summary
- Feeling off balance
- May hold onto furniture while walking about the house
- May be ataxic
- Cerebellar signs on physical exam
Other Considerations with “Dizzy”
- CVA/TIA
- MI
- Intracranial Bleed
- Carotid Artery Dz
- Lung Dz/Low O2
