Dizziness Flashcards by Ryan C

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

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Common disorders that are under the umbrella of “Dizziness”

Vertigo
Presyncope
Disequilibrium

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Other Common Terms for “Dizziness”

Lightheaded
Faint
Swimmy headed
Foggy headed
Swooning
Off Balance
Woozy

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This is the sensation of moving or spinning.

Vertigo

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This is the sense of imbalance, usually while walking.

Disequilibrium

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This is the sensation associated with near fainting. (Lightheaded, Feeling Foggy, Feeling Faint)

Presyncope

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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

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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

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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

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Important PMH to note

DM
Sz
Migraines
Arrhythmia
MS
TIA/CVA
CAD
Anemia

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Important Medications to note

Digoxin
BB
Some Abx
Diuretics
Antidepressants

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Important Social Hx to note

EtOH

- Drugs

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Important Family Hx to note

Arrhythmia
CAD
CVA
Migraine
DM

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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

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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

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What is the most common cause of “dizziness?”

Vertigo

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Vertigo is a symptom of vestibular disease (Central vs. Peripheral)

Okay?

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T/F: Patients experience a false sense of movement that may be described as spinning, whirling, tilting or moving.

True

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Causes of Peripheral Vertigo

Benign Positional Vertigo
Meniere’s Dz
Vestibular Neuritis
Medications (ototoxic)
Acoustic Neuroma

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Causes of Central Vertigo

Multiple Sclerosis
Vertebrobasilar Insufficiency
Migraine assc. vertigo

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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

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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.

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Differences between Peripheral Vertigo and Central Vertigo with Nystagmus in terms of Effect of Visual Fixation

Peripheral: Suppressed
Central: Not suppressed

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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