dizziness

Question 1

assessment

Answer 1

Hx and PE = key. labs/imaging = not very helpful

Question 2

“dizziness”

Answer 2

is subjective and can mean many things and must be clarified

Question 3

5 categories of “dizziness”

Answer 3

vertigo, pre-syncope/syncope, dysequiligrium, ill-defined lightheadedness, true muscular weakness

Question 4

vertigo

Answer 4

perception of rotation or spinning sensation. feels like “drunk” or “sea-sick.” is it peripheral or central? associated w/hearing loss or tinnitus?

Question 5

central vs. peripheral vertigo: onset

Answer 5

central: slow. peripheral: rapid

Question 6

central vs. peripheral vertigo: severity

Answer 6

central: mild. peripheral: worse

Question 7

central vs. peripheral vertigo: CN findings

Answer 7

central: +, peripheral: -

Question 8

central vs. peripheral vertigo: latency

Answer 8

central: -, peripheral: +

Question 9

central vs. peripheral vertigo: nylen-barany

Answer 9

central: nystagmus persists. peripheral: nystagmus extinguishes

Question 10

central vs. peripheral vertigo: etiologies

Answer 10

central: brain stem ischemia, posterior fossa tumors, MS, drugs: anticonvulsants, PCP, ethanol. peripheral: acoustic schwannoma, meniere’s dz, labyrinthitis (infection), BPV, trauma (endolymphatic fistula), labyrinthine concussion

Question 11

peripheral vertigo

Answer 11

recurs and abates every few hrs. more violent and severe = more likely peripheral

Question 12

central vertigo

Answer 12

gradual onset, contant, not affected by movement. brain stem or cerebellar Sx including dysphasia, dysphonia, ataxia, diplopia, miosis, or b/l blurred vision = common. may be acute onset if acute ischemia is cause but will see cranial nerve findings

Question 13

vertigo w/+ hearing loss

Answer 13

acute labyrinthitis, typically URIs/otitis media

Question 14

vertigo w/+ hearing loss and tinnitus

Answer 14

= classic triad of meniere’s dz. often occurs in middle age, can recur and Sx increase w/each recurrence until peaks and slow decrease in intensity. hearing loss typically persists between episodes

Question 15

trauma-related vertigo

Answer 15

perilymphatic fistula -> leakage of endolymph from round or oval window into middle ear. pts complain of acute worsening of dizziness when middle ear pressure increases during coughing, sneezing, or straining. nonspecific dizziness may be seen as part of post-concussive syndrome but the increase in Sx w/coughing is not seen. labyrinthine concussion or post-traumatic positional vertigo

Question 16

vertigo: PE

Answer 16

good neuro exam = key, particularly CNs, cerebellar fxn, nystagmus, and positional testing. nystagmus seen in central and peripheral. best observed in the dark so pt has nothing to fixate on (can extinguish peripheral nystagmus)

Question 17

peripheral nystagmus

Answer 17

rotatory or horizontal

Question 18

central nystagmus

Answer 18

vertical or dysconjugate

Question 19

nylan-barany maneuver

Answer 19

aka dix-hallpike. fast phase toward effected ear

Question 20

presyncope/syncope

Answer 20

due to dec. cerebral blood flow. caused by anything that alters body’s normal vascular reflexes. typically “dizziness” only happens when pts. stand. assess for volume loss.

Question 21

dysequilibrium

Answer 21

= unsteady, stumbling gait disturbance. cause = loss of significant sensory fxn: sight, light touch, proprioception. dizziness often goes away w/holding onto stationary object.

Question 22

dysequilibrium: PE

Answer 22

visual acuity, fudoscopic exam, complete neuro exam w/focus on light touch, pinprick, proprioception in lower ext. pts. may have wide based or stumbling gait but not ataxic - can test cerebellar fxn w/finger nose + rapid alternating movements. must be careful to do good neuro exam to evaluate for true weakness or ataxia.

Question 23

dysequilibrium: etiologies

Answer 23

poor vision, diabetic or ethanol neuropathy, B12 deficiency, tabes dorsalis. can also be a Sx of motor gait disturbances due to cerebellar degenteration or PD - neuro exam helps differentiate

Question 24

ill-defined lightheadedness

Answer 24

very vague. often suggests psych etiology e.g. depression, hyperventilation, anxiety, meds. if pt appears ill or many med problems, may be hyperCa, hyperMg, uremia, anemia, chronic subdural hematoma, myocardial ischemia