Dizziness

Question 1

Key differentiating questions

Answer 1

• Head movements/ turning in bed/ looking up (BPPV)
• After my ear feels blocked/ hearing goes/ tinnitus (Meniere’s)
• Sudden onset and felt dreadful for weeks
  
  • No hearing loss (vestibular neuronitis)
  • Hearing loss (acute labyrinthitis)
• Sometimes occurs with the symptoms I used to get before my migraines or with a headache (vestibular migraine)
• After I was on a boat (mal de barquement syndrome)
• When I get up from a chair and feel lightheaded (postural hypotension)
• If they describe non-rotatory dizziness before mealtimes (hypoglycaemia)

Question 2

Sensory inputs controlling balance

Answer 2

• Visual stimulus
  
  • Halmaygi head thrust/ Head impulse test
    
    • Vestibular-ocular reflex
• Proprioception
  
  • Romberg’s test
  • Test of proprioception
• Vestibular function
  
  • Unterberger’s test
    
    • Vestibular function
  • Halmaygi head thrust/ Head impulse test
    
    • Vestibular-ocular reflex

Question 3

Differentiating dizziness

Answer 3

Question 4

Nystagmus

Answer 4

• Two phases - slow and fast
• Direction of nystagmus defined by the fast phase
• Causes:
  
  • Physiological
    
    • At extremes of eye deviation
  • Spontaneous nystagmus (pathological vestibular)
    
    • Constant drift of eyes to side of lesion, interrupted by fast component in contralateral direction, graded by Alexander’s law
  • Gaze evoked nystagmus
    
    • Cannot sustain gaze away from primary position
    • Central dysfunction (i.e. areas controlling reflexes)
    • May be iatrogenic (i.e. anticonvulsants, psychotropic) or due to alcohol
  • Positional nystagmus
    
    • BPPV
  • Central positional
    
    • No vertigo present, no fatiguability, no latency
    • MS, Arnold-Chiari malformation, cerebellar vascular disease

Question 5

Halmaygi head thrust test/head impulse test

Answer 5

• Check the patient has no neck pain or neck problems
• Ask patient to look at your nose
• Tell them you are going to hold their head and turn it but not going to tell them which way
• Gently turn head from left to right
  
  • Check the patient is still looking at your nose
• Add in some quick head movements to one side and then the other
  
  • Normal – patient is looking at your nose
  • Abnormal – patient looks to the side that you have turned their head then a corrective saccade occurs

Question 6

Romberg’s test

Answer 6

• Ask the patient to “stand up”
  
  • “Put your arms out in front of you”
  • “Close your eyes”
  • “Stay where you are”
  • “Keep your arms where they are”
• Press downwards on their arms to see if they can keep them in position

Question 7

Unterberger’s test

Answer 7

• Perform if the patient has managed to stay upright during Romberg’s test
• Instructions
  
  • “Keep your eyes closed”
  • “March on the spot as quickly as you can”
• Normal range up to 20^o rotation
• For at least 50 steps/ 30 seconds
• You can march with them so that they do not slow down
• Stand nearby and reassure the patient that you will hold them if you think they will fall
• You can grab their arm and support their back
• Ensure the chair is still behind the patient

Question 8

Dix-Hallpike test

Answer 8

• Head turned 45^o towards the test ear
• Patient looks at a fixed point (i.e. your nose)
• Bring the patient’s head and body so that they are lying flat with the head over the edge of the bed (15-20^o) and turned to test side
• Eyes kept open
• Look for rotatory nystagmus
• May occur after a few seconds
• Observe for at least 30s
• Repeat on other side
• Results:
  
  • Upbeating, tortional nystagmus towards the patient’s forehead = posterior canal BPPV (85% of patients)
  • Downbeating, tortional nystagmus = anterior canal BPPV
  • Mixed vertical and torsional nystagmus = cupulithiasis (otoliths adherent to cupula)

Question 9

Epley manoeuvre

Answer 9

• All positions held or at least 30 seconds or until symptoms resolve
• Turn patient’s head to affected side
• Assist the patient to lie flat with their head off the couch and turned to the affected side
• Turn head towards the “good” side
• Patient rolls on to “good” side then turns head to look at the floor.
• Assist the patient in siting up. Patient puts their chin on their chest
• 1 Epley successful in 80% - 95%, 2 = 97%, 3 = 99%