Dizziness and Vertigo

DIZZINESS AND VERTIGO
JOSHUA F. SMITH, PA-C
Disclosures
I am the chair of the NCAPA Professional
Development Review Panel.
I am a paid speaker for the NCAPA.
Learning Objectives
1. Understand the components needed for balance
2. Be able to perform a competent history and physical exam
on a dizzy patient
3. Understand how timing and the duration of symptoms can
help you narrow your differential diagnosis
4. Develop a working differential diagnosis list for the chief
complaint of dizziness
5. Understand the different treatments for the different causes
of dizziness
Case Report
77 year old female with dizziness presents to ED
!
“I felt all swimmy-headed, just….dizzy.”
!
Multiple tests are performed including:
CT head
EKG
Cardiac enzymes and other labs
!
Finally after hours in the ED, she was diagnosed with…
“Vertigo.”
!
She was given a prescription for meclizine and told to follow up
with her local ENT.
DIAGNOSIS “VERTIGO”
Dizziness
1. You must take a thorough history.
2. You MUST take a thorough history.
3. It is appropriate to rule out serious causes first.
4. Vertigo is a SYMPTOM, not a diagnosis.
5. Meclizine will likely make your patient MORE dizzy, and
should hardly ever be prescribed.
6. There is not one treatment for dizziness. Each individual
condition has a unique treatment plan.
Epley
Maneuvers
Adjust
BP meds
Fluids
Cardio
Lifestyle
Adjustment
Rehab
BPPV
Orthostatic
Hypotension
Multisensory
Dizziness
Low Salt
Diuretics
Surgery
Meniere's
Dizziness
Labyrinthitis
Acoustic
Neuroma
or Tumor
Cardiac
Arrhythmia
Vestibular
Migraine
Surgery
Radiation
Rate control
Ablation
Triptan
Beta Blocker
Neuroleptic
Vestibular
Rehab
BALANCE
VESTIBULAR SYSTEM
!
THE MECHANISM OF BALANCE
!
The Vestibular System
Components of Balance
Vestibular system
Visual input
Peripheral nervous
system
Central nervous system
Motor output
Each balance component
relies on the others
Vestibular
rioce
p
Prop
n
Visio
tion
CNS
Somatosensory
Vestibular
Visual
Peripheral Neuropathy
Stroke
Parkinson’s
Meniere’s
Labyrinthitis
Neuroma
Cataracts
Retinopathy
Macular Degeneration
Vestibular Suppressants
Meclizine, Diazepam,
Scopolamine
Block neurotransmitters
which carry signal from
peripheral organ to the
central nervous system
Only for acute vertigo which
last at least 1-2 hours
NOT indicated for
lightheadedness,
disequilibrium or brief
episodes of vertigo
Long-term use impedes the
compensation process and
recovery is much longer
Interferes with vestibular
testing
WHAT IS
DIZZINESS?
LIGHTHEADEDNESS
!
DISEQUILIBRIUM
!
VERTIGO
Dizziness
The complaint of “dizziness” is very non-specific. Many people experience dizziness in a different way and
have a hard time describing their symptoms.
It is important to try to the sensation that the patient is
really experiencing:
Lightheadedness
Disequilibrium
Vertigo
Lightheadedness
The feeling that you are about
to faint
Usually occurs after sitting up
or standing up
If no loss of consciousness —
“pre-syncope”
If loss of consciousness —
“syncope”
Usually a sign of
cardiovascular dysfunction
Disequilibrium
The sensation of being
unable to walk straight
Feeling like you are going
to fall over
Generalized imbalance
without vertigo
Intolerance to quick
movements
Vertigo
A hallucinatory sensation
of motion
Rotational spinning
Elevator moving up or
down
Ground rocks back
and forth
DIFFERENTIAL
DIAGNOSIS OF
DIZZINESS
NEUROLOGIC
!
CARDIOVASCULAR
!
OTOLOGIC
Differential Diagnosis
Cardiologic
Metabolic/Endocrine
Otologic
Orthostatic hypotension
Hypothyroid
BPPV
Arrhythmia
Menopause
Meniere’s Disease
CAD
Hormone induced
migraines
Vestibular Neuronitis
Neurologic
Stroke/TIA
Parkinson’s
Peripheral Neuropathy
Migraine
Brain tumor
Hematologic
Anemia
Psychologic
Panic Attack
Orthopedic
Cervical disc disease
Arthritis (back, hips, knees)
Geriatric
Loss of vision
Loss of proprioception
Loss of strength
Loss of center of balance
Labyrinthitis
Vestibular concussion
Perilymphatic Fistula
Superior Semi-circular
canal dehiscence
Acoustic neuroma
Pharmacologic
Polypharmacy/side effects
CARDIOLOGIC
DIZZINESS
ORTHOSTATIC HYPOTENSION
!
VASOVAGAL SYNCOPE
!
CARDIAC ARRHYTHMIA
Orthostatic Hypotension
Occurs when patient stands up too
fast
Blood pressure changes
20mmHg drop in systolic pressure
10mmHg drop in diastolic
pressure
Sudden onset of dizziness
Pre-syncope/lightheadedness
Tachycardia
Tunnel vision
Can lead to actual syncope
Vasovagal Syncope
Recurrent lightheadedness
and syncope caused by a
specific trigger
Vasodilation and/or
decreased heart rate leads
to hypotension which
decreases blood flow to
brain.
The patient will pass out and
fall, thus restoring blood
flow to the brain.
Symptoms: Lightheadedness, nausea,
hot/cold sensation, sweating,
tinnitus, tunnel vision
Treatment:
Avoid triggers
Increase pressure in
impending syncope
Avoid anti-hypertensives
Increase fluids and sodium
before impending trigger.
Cardiac Arrhythmia
Atrial fibrillation
SVT, PVCs, many more
Symptoms:
Lightheadedness
Dizziness
Fluttering
Pounding Chest
Shortness of breath
Chest discomfort
Pre-syncope/Syncope
Cardiology consult
NEUROLOGIC
DIZZINESS
VESTIBULAR MIGRAINE
!
MULTI-SENSORY DIZZINESS
Vestibular
Migraines
Migraine with aura
Vasoconstriction phase
leads to neurologic
symptoms:
Vertigo
Photophobia
Nausea
Tinnitus
Vasodilation phase causes
headache (of any severity)
Multi-sensory Dizziness
Often seen in elderly or diabetic
patients
Treat with PT, vision correction
if possible, use of cane or
walker, lots of patient education
Vestibular
rioce
ption
n
Falls at night
Visio
Will feel constantly off-balance,
difficulty making quick
movements
CNS
Prop
Due to peripheral neuropathy,
vision loss and/or vestibular
dysfunction
OTOLOGIC
DIZZINESS
BPPV
!
MENIERE’S
!
LABYRINTHITIS
!
ACOUSTIC NEUROMA
Benign Paroxysmal
Positional Vertigo
Caused by displaced otoliths
Episodic vertigo lasting <30
seconds
Provoked with head
movements, rolling in bed,
looking up or bending over
Positive Dix-Hallpike
Treated with Epley maneuvers
Meniere’s Disease
Not well defined disorder, possibly due
to increased endolymphatic fluid
pressure
Classic symptoms:
Vertigo with:
Episodic low frequency SNHL
Tinnitus
Aural fullness and pressure
Treatment:
Low sodium diet (1500-2000mg/day)
Diuretic
Diazepam or meclizine for vertigo
Vestibular Neuronitis
Acute Labyrinthitis
Viral infection of the inner ear
Vestibular neuronitis: vertigo only
Labyrinthitis: vertigo and SNHL
Vertigo is severe, lasting 24-48 hours
After vertigo, severe imbalance for
1 week
Several weeks to months of gradually
improving imbalance
Treat sudden SNHL with prednisone
Treat imbalance with physical therapy
Acoustic Neuroma
Rare, slow growing benign tumor
Arises from Schwann cells of
vestibular nerve.
Symptoms:
Asymmetric SNHL
Asymmetric tinnitus
Chronic worsening imbalance
Diagnosed with MRI of internal
auditory canal
Treatment:
Stereotactic radiation
Surgical excision
TAKING A
PROPER
HISTORY OF A
DIZZY PATIENT
Pointers….
Allow the patient an opportunity to briefly explain their symptoms.
Start at the onset and work towards today.
Quality: Vertigo vs. Lightheadedness vs. Disequilibrium
Vertigo duration and frequency (more on this later!)
Medications (HTN, Prostate, Vestibular Suppressants)
Associated symptoms:
Hearing loss or tinnitus associated? Is there any positional influence?
Headache, photophobia, nausea
Palpitations
Near-syncope or Syncope
Precipitating Symptoms
Rolling over in bed, tilting head up
Standing up too fast
Loud noises
Medication use
Darkness/eyes closed
Mechanical fall
DURATION OF
SYMPTOMS
FLEETING
!
SECONDS
!
MINUTES
!
HOURS
!
DAYS
!
CONSTANT
Duration/Frequency of
Dizziness
This is the most important question to ask and
understand. You want to know how long the patient experiences
sustained vertigo.
This one piece of information will help to cut your large
differential diagnosis into easier to manage fractions. It is important to understand when associated
symptoms occur in time with the dizziness.
Fleeting
With head movements: Old vestibular weakness
Paroxysmal: Heart palpitations
With standing: Orthostatic hypotension
Seconds
Usually BPPV
Provoked by head movements
Lasts less than 30 seconds
Severity
10
7
5
Asymptomatic
3
0
1
Week
4
Weeks
1
year
Minutes
5-20 minutes of vertigo usually indicates either:
Migraine symptom
Transient ischemic attack
Severity
10
7
5
3
0
10-20
minutes
Headache
Photophobia
Nausea
Scotomata
Tinnitus
Hyperacusis
Slurred speech
Facial paralysis
Loss of vision
1
week
Hours
Usually caused by Meniere’s
Symptoms last anywhere from 20 minutes to 24 hours
Usually 2-8 hours
Severity
10
7
Vertigo
Hearing Loss
Tinnitus
Aural fullness
Vertigo
Hearing Loss
Tinnitus
Aural fullness
Vertigo
Hearing Loss
Tinnitus
Aural fullness
5
3
0
2-8
Hours
1
month
2
months
3
months
Days
Vertigo lasting 24-48 hours is usually an inner ear infection:
Acute labyrinthitis
Vestibular Neuronitis
The next week will have severe disequilibrium
3
m
o
Dis Sev
eq ere
uil
ibr
iu
5
tig
7
Ve
r
Severity
10
Gradual
Resolution
0
24-48
hours
1 week
??
Constant
Patients who complain of persistent vertigo longer than 48 hours usually
are not actually having constant vertigo. Usually they have:
Severe disequilibrium or multi-sensory dizziness
Episodic vertigo (like BPPV or migraines) occurring multiple times a
day
Severity
10
7
5
3
0
Months
Years
PHYSICAL
EXAM
GAIT AND BALANCE
EARS
EYES
CRANIAL NERVES
ORTHOSTATIC PRESSURE
Vital Signs
For dizziness, the most important vital signs are:
Blood pressure
Does the patient have resting hypotension?
Orthostatic blood pressures if indicated
Pulse
Tachycardia or bradycardia? Regular Rhythm?
Gait and Balance
Watch patient walk into the room
Unsteadiness
Inability to walk a line
Wheelchair?
Romberg Testing
Proprioception
Vision Vestibular function
Ear exam
Usually, inspection of the
EAC and TMs are normal
!
Dix-Hallpike can have a
good yield if you suspect
BPPV based on history
Neurologic exam
Evaluate extra ocular mobility
Look for spontaneous
nystagmus
Evaluate for sustained gaze
evoked nystagmus
Cranial nerve testing
will help you determine
the presence of: Tumor
TIA/CVA
DIAGNOSTIC
TESTING
Audiogram
An audiogram shows cochlear
function which can give an
insight into the health of the
vestibulo-cochlear system.
Look for asymmetric SNHL or
low-frequency asymmetric
SNHL.
Videonystagmography
Objective test which can
determine if dizziness is
vestibular or central in origin. The VNG will compare relative
vestibular strength between ears
using a cold/hot water
stimulation, aka caloric testing.
Additional tests include
optokinetic and occulomotor
testing, positional testing, evoked
myopotential and rotary chair.
Magnetic Resonance Imaging
Studies show that the use of CT brain scan in the emergency
setting for the complaint of dizziness has an extremely low yield
of finding the cause of the symptoms. MRI Brain with contrast has a much higher yield and can
effectively evaluate for: Tumor of IAC, cortex and cerebellum
Acute and chronic stroke
Demyelinating disorders
Chronic brain atrophy
CASE REPORTS
Case Report
Audiogram
56 year old female
!
Complaint of vertigo when lying
down and rolling to the left or
looking up
!
Symptoms last 30 seconds and
resolve
Dix-Hallpike
!
Normal hearing on audiometric
testing
LEFT BENIGN PAROXYSMAL POSITIONAL VERTIGO
Case Report
79 year old man
!
Complains of positional vertigo
Dix-Hallpike
Negative
!
Worse when sitting up in bed or
when standing up
!
Better when lying down
!
No hearing loss
!
Upon further questioning, feels
lightheaded, no vertigo
ORTHOSTATIC HYPOTENSION
Orthostatic Blood Pressures
Supine: 145/90
Sitting: 140/90
Standing: 115/80
Case Report
35 year-old male
Episodic vertigo for 6 hours
Associated hearing loss in
left ear and tinnitus
Videonystagmogram
Right ear warm caloric
Audiogram
Left ear warm caloric
MENIERE’S DISEASE
Case Report
49 year old female
!
Complains of vertigo, every
day, lasting 15 minutes
Videonystagmogram
Normal Vestibular Function
Audiogram
!
Had severe migraines as a
youth, but now says
symptoms aren’t
consistent with that
!
Has daily mild headache,
photophobia and nausea
MIGRAINE HEADACHES
CT Head and Sinus
No intracranial or sinus disease
Case Report
Audiogram
65 year-old male
!
1 day ago had acute onset of
severe, constant vertigo
!
Unable to function
!
Associated left tinnitus and ear
fullness
ACUTE LABYRINTHITIS
Videonystagmogram
Case Report
Videonystagmogram
36 year old male
!
Complaint of vertigo when lying down
and looking straight back
!
Symptoms last 30 seconds and resolve
!
Generalized disequilibrium
!
Normal hearing on audiometric testing
CNS TUMOR: CEREBELLAR MASS
LATER FOUND TO BE PILOCYTIC ASTROCYTOMA
MRI Brain w/ contrast
THANK YOU!
REFERENCES
http://bestpractice.bmj.com/best-­‐practice/monograph/73/diagnosis/step-­‐by-­‐step.html
!
http://vestibular.org/understanding-­‐vestibular-­‐disorder/human-­‐balance-­‐system !
http://dizziness.webs.com/anatomyphysiology.htm
!
http://american-­‐hearing.org/disorders/acoustic-­‐neuroma/
!
https://www.hearinglink.org/hearing-­‐tests !
Wasay M, Dubey N, and Bakshi R. “Dizziness and yield of emergency CT scan: Is it cost effective?” Emerg Med J. April 2005; 22(4): 312. !
www.medscape.com/viewarticle/803429_1
!
http://lookfordiagnosis.com/mesh_info.php?term=Hypotension%2C+Orthostatic&lang=1
!
http://en.wikipedia.org/wiki/Vasovagal_response
!
http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/cardiology/cardiac-­‐
arrhythmias/ !
http://www.dana.org/Publications/GuideDetails.aspx?id=50011
!
http://www.vestib.com/antivertigo-­‐drugs.html
REFERENCES
http://married2medicine.hubpages.com/hub/Orthostatic-­‐Hypotension-­‐And-­‐General-­‐Principles-­‐In-­‐Antihypertensive-­‐Therap
!
http://ccentandaudiology.com/videonystagmography-­‐vgn/
!
http://www.human-­‐anatomy-­‐models.com/shop/3d-­‐male-­‐nervous-­‐model
!
http://www.painfreefeet.ca/index.cfm?id=24340
!
http://myllu.llu.edu/newsoftheweek/story/?id=11453
!
http://doctorrennie.wordpress.com/2012/03/07/dizziness-­‐vertigo-­‐and-­‐lightheadedness-­‐a-­‐discussion-­‐of-­‐possible-­‐causes/
!
http://www.sos03.com/Diseases/Extreme_Conditions/Syncope
!
http://otitismedia.hawkelibrary.com/normal/1_G !
https://www2.aofoundation.org/ !
http://www.britannica.com/EBchecked/media/46720/The-­‐cranial-­‐nerves-­‐and-­‐their-­‐areas-­‐of-­‐innervation
http://www.learntheheart.com/cardiology-­‐review/atrial-­‐gibrillation/
!
http://glipper.diff.org/app/items/5455
!
http://www.phsa.ca/AgenciesAndServices/Services/BCEarlyHearing/ForFamilies/Assessing-­‐Hearing/How-­‐Read-­‐
Audiogram.htm
!
http://www.vestibular.ro/neuronita-­‐vestibulara/
!
http://utahhearingandbalance.com/balance-­‐and-­‐dizziness-­‐tests/what-­‐to-­‐expect-­‐during-­‐a-­‐videonystagmography-­‐vng-­‐test/
!
http://www.dizziness-­‐and-­‐balance.com/disorders/tumors/acoustic_neuroma.htm