Dizziness – AAFP 2010

Non-vertiginous dizziness:

Syncope

• Sudden transient LOC due to global cerebral HoTN
• Cardiac arrhythmias, AS, vasovagal, orthostatic HoTN, hyperventilation, metabolic causes (HoTN, med S/E, caffeine, nicotine)
• High mortality / Morbidity: CVA, AS, arrhythmias, high ICP
• If CPR or cardioversion required, then SCD and NOT syncope

Pre-Syncope

• Prodromal symptoms of fainting, nearly fainted / blacked out
• lightheadedness, sweating, panic, anxious, difficulty maintaining posture

Disequilibrium

• Sense of imbalance, occurs when walking, unsteady on feet; not present lying or sitting
• eg. peripheral neuropathy, cerebellum or posterior column dz, Parkinson dz

Psychogenic dizziness

• Constant complaints, difficult to describe, localize, underlying psychiatric dz likely
• Depression, anxiety, panic disorders, phboic dizziness

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Vertigo: Two types

• Illusion of rotational, linear, or tilting movement of self or environment
• Produced by peripheral (inner ear) or central (brainstem-cerebellum) stimulation
• The result of a mismatch between the 3 sensory systems: the vestibular, visual, and somatosensory systems

1) Central Vertigo

• Mild-mod imbalance, variable N/V, rare auditory symptoms, common neurologic symptoms, slow compensation, bidrectional nystagmus (horizontal or vertical)

2) Peripheral Vertigo

• Mod-Severe imbalance, severe N/V, common auditory symptoms, rare neurologic symptoms, rapid compensation (wk), unidirectional nystagmus (horizontal or rotatory)

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1  In patients complaining of dizziness, rule out serious cardiovascular, cerebrovascular, and other neurologic disease (e.g., arrhythmia, myocardial infarction [MI], stroke, multiple sclerosis).

• Presyncope / Syncope: arrhythmia, MI, stroke, carotid artery stenosis, orthostatic HoTN, AAA, sepsis, carotid sinus hypersensitivity, orthostatic HoTN, vasovagal, situational
  • HPI:
    • Symptoms with change in position / exertion (postural HoTN)
    • Palpitations, chest pain
    • a-blocker, b-blocker, diuretic, nitrates, Viagra, opioids, antipsychotics, TCA, Parkinson’s meds
    • syncope immediately follows cough, sneeze, defecation, micturition (situational)
    • Syncope associated with head turning, tight shirt collars (carotid hypersensitivity)
    • Prodromes: sweaty, lightheaded, tinnitus, palor, slow onset, nausea, blurry vision (vasovagal)
  • PEx:
    • Orthostatic VS, check pulses for arrhythmia
    • Carotid bruit, carotid sinus massage (carotid hypersensitivity)
    • Tilt-table (vaso-vagal)
  • Ix:
    • ECG, Holter
    • Carotid doppler
  • Tx:
    • Orthotstaic HoTN – Lifestyle and a-agonists – Midodrine 10mg po tid; Mineralocorticoid: Fludrocortisone 0.1mg po daily 
• Disequilibrium: Parkinson’s, peripheral neuropathy, MS, other MSK weakness; stroke (generally with other neurologic symptoms)
  • HPI: r/o stroke / TIA – unilateral weakness, garbled speech
  • PEx: Gait
• Vertigo: BPPV, Meniere’s, Labyrinthitis, migraine
  • HPI: hearing loss, tinnitus
    • Migraine / photophobia / phonophobia / aura
  • PEx:
    • Dix-Hall pike maneuver – head at 45o and lay back causing nystagmus
    • Webber & Rinne (air > bone & hearing loss – sensory neural problem)
  • Ix:
    • hearing test, investigate further if central vertigo
  • Tx:
    • BPPV – Epley or Meclizine (Antivert) 25-50mg po Q4-6h, vestibular rehabilitation
    • Meniere Dz – salt restriction, avoid cofee / EtOH, SERC+ diuretics (HCZ) or intratympanic dexamethasone or gentamicin (ENT)
    • Vestibular neuritis – Methylprednisolone (DepoMedrol) 100mg po daily and taper to 10mg over 3 weeks
    • Migrainous vertigo – Prophylaxis with anticonvulsant, TCA, propanolol, Candasartan
• Light-headedness with hyperventilation – r/o anxiety / panic attacks
  • Tx: breathing control exercise, B-blockers antianxity agents

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DDx of Dizziness

1) Vertigo:
Nystagmus & vertigo

• BPPV
  • Normal hearing, episodic
• Labyrinthitis
  • + hearing loss, persistent vertigo
• Vestibular neuronitis
  • normal hearing, persistent vertigo
• Meniere’s dz – increased endolymphatic fluid
  • episodic vertigo with + hearing loss / tinnitus
• Recurrent vestibulopathy, Perilymph Fistula
• Temporal bone #, superior semicircular canal dehiscence
• Ototoxic drug exposure
• Autoimmune inner ear dz, Cholesteatoma

Central

• Cerebrovascular disorders
  • Vertebrobasiliar insufficiency: 5D’s-
    • Drop attacks, Dysarthria, Diplopia, Dizziness, Dysphagia (features r/o peripheral vertigo)
  • TIA, Wallenberg’s syndrome
  • Cerebellar infarction
• Migrainous vertigo / vestibular migraine
  • episodic vertigo with signs of migraine
• MS – see MS post
• Tumours: CPA tumours, Posterior fossa tumours, Glomus tumours
• Inflammation: Meningitis, Cerebellar abcess
• Trauma: cerebellar contusion
• Toxic: alcohol, hypnotics, drug

2) Non-Vertiginous – Organic dz

• Cardiac: AS, Arrhythmias
• Vasovagal (Neurocardiogenic)
• Orthostatic HoTN (30-20-10 rule)
  • commonly due to meds
  • Tx: alpha agonists, mineralcorticoids, lifestyle changes
• Anemia
• Peripheral Neuropathy – disequilibrium – decreased tactile response when walking
• Visual Impairment
• Parkinson dz – disequilibrium – dysfunction in gait causing imbalance and falls
  • shuffling gait with reduced arm swing

Functional

• Depression, anxiety, panic disorder (hyperventilation), Personality disorder
• Phobic dizziness

Condition	Duration	Hearing loss	Tinnitus	Aural fullness	Other features
BPPV	Seconds	–	–	–
Meniere’s dz	Min to hr precedes attack	Uni/bilateral, fluctuating	+	Pressure / warmth
Vestibular Neuronitis	Hours to days	–	–	–
Labyrinthitis	Days	Unilateral	Whistling	–	Recent AOM
Acoustic neuroma	Chronic	Progressive	+	–	Ataxia, CNVII palsy

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2  In patients complaining of dizziness, take a careful history to distinguish vertigo, presyncope, and syncope.

Hx:

• Describe the sensation – distinguish vertigo, presyncope, and syncope
  • Vertigo – false sense of motion, possibly spinning sensation
  • Disequilibrium – off-balance or wobbly
  • Presyncope – feeling of blacking out, associated palpitations / SOB
  • Lightheadedness – vague symptoms, possibly feeling disconnected with the environment
• Onset, palliative when sitting, severity, timing, direction of spinning
• Associated otologic symptoms: tinnitus / aural fullness / hearing loss, occur with vertigo episode or permanent
  • Recent URTI, OM, trauma, N/V
  • Travel, sick contacts, rashes, tick bites
• Associated neurological symptoms: dysarthria / dysphagia, LOC, H/A,ataxis, falls
  • Is there difficulty walking? Is the speech slurred?
  • Are there visual disturbances: diplopia, poor vision, etc?
  • Any CNS symptoms (assume central vertigo)?
• Changes in vision, hearing eyes moving (canal dehiscence)

Red flags:

• syncope, angina, focal neurologic deficits, H/A, diplopia

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3  In patients complaining of dizziness, measure postural vital signs.

Orthostatic VS have the highest yield and is the most cost effective PEx for syncope

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4  Examine patients with dizziness closely for neurologic signs.

PEx

• General: ABC / VS, orthostatic VS, GCS
• Neuro-otologica exam (vertigo)
  • General appearance
  • Ears – canal and TM, Webber & Renne (conductive vs sensorineural hearing loss)
  • Nose – signs of URTI
  • Oral cavity / oralpharynx – signs of pharyngitis
  • Neck – masses / LN
  • CN: 2-12 – smooth pursuit (CN 3,4,6) – saccadic eye movements associated with central cause, eg brainstem or cerebellar dz
  • Vestibulo-ocular reflex
  • Head shaking (pt lean forward 30 degrees while MD shakes head back and forth x 20sec) nystagmus = peripheral cause
  • Cerebellar exam:
    • Romberg – swaying toward one side indicative of vestibular dysfunction
    • Gait – slow, wide-based, irregular – indicative of cerebellar dysfunction
    • tandem gait, finger-to-nose, heal-shin, dysdiadochokinesis, dysmetria
  • Screening for peripheral neuropathy
  • Fundoscopy to look for hich ICP
  • Dix-Hallpike – dx for BPPV
• Cardiovascular exam – carotid bruits, systolic murmur (AS)
  • Ask pt rapidly take 20 deep breaths – attempt to reproduce symptoms of hyperventilation syndrome
  • ECG, holter, carotid doppler

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5  In hypotensive dizzy patients, exclude serious conditions (e.g., MI, abdominal aortic aneurysm, sepsis, gastrointestinal bleeding) as the cause.

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Ix: generally low yeild

• B/W: CBC, electrolytes, Cr, urea, Troponin, TSH
• Radiology: CXR, carotid doppler, CT (labrynthitis), CT head (central vertigo), MRI (acoustic neuroma), MRA head (brain lesions, infections, CVA)
• Speical tests
  • ECG, 24hr Holter monitor (arrhythmias)
  • BNP (CHF)
  • EEG (Sz)
  • Pure-tone audiometry, audiogram
  • VNG – calorics, ENG, posturography

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6  In patients with chronic dizziness, who present with a change in baseline symptoms, reassess to rule out serious causes.

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7  In a dizzy patient, review medications (including prescription and over-the-counter medications) for possible reversible causes of the dizziness.

A medication history should be obtained because dizziness (especially from orthostatic hypotension) is a well-known adverse effect of many drugs

• Cardiac Medications
  • Alpha blockers – terazosin
  • a/b blockers – labetalol
  • ACEi, b-blockers
  • Clonidine, dipyridamole (persantine), hydralazine, methyldopa
  • Diuretics: furosemide
  • Nitrates: nitroglycerin
• CNS medications
  • Antipsychotics: clozapine
  • EtOH, caffeine
  • Opioids
  • Parkinsonian drugs – bromocriptine, levodopa/carbidopa
  • Skeletal muscle relaxants: baclofen, cyclobenzaprine
  • TCA: amitriptyline, trazodone
• Urologic medications
  • Phosphodiesterase 5 inhibitors: sildenafil
  • Urinary anti-cholinergics: oxybutynin

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8  Investigate further those patients complaining of dizziness who have:
– signs or symptoms of central vertigo.
– a history of trauma.
– signs, symptoms, or other reasons (e.g., anticoagulation) to suspect a possible serious underlying cause.

Central Vertigo

• Mild-moderate imbalance
• Variable N/V
• Rare auditory symptoms
• Common neurologic symptoms: dysarthria, diplopia, facial droop, dysphagia, limb dysmetria, gait impairment
• slow compensation
• Bidirectional nystagmus – horizontal or vertical

Consult neurologist with central vertigo or peripheral vertigo > 2 weeks

Order CT / MRI of head –

• Vertebrobasilar TIA: older pt, vascular risk factors, cervical trauma
• Brainstem infarct: sudden onset, persistent over days to weeks, usually other brainstem symptoms (lateral medullary signs)
• Cerebellar infarction / hemorrhage: sudden onset, persistent symptoms, vacular risk factors (HTN), Gait impairement, H/A, limb dysmetria, dysphagia
• Migrainous vertigo : normal imaing tests

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References: