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
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)
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
- HPI:
- 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
- HPI: hearing loss, tinnitus
- Light-headedness with hyperventilation – r/o anxiety / panic attacks
- Tx: breathing control exercise, B-blockers antianxity agents
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
- Vertebrobasiliar insufficiency: 5D’s-
- 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 |
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
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
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
5 In hypotensive dizzy patients, exclude serious conditions (e.g., MI, abdominal aortic aneurysm, sepsis, gastrointestinal bleeding) as the cause.
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
6 In patients with chronic dizziness, who present with a change in baseline symptoms, reassess to rule out serious causes.
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
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
References:
- http://www.aafp.org/afp/2010/0815/p361.html#afp20100815p361-t1
- TN 2014
- Edmonton Manual 2011 edition
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