Approach to the dizzy patient

By: Laurence Poliquin-Lasnier

R2 Neurology

What Dizzy means?

• Illusory movement of the environment (vertigo)

• Lightheadedness• Imbalance• Pre-syncope

Questions to ask

• Constant or episodic• Associated symptoms• Gradual vs sudden onset• Aggravating/alleviating symptoms• Duration and frequency of attacks if

episodic• Triggers

Distinguishing vertigo from other types of dizziness

• Time course

– Vertigo is never continuous

– The CNS adapts to the defect so that vertigo subsides over several wks

Distinguishing vertigo from other types of dizziness

• Provoking factors– Certain vertigo occur spontaneously, while others

are precipitated by maneuvers that change head position or middle ear pressure ( coughing, sneezing, or Valsalva maneuvers)

– Positional vertigo and postural presyncope are both are associated with dizziness upon standing

– Determine whether dizziness can be provoked by maneuvers that change head position without lowering BP or decreasing cerebral blood flow

– Such maneuvers include lying down, rolling over in bed, and bending the neck back to look up

Distinguishing vertigo from other types of dizziness

• Aggravating factors

– All vertigo is made worse by moving the head– Many patients in the midst of a vertiginous attack

are petrified to move– If head motion does not worsen the feeling, it is

probably another type of dizziness

Key point

• Any type of dizziness may worsen with position change but disorders such as benign positional vertigo only occur after position change

Causes of dizziness

• Peripheral

• Central

• Systemic

Peripheral causes

Hx Duration Associated symptoms

Physical

Vestibular neuritis/labyrinthitis

Single prolonged episode

Days Nausea, imbalance Peripheral nystagmus, + head thrust, imbalance

BPV Positionally triggered episodes

< 1 min Nausea, ask for history of trauma

Positionally triggered burst of nystagmus

Ménière disease

May be triggered by salty food

hours Unilateral ear fullness, tinnitus, hearing loss, nausea

Unilateral low frequency hearing loss

Vestibular paroxysmia

Abrupt onset, spont or positionally triggered

seconds Tinnitus, hearing loss normal

Perilymphatic fistula

Triggered by sound or pressure change or physical strain

seconds Hearing loss, hyperacusis, ask for history of trauma

Nystagmus with change in pressure

Vestibular Neuritis

• Young adults• Severe vertigo of rapid onset• Nausea, vomiting, imbalance• Symptoms gradually resolve over several

days• Probably viral etiology• Generally benign, self-limited course

Benign paroxysmal positional vertigo

• Most commonly recognized cause of vertigo

• Calcium debris within the posterior semicircular canal (canalithiasis)

• Brief spinning sensation brought on when turning in bed or tilting the head backward to look up

• Dizziness is quite brief, usually secs, rarely mins

• May be severe enough to halt activity for this duration

• Dix-Hallpike maneuver can provide further evidence of its presence, but is positive in only 50 to 80% of patients

• Natural hx of BPPV is one of repeated, brief vertiginous episodes that are predictably provoked and continue for wks or months

Ménière’s disease

• Reccurent attacks of vertigo associated with auditory symptoms (hearing loss, tinnitus, aural fullness)

• Attacks variable in duration, most last > 20 min• Severe nausea and vomiting• Progressive hearing loss• Bilateral ménière in 1/3 of patients• Caused by hydrolymphatic hydrops• Can get acute episodes of falling/being pulled to the

ground caused by acute stimulation of otolith “otolithic catastrophes of Tumarkin”

Vestibular paroxysmia

• Brief episode of vertigo lasting seconds• No trigger• Thought to be 2ary to spontaneous

discharges from damaged VIII cranial nerve

Vestibular fistula

• Tear or defect in the oval window and/or the round window (membranes that separate the middle ear from the fluid-filled inner ear)

• Changes in middle ear pressure will directly affect the inner ear, stimulating the balance and/or hearing structures and causing symptoms

Acoustic neuroma

• Very rare to have vertigo as it is slow growing so that the CNS has time to adapt and compensate

• Mostly unilateral hearing loss

Central CausesHx Duration Associated

symptomsPhysical exam

Stroke/Tia Abrupt onset >24hrs vs minutes

Brainstem, cerebellar

Central nystagmus, focal neuro signs

Multiple sclerosis

Subacute onset

Min-wks Unilateral vision loss, diplopia ataxia

Central, peripheral or positional nystagmus

Neurodegenerative disorder

Spontaneous or positionally triggered

Min-hours ataxia Central/ peripheral nystagmus, cerebellar, extrapyramidal, frontal signs

Basilar migraine

Onset with typical migraine triggers

Seconds to days

Headache, visual aura, photo/phonophobia

Peripheral/ central/ positional nystagmus

Familial ataxia syndromes

Acute-subacute, episodic type with stress, exercise

hours ataxia Central/ positional

Brainstem/cerebellar infarct

• Vertigo is a common symptom in Wallenberg syndrome/PICA infarct

• Associated with diplopia, horner, crossed pain & temp loss

• Vertigo may be the only symptom in cerebellar infarct

• Oculomotor testing can show:1- Pure unidirectional nystagmus

2- Direction-changing gaze evoked nystagmus

3- Impaired smooth pursuit

4- Overshooting saccades

Multiple Sclerosis

• May be the initial symptom in 5% of patients• Can get almost any type of vertigo,

including peripheral vertigo when plaque affects root entry zone of the vestibular nerve

Neurodegenerative disorder

• Parkinson• Progressive supranuclear palsy• Multi-system atrophy• Progressive ataxia disorders• Dizziness in these patients often better

clarified as imbalance

Posterior fossa structural abnormalities

• Chiari malformation causes pressure on cerebellum

• Unsteadiness of gait may be described as dizziness by patients

• Vertigo is rare

• Posterior fossa tumor (eg medulloblastoma, gliomas)

Migraine

• Benign recurrent vertigo may be considered as a migraine equivalent

• With typical migraine triggers• + family history• Normal neuro exam• No progressive hearing loss

Familial ataxia syndromes

• Spinocerebellar ataxia• Friedreich ataxia• Episodic ataxia

• + oscillopsia

Systemic causes

• Medications• Hypotension, presyncope• Infectious diseases (eg.: syphilis, viral, bacterial meningitides

& systemic infection)• Endocrine diseases (eg.: DB/hypoglycemia &

hypothyroidism)• Vasculitis (eg.: collagen vascular disease, giant cell arteritis,

drug-induced vasculitis)• Hematological disorders• Hyperventilation, panic attack

On exam:

• Postural vitals• General physical exam• General neuro exam• Neuro-otological exam

Neuro-otological exam

• Ocular motor function testing– Look for spontaneous nystagmus or saccadic

intrusions– Nystagmus suggests that the dizziness is vertigo

• Gaze testing– Look for gaze-evoked nystagmus– Normal to have non-sustained nystagmus with gaze

greater than 30 degrees– Vertical nystagmus that increases with lateral gaze

localizes to craniocervical junction and midline cerebellum

Nystagmus

Feature Central Peripheral

Latency none 2-15 sec

Duration > 30 sec 5-30 sec

Fatiguability +/- ++

Vertigo Usually absent Usually present

Fixation No suppression suppression

Direction Vertical or horizontal, direction may change with head position

Unidirectional, Horizontal or rotatory, fast phase toward normal ear, increased with gaze in direction of fast phase

Neuro-otological exam

• Smooth pursuit– Voluntary mvt of of the eyes used to track

a target moving at a low velocity– Look for saccadic pursuit– May occur with early/mild cerebellar

degenerative disorders as the only finding with minimal ataxia

Neuro-otological exam

• Saccades– Fast eye mvts used to quickly bring the

image of an object on the fovea– Shift gaze from one object to another under

voluntary control– Slowing of saccades = lesion in

pons/midbrain, oculomotor neuron or extra-ocular muscles

– Overshooting saccades = ocular dysmetria, sign of cerebellar lesion

– Undershooting saccades less specific and occur in normal people

Neuro-otological exam

• Optokinetic nystagmus– Combination of fast saccadic and slow smooth

pursuit observed in N people observing a moving object

– Patients with severe slowing of saccades will not be able to generate OKN and will have their eyes pinned on one side

• Vestibulo-ocular reflex suppression– Normal individual can fixate his thumb while pt

being turned on himself– Will elicit nystagmus in pts who have impaired

smooth pursuit

Vestibular nerve exam

• Head thrust test– When quickly unpredictably turn head of

patient by 30 degree on side, eyes will go on opposite direction (vestibulo-ocular reflex) to continue to fixate target

– Abnormal vestibulo-ocular reflex if observe corrective saccade bringing eyes back to target after head thrust

– Sensitivity 71% and specificity 82%

Positional testing

• Dix-Hall-Pike– Burst of upbeat, torsional nystagmus

triggered in patients with BPV by rapid change from erect sitting to supine head-hanging right or left

• Epley manoeuver– More than 80% effective in treating

patients with posterior canal BPPV

Epley Maneuver

Epley maneuver

• Key feature is the roll-across in the plane of the posterior canal so that the clot rotates around the posterior canal and out into the utricle

Fistula testing

• Test for it if patient reports sound or pressure induced dizziness

• Pressing or releasing the tragus will trigger nystagmus

• Other variant with valsava

Gait assessment

• Wide based gait• Acute vestibular loss may cause the

patient to lean on the side of the affected ear

Auditory examination

• Otoscopy• Whisper test (stand behind to prevent lip reading

and occlude/mask the non-tested ear by finger rub or occluding external auditory canal)

• Whisper 3-6 numbers or letters• Normal if can repeat 50%• Weber: lateralizes to ipsi conductive impairment

or contralateral sensorineural• Rinne: if bone conduction > air conduction = ipsi

conductive hearing loss

Conclusion

• Clarify what dizzy means• Be patient as history is the most important

part, physical is confirmatory• Peripheral vs central vs systemic causes• General physical and neuro exam• Neuro-otological exam

- Ocular mvts/nystagmus

- Head-thrust

- Dix-Hall pike