DIZZINESSDIZZINESS

Jonathon HarrisonKyle DeFreitasElaine Holland

Dizziness and Dizziness and VertigoVertigo

Merck: imprecise term. Symptoms include:• Faintness• Light-headedness• Imbalance or unsteadiness• Vague spaced-out/swimmy head Vertigo: false sensation of movement of the self or the

environment. Usually the perceived movement is rotary (a spinning or wheeling sensation) but some patients simply feel pulled to one side. Vertigo is not a diagnosis, it is a description of a sensation.

Dizziness and Dizziness and VertigoVertigo

May be incapacitating, esp. when accompanied by nausea and vomiting or difficulty with balance and gait

Dizziness accounts for about 5 to 6% of physician visits More common with increasing age; it affects about 40% of

people over 40 yr at some time. Dizziness may be temporary or chronic. Chronic dizziness, defined as lasting > 1 mo, is more common

among elderly people.

The most common causes of dizziness without vertigo are usually not otologic and probably are drug effects, multifactorial or idiopahic

Case Study #1Case Study #1Chief complaint: 52 year old male complaining of dizziness

and unsteadiness of gait with accompanying neck pain and headaches

Social History: construction worker, 1-2 hours of TV and computer/day, uses tobacco weekly (cutting back), 4-5 servings of coffee/day, 1-2 servings of alcohol/ month, 20 oz of soda/day

Past History: no history of recent infections, has hypertension, multiple joints injuries (head and back injuries), no surgeries reported

Review of systems: headaches, dizziness, nausea/vomiting, ear noises, deafness, stiff neck, high blood pressure

Case Study #1Case Study #1Onset and duration: Dizziness and unsteadiness began 1 week ago, etiology

unknown. Headaches/ neck pain insidious onset over past 20 yearsPalliative/provocative: Dizziness: improves with time only; no factors

provoke. Neck pain: improves with aspirin; worsens with work activities, driving, recreational activities

Quality of symptoms: Loss of balance, room is spinning. Dull, achiness and tightness in head and neck

Timing of symptoms: Episodes of dizziness last 2-4 hours, occurred 2x since onset. Neck pain and headaches have become more constant over time

ADL’s Affected: Dizziness totally incapacitates activities during episodes. Neck pain/ headaches limit work activities, driving, recreational activities

Modifying factors: Intermittent loss of hearing in right ear, right ear feels full, and ringing in right ear (tinnitus)

Case Study #1Case Study #1Neurological exam: Cranial Nerves- Weber’s and Rinne reveal sensorineural loss in

right ear, Hallpike’s negative, Head thrust test negative, Turn Test positive to the left

ROM exam: Neck: all motions restricted, pain with extension, poor quality motion with bilateral flexion

Orthopedic Exam: Jackson’s compression and foraminal compression (+) bilaterally with localized pain

Chiropractic Exam: Listings:• C5: RP, +2 pain, moderate restriction• C7: RP, +2 pain, severe restriction• T2: RP, +1 pain, mild restriction• L5: RP, +1 pain, mild restriction

Radiographic Exam: Cervical Spine- Loss of normal cervical lordosis, DDD of C6/C7

DDX- Meniere’sDDX- Meniere’s• Acoustic Neuroma (388.5)

- R/I- hearing loss, tinnitus, feeling of fullness - R/O- no numbness/ weakness of facial nerve, no otalgia

• Benign Paroxysmal Positional Vertigo(386.11)– R/I- recent trauma to the area– R/O- reproducible, dizzy last more than a min

• Labyrinthitis (386.30)– R/I- dizzy, ringing in ear– R/O- no infection, hearing loss

• Otosclerosis(387.9)– R/I- conductive hearing loss– R/O- no dizziness

• Meniere’s Disease (386.0)– R/I-Dizzy for long time, not reproducible, fullness of ear, hearing lost

Meniere’s DiseaseMeniere’s DiseaseMerck: an inner ear disorder, pressure and volume changes of

the labyrinthine endolymph affect inner ear function which produces specific symptoms:

Vertigo (last up to 24 hours often with nausea and vomiting) Sensorineural hearing loss Tinnitus (constant or intermittant, not related to position or

motion) Sense of fullness or pressure in the affected ear (50%

unilateral)Early stages: episodic, may be asymptomatic for periods > 1 yrLater stages: Hearing impairment persists and worsens, tinnitus

may be constant

Meniere’s DiseaseMeniere’s DiseaseClinical findings: During attack: nystagmus, pt. falls towards affected side Between attacks: mittlemeyer test shows pt. turns away from

affected ear. Rinne and Webster’s may indicate sensorineural hearing loss

The etiology is unknown. Risk factors include a family history of Meniere's disease, preexisting autoimmune disorders, allergies, trauma to the head or ear, and, rarely syphilis

Peak incidence between 20-50 yoa

Case Study #2Case Study #2Chief Compliant: A 32 year old male

complaining of episodes of vertigo that occur with certain head positions. The vertigo lasts for seconds to a few minutes.

Past history: Patient was hit by a car when he was 6, has hypertension, multiple job injuries, no surgeries reported, takes medication for hypertension.

Review of Systems: Headaches, dizziness, lightheadedness, nausea, balance issues

Case Study #2Case Study #2

Onset and Duration: Dizziness and balance issues started three years ago

Palliative/Provocative: Dizziness: better with not moving head to extension or flexion. Worse with movement

Quality of symptoms: Loss of balance, fear of falling

Timing of symptoms: Dizziness whenever flexion or extension of neck lasting a couple of seconds to a few minutes, getting worse since new job as a painter

ADL’s affected: Dizziness stops him from working. Work activities increase occurrences

Case Study #2Case Study #2Neurological Exam: Cranial nerves:

• Weber’s and Rinne’s test normal• Hallpike POSITIVE• Head thrust test positive• Turn test to left

– Motor: +5/5 in all myotomes– Reflexes: +2 for all DTR’s

ROM: Neck: restricted extension and lateral flexion bilateralOrthopedic Exam: all negativeRadiographic Examination: Loss of cervical lordosis

DDX- BPPVDDX- BPPV• Labyrinthitis (386.30)

– R/I- dizzy– R/O- no ringing in ears, no infection, no hearing loss, not reproducible

• Meniere’s Disease (386.00)– R/I- dizzy for a period of time– R/O- Dizzy for a long period of time, no fullness of ear, no Hearing lost,

dizziness was reproducible• Vestibular Neuritis (386.12)

– R/I- dizzy, nausea, lying still helps, no hearing loss– R/O- dizziness last for days, to previous cold

• Benign Paroxysmal Positional Vertigo (386.11)– R/I-Trauma to area, dizziness last seconds to minutes, reproducible

Benign Paroxysmal Benign Paroxysmal Positional VertigoPositional Vertigo

Merck: Short (< 60 sec) episodes of vertigo occurring with certain head positions. Nausea and nystagmus develop.

• most common cause of relapsing otogenic vertigo. It affects people increasingly as they age and can severely affect balance in the elderly, leading to potentially injurious falls.

• Thought to be caused by displacement of otoconial crystals (Ca carbonate crystals normally embedded in the saccule and utricle). This displaced material stimulates hair cells in the posterior semicircular canal, creating the illusion of motion.

Benign Paroxysmal Benign Paroxysmal Positional VertigoPositional Vertigo

• Etiologic factors: spontaneous degeneration of the utricular otolithic membranes, labyrinthine concussion, otitis media, ear surgery, recent viral infection (such as viral neuronitis), head trauma, prolonged anesthesia or bed rest, previous vestibular disorders (eg, Meniere's disease), and occlusion of the anterior vestibular artery.

• Symptoms and Signs: Vertigo is triggered when the patient's head moves. Acute vertigo lasts only a few seconds to minutes; episodes tend to peak in the morning and abate throughout the day. Nausea and vomiting may occur, but hearing loss and tinnitus do not.

• BPPV usually subsides spontaneously in several weeks or months but may continue for months or years.

Case Study #3Case Study #3

45-year-old male patient presents to the office and states that about 3 weeks ago after just getting over a cold, he was going through some paperwork at his home office with his neck bent forward for a long period of time. When he raised his head, he experienced the abrupt onset of horizontal spinning of the room that was accompanied by nausea. The sensation lasted approximately 30 minutes. The next morning, after eating breakfast, he sat down onto the couch and he experienced the abrupt onset of similar horizontal dizziness, which was again accompanied by nausea and eventually by vomiting. This time the nausea and vomiting lasted six to eight hours, while the dizziness remained for a few days. The only thing that seems to help him is lying still on his back. While rapid head movements and sitting or standing rapidly makes his symptoms much worse. He now states that he has been feeling "off" ever since.

Case Study #3Case Study #3Provisional Diagnosis??

Cervical ROMs were unable to be performed due to patient feeling dizzy upon head movement, Neurological exam unremarkable except for left eye peripheral nystagmus to the left (paying particular attention to these tests because they are direct reflections of cerebellar problems):

• Ataxia- negative• Dysarthria- negative• Finger to nose test- negative• Supination/Pronation- negative• Sharp/Dull- negative• Weber test- negative• Rinne test- negative: AC>BC, Friction Rub- negative, Hears sound equally on both sides

• If case is extreme the following tests may be ordered: Audiogram (to distinguish labyrinthitis from neuritis, and to detect Meniere's disease), Vestibular Evoked Myogenic Potential Testing (VEMP) (to detect vestibular neuritis)

• - MRI of brain and IAC, with and without contrast (to be sure there are no tumors, inflammation of nerve or cochlea).

DDX- Vestibular DDX- Vestibular NeuritisNeuritis

• Cerebellar stroke (V12.54)- R/O: Negative Ataxia, Dysarthria, Finger to nose test, Supination/Pronation and sharp/dull neurological exam findings. Peripheral nystagmus instead of central nystagmus found

• Meniere’s Disease (386.00)- R/O: Webers/Rinnes test- negative and lack of complaint of tinnitus and headaches

• Benign Paroxysmal Positional Vertigo (BPPV) (386.11)- R/O: Peripheral nystagmus instead of vertical nystagmus found and lack of patient complaint of migraine headaches

• Vestibular Neuritis (386.12)- R/I: Classic symptoms of dizziness, nausea and vomiting following a common cold, and major neurological finding of peripheral nystagmus

Vestibular NeuritisVestibular NeuritisMerck: Vestibular neuritis causes a self-limited episode of vertigo,

presumably due to inflammation of the vestibular division of the 8th cranial nerve; some vestibular dysfunction may persist.

• Etiology is unclear, a viral cause is suspected.• Symptoms include a single attack of severe vertigo, with nausea

and vomiting and persistent nystagmus toward the affected side, which lasts 7 to 10 days. The nystagmus is unidirectional, horizontal, and spontaneous, with fast-beat oscillations in the direction of the unaffected ear.

• Absence of tinnitus or hearing loss is a hallmark of vestibular neuronitis.

• The condition slowly subsides after this initial episode. Some patients have residual disequilibrium, probably due to permanent vestibular injury.

Case Study #4Case Study #4• 55-year-old female patient presents with complaint of hearing loss

and dizziness sometimes with associated ringing in her right ear. She states that the hearing loss began about 2 years ago and was mild at first so she attributed it to just getting old. Over the past six months the ringing in her right ear has increased in frequency and she is constantly dizzy. She feels that her hearing is getting worse and now her right ear feels “full.”

• Patient was very sick as a child and had multiple ear infections that

resulted in tubes at age 4. Ruptured right eardrum at a rock concert when she was 20- no treatment was provided, It healed on its own

• Used to smoke cigarettes, but only when she drank• Was a heavy drinker until the age of 30 when she got married. She

now drinks 3-4 glasses of wine a day.

Case Study #4Case Study #4Provisional Diagnosis??

Physical Examination: VBAI- negative, Cranial Nerves –difficulty with facial sharp/dull, H Eye Movements- NAD, no nystagmus seen, Dermatomes - All WNL, Bilaterally

Weber test- lateralizes to the left - (Hear the sound louder in the unaffected ear, because the affected ear is less effective at picking up sound even if it is transmitted directly by conduction into the inner ear)

Rinne test- positive - AC>BC – (In sensorineural hearing loss, bone conduction and air conduction are both equally depreciated, maintaining the relative difference between the two)

Friction Rub- positive - Heard sound louder on the left Diagnostic Imaging: MRI scan of the brain with contrast- Revealed a small acoustic neuroma in the IAC comprising CN 8 (Vestibulocochlear

nerve) on the right side of brain

Case Study #4Case Study #4

MRI- Coronal MRI- Axial with contrast

DDX- Acoustic DDX- Acoustic NeuromaNeuroma

• Vestibular Migraine- R/O: Diagnostic Imaging revealed an acoustic neuroma

• Meniere’s Disease (386.00)- R/O: Diagnostic Imaging revealed an acoustic neuroma

• Acoustic Neuroma (388.5)- R/I: Diagnostic imaging revealed an acoustic neuroma and

due to patient complaint of loss of hearing, ringing in the ear, sense of fullness in the ear, trauma history of ear infections, tubes and ruptured ear drum.

Acoustic NeuromaAcoustic NeuromaMerck: An acoustic neuroma is a Schwann cell–derived tumor of the 8th

cranial nerve. • Acoustic neuromas almost always arise from the vestibular division of the

8th cranial nerve and account for about 7% of all intracranial tumors. As the tumor expands, it projects from the internal auditory meatus into the cerebellopontine angle and compresses the cerebellum and brain stem. The 5th cranial nerve and later the 7th cranial nerve are affected.

Acoustic NeuromaAcoustic Neuroma• Bilateral acoustic neuromas are common in

neurofibromatosis type 2.• Slowly progressive unilateral sensorineural

hearing loss is the hallmark symptom. Other early symptoms include unilateral tinnitus, dizziness and dysequilibrium, headache, sensation of pressure or fullness in the ear, otalgia, trigeminal neuralgia, and numbness or weakness of the facial nerve.

Drug effects: Drug effects: DizzinessDizziness• TOO MANY TO LIST!

• 2885 drugs• Many were common OTC

Drug effects: Drug effects: VertigoVertigo

Essential QuestionsEssential Questions• How long do the episodes of dizziness last?• Do you have ringing in the ear?• Is there a feeling of increased pressure or

fullness in the ear?• Have you had any recent trauma?• Have you had any associated hearing loss?• Have you recently had a cold/viral

infection?• Are you taking any medications?

ReferencesReferences• Differential Diagnosis and Management for the

Chiropractor, Protocols and Algorithms, 4th ed., T. Souza, 2009. Chapter 18

• http://www.dizziness-and-balance.com/disorders/unilat/vneurit.html

• http://oak.cats.ohiou.edu/~kochl/lisakoch.html• www.merck.com• www.wrongdiagnosis.com• http://www.dizziness-and-balance.com/disorders/tumors/

acoustic_neuroma.htm• http://www.acousticneuroma.org/

diagnosis_of_acoustic_neuroma_acoustic_neuroma.htm