Dizziness PART 1

8/3/2019 Dizziness PART 1

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APPROACH TO DIZZINESS

EDITED BYMotasem Al-AmariJoud Jarrah


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What is dizziness ??

Dizziness is a subjective experience.Dizziness is a term used to describe everything from feelingfaint or lightheaded to feeling weak or unsteady.

One of the most common symptoms causing patients tovisit a physician.

Why Dizziness is frustrating ??

1. Wide differential diagnosis

2. Patient can t describe exactly what he feels3. Doctor can t understand

4. No effective tre atment


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Th e mec h anisms in t h e body t h at contributeto a sense of stability

S ystems used to provide stability include:visionthe peripheral vestibular and auditory systems

proprioceptive receptors in joints of the spine and extremitiesthe cerebral cortexthe vestibular nucleithe brainstem and the cerebellum

the cardiovascular system, which maintains vascular tone


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Dizziness is a general term and divided into 4categories:

feeling of imbalance w h en standing, especially w h ile walking.neuromuscular problems

, proprioceptive disorders, visualimpairment, or central nervous system disease.


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DDx of vertigo

Peripheral Vestibular Disorders

BPPVBenign paro x ysymal positional vertigo

Vestibular neuritis

Labyrinthitis

Meniere s disease

Physiological

superior canal dehiscence

syndrome

Central Vestibular Disorders

Strokes and TIA

Migraine

Trauma (concussion, whiplashinjuries)

benign tumors, multiplesclerosis, vestibular epilepsy,

cerebellar degeneration


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DDx

syncope-Pre

Orthostatic Hypotension

Cardiac arrhythmias

Cardiac valvular disorders

Carotid sinus syndrome

Viral syndrome

Anemia, acute blood loss

Disequilibrium

Cerebellar disorder

Peripheral neuropathies

Physical deconditioning

Aminoglycoside toxicity


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DDX of non-specific dizziness

Psychiatric disorders

Panic disorder

Generalized anxiety disorder

Hyperventilation

depression

Other disorders

Medication related

Metabolic (hyper/hypoglycemia, thyrotoxicosis)

Non- vestibularneurological causes(Parkinson s disease)


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Perip h eral vestibular disordersBPPV-THE MOST COMMON 90%due to one or more particulates freely-

floating within the endolymph of the semicircular canal. Characterized bybrief episodes of vertigo that occurs suddenly , associated with change inhead position . Resolves with not moving the head.

Vestibular neuritis -causes usually unknown, but may follow a viral URTI.

Patients will have acute vertigo that is prolonged and severe (hours todays). May be accompanied by nystagmus, imbalance and nausea andvomiting. No other neurological or hearing problems. Fortunately itgenerally subsides and clears up on its own.

Meniere s disease- repeated vertigo attack lasting for hours and days , andeven months, accompanied by mild tinnitus, hearing loss and feeling ofblockage in the affected ear . Usually associated with nausea andvomiting. Caused by impaired resorption of endolymph resulting inendolymphatic HTN and hydrops (dilation of endolymphatic spaces) .


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Vestibular migraine- happens to people who are very sensitive tomotion, is triggered by turning head quickly, driving, being in crowdedplaces and even watching motion in TV. Vertigo last from minutes toseveral days , and can be without an actual migraine.

Acoustic neuroma- benign neoplasm that arises from vestibular portionof 8th cranial nerve. It is a slow growing lesion, that will causeprogressive sensorineural hearing loss and dizziness.

Physiologic vertigo (motion sickness) discordance betweenphysiological system, such as between vision and vestibular excitement. It is fairly common. (ex: merry go round- the vestibular system has been excited by the movement, but the visual system

recognizes there s no longer physical spinning.)


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C entral vestibular disordersmore serious, more in elderly

1-Strokes and transient ischemic attacks:-Other brainstem signs and symptoms, such as cranial nerve abnormalities, are

often present.

-Presentation may include a combination of peripheral and central symptomsbecause, an artery, as in the case of the anterior inferior cerebellar artery, maysupply both peripheral and central territories.

2- Migraine:vertigo is the aura prior to the typical hemicranial headache

3 Trauma4-Less common:

-Benign tumors (acoustic neuromas or posterior fossae tumors).-Multiple sclerosis-Vestibular epilepsy-Cerebellar degeneration : alcoholism, infarction.-neurosyphilis


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D rugs causing dizziness:

B-blockers , Antihypertensives

Oral hypoglycemic agents

Aminoglycosides + Loop diuretics (8 th CN damage)

Digotoxin

Nicotine withdrawal


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HOW TO APPROACH

PATIENT WITHDIZZINESS???


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H istory

Are you dizzy or fatigued?Patient description.. diff. dizziness from vertigoFrequency :episodic or continuousSeverityAggravating and relieving factorsDuration: seconds , minutes, hours or days?Previous episodes, tests, diagnosis and treatmentDid the treatment help you?When does it occur - turning over in bed

- sitting up in chair - turning head suddenly while driving- when wearing tight collars- only on walking (aortic stenosis)- all the time , or before/after meals

Associated with : weakness, numbness, double vision, mental staus, gait andcoordination ,palpitation, block outs, seizures


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C ont.

Last visual acuity check, any new glasses, lenses, eye drops..How is your hearing? Any fluctuations during episodes?Any pain in ears? Fullness ? Tinnitus ?

History of URTI, sinus congestion, allergy or headache

History of traumaAssociated nausea, vomiting or hearing lossMedical ,surgical and drug history(new medicationsRelation to stress and anxietyHow you re feeling otherwise?

Alcohol intake?


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Why duration is important in vertigo?

Seconds BPPV , vertebrobasilar TIAMinutes Vertebrobasilar inssuficiency, panicdisorder

Hours- Meniere s syndrome

Days- Vestibular Neuritis, labyrinth infarction

Long standing and fluctuating G AD, depression

Days to months( diminishing with time)- Posterior circulation stroke


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S everity

If initial symptoms are severe but lessen over t h e ne x tfew days acute vestibular neuronitis.

If initially increase in severity t h en lessen later onM enieres disease (comes as attacks).

If it was constant and for weeks, t h ink psyc h ological.


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P rovoking factorsIf symptoms occur only wit h positional c h anges , as turning over inbed, bending over at t h e waist and t h en straig h tening up, orhypere x tending t h e neck BPPV .

H x of recent viral UR T infection acute vestibular neuronitis or acute

labyrint h itis.

M ovements t h at place t h e affected ear downward th us provokingvertigo perilymp h atic fistula (trauma, scuba diving, e x cessivestraining).

Tullios p h enomenon: Nystagmus and Vertigo caused by loudnoises or sounds at a particular frequency perip h eral vertigo(fistula).


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A ssociated signs and symptoms :Nystagmus The presence of nystagmus suggests that dizziness is vertigo. Nystagmus is notalways readily visible, although it often can be elicited by provocative maneuvers or withelectronystagmography.

Postural instability The effects of lesions of the vestibular system upon postural stability arevariable, but it is common for patients with vertigo to have difficulty maintaining steady uprightposture when walking, standing, and even sitting unsupported, particularly when the symptoms areacute .

Hearing loss Symptoms of ear involvement are very suggestive of a peripheral cause of vertigo,although their absence does not exclude the diagnosis. The physician should ask if there has beenany hearing loss, its duration and progression, whether unilateral or bilateral, and accompanyingsymptoms such as discharge or drainage from the ear, tinnitus, or a history of otitis.

Subclinical hearing loss can be detected with reasonable sensitivity in the office by holding your fingers a few inches away from the patient's ear and rubbing them together softly or asking thepatient to repeat a few numbers or words whispered into his or her ear. Audiometry is moresensitive.

Brainstem signs The presence of additional neurologic signs strongly suggests the presence of acentral vestibular lesion. Symptoms such as staggering or ataxic gait, vomiting, headache, doublevision, visual loss, slurred speech, numbness of the face or body, weakness, clumsiness, or incoordination should be reviewed with the patient .


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Peripheral vs Central VertigoSymptoms Peripheral Central

onset sudden gradualseverity > severe < severefrequency episodic constantNausea and vomiting severe moderate

Imbalance mild severeHearing loss common rareOscillopsia* mild severe

Neurological symptoms rare common

Speed of compensation rapid slow

* A feeling that the environment moves up and down, bounces, or rocks when the

person walks


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RED FLAG SHearing lossCerebrovascular accidentA new different or severe headacheBlurred visionSpeech impairmentLeg or arm weaknessLoss of consciousnessFalling or difficulty walkingNumbness or tinglingChest pain or rapid / slow heart rate

If patient comes with one of these red flags, appropriateintervention should be done ASAP!


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P/EG eneral conditionsVital signsCVS examinationEar examination and hearing testNeurological examinationDix-Hallpike maneuver Romberg testHyperventilation test- done for 2-3 minutes,then monitor the reproduction of dizziness

Dizziness PART 1

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