2 Dizziness One of the most common complaints in all practice Affects 20-30% of the populationI have been hospitalized twice in my life with severe vertigo and uncontrolled vomiting
3 Dizziness Makes up a tremendous number of ER and Urgent Care visits. True persistent dizziness can lead to falls, and subsequent injuries and substantial day to day dysfunction of daily activities.Balance related falls leads to death in the elderly—i.e. hip fracture and subsequent blood clots and pulmonary embolus or subdurals but rarely are these falls due to VERTIGO
4 Dizziness Nonspecific when the patient walks in and says I am dizzy Your job is to figure out what the patient means by dizzinessThe key issue is whether the patient has true Vertigo a sense of rotation.
5 Dizziness There is a specific “Dizziness” clinic at Mayo’s Classic paper by Daniel Drachman on the % of patients with various symptoms who complain of dizzinessTrue Neurological vertigo is RARE
6 Dizziness Vertigo Neurologic Presyncope NON Neurologic Disequilibrium Often NeurologicLightheadedness Rarely Neurologic
9 DizzinessVertigo, The illusion or sense of a spinning rotation of the room BUT it may be the patient who feels they are doing the spinning BUT there is a sense of rotation!Peripheral vs CentralPeripheral is a reflection of disorders of the semicircular canals, utricle –the Vestibular End Organs or the 8th Nerve (ENT Docs say 8th nerve vertigo is central!)Central Vertigo implies dysfunction of the Vestibular Nuclear Connections or Cerebellum (less likely)The book is misleading on this point
12 Dizziness Peripheral Vertigo Prominent Nausea and Vomiting Unidirectional NystagumusSudden OnsetAuditory Issues such as Hearing Loss or TinnitusMay be positionalVery DisablingDelay anf fatigue
13 Dizziness Central Vertigo Nystagmus is variable Less prominent nausea and vomitingMay not be disablingVariable onsetNo hearing issuesOther brainstem findings
14 Dizziness Presyncope The sensation that one is about to faint “feel faint”NauseaDimming of VisionSweatingTremorCardiovascular, Metabolic or much less likely Hematologic in nature
15 Disequilibrium The sense one is about to fall Motor weakness may cause thisLoss of sensory input from neuropathy may cause thisBalance and gait are the issues!
16 Dizziness Lightheadedness Non specific Hyperventilation is the classic Psych issuesMedsAltered SensoriumMy 8th grade auditorium
17 DizzinessVertigoCentral Vertigo always requires immediate evaluation including neuro imagingMust eliminate the possibility of a posterior fossa mass pressing on the brainstem or primary brainstem pathology.
18 Dizziness Peripheral Vertigo Sudden Brief Attacks Fall to the ground Spells of TumarkenNo pre-syncopeNo seizure stigmataNausea, vomiting and uni-directional nystagmusPeripheral Nystagmus (Horizontal with a Rotatory Component) Dampens with Fixation!
19 Dizziness Central Vertigo Often a more gradual onset They may not be able to walk but this may reflect other issues including hemiparesisVertical Nystagmus is always of central originUnlike peripheral nystagmus central nystagmus may persist beyond 48 hours.Peripheral Vertigo always compensates over time
21 Dizziness Brainstem Lesions Which Cause Vertigo Always involves other tracts, motor, sensory or other cranial nerve nuclei so look for signs of other deficits on Neuro examWallenberg’s Syndrome in the distribution of the Posterior Inferior Cerebellar Artery BUT usually due to vertebral occlusive disease is the classic brainstem syndrome causing vertigo
27 Dizziness Cerebellar Lesions Causing Vertigo Cerebellar Infarcts (Medical Emergency)—Swell and compress the brainstem (posterior Fossa Herniation Syndrome)Cerebellar signs- Past pointing, dysmetria, dysdiadokinesis (rapid alternating movements)
28 Dizziness Vertigo associated with transient Brainstem Ischemia Vertebrobasilar Insufficiency---diplopia, transient homonomous visual defects, dyarthriaDrop Attacks VBI but patient does not lose consciousness
29 Dizziness Brainstem Stroke has a myriad of features! Any stroke’s findings is a reflection of the affected artery and it’s collateral blood flowOpthalmoplegiaHearing LossVisual Field DefectsSensory LossAtaxiaMONOCULAR BLINDNESS IS ANTERIOR CIRCULATION
30 Dizziness Cerebellar Bleeds Headache Nausea Vomiting Nystagmus Ataxia of GaitDepressed Level of ConsciousnessEMERGENCY SURGERY!Prevent Herniation of Cerebellum into the Brainstem
32 DizzinessPeripheral Causes of Vertigo Much More Common than Central Causes…Statistically whenever you see someone with severe Vertigo is usually peripheral.
33 Dizziness BPPV (Benign Paroxysmal Positional Vertigo) Most common cause of vertigoUsually elderlyPositional One side or the other DOWN on the PillowLatencyFatigue with repetitive episodes, Lasts 60 seconds per episodeCupulolitiasis----Debris from the Utricle flowing freely in the semi-circular canals endolymphThis acts as a plug like a plunger causing a push and pull effect on the cupula creating asymetric neural impulses from the ears WHICH IS THE MECHANISM of Peripheral Vertigo and Nystagmus!Rolling Over in Bed much more often than LOOKING UP!
35 Dizziness Vestibular Neuronitis Probably akin to the same mechanism as Bell’s Palsy (reactivation of latent Herpes Virus BUT affecting the vestibular portion of the 8th nerve)Often after a viral infectionMay be a viral infection of the vestibular apparatus this is not like the book says NUCLEAR this is PERIPHERAL NOT CENTRALLasts weeks but the acute vertigo is over after about 48 hours and the patient then feels disequilibrium for about 6-8 weeks. The vertigo can be recurrent during that time frame.
36 Dizziness Labyrinthitis By definition there is a decrease in hearing unlike vestibular neuronitisThe Labyrinthe is affectedCan be viral or bacterial or spirochetalThe end organ of hearing is involved by definitionOtitis Media bacterial spread through a ruptured membrane or a perilymph fistula
37 DizzinessThese patients with labyrinthitis usually appear quite ill and have fever.Unlike vestibular neuronitis where fever is uncommonIf you have Labyrinthitis there must be hearing loss and usually vertigo with nausea vomiting a peripheral pattern of nystagmusENT Emergency
38 Dizziness Ramsay Hunt Syndrome Varicella Zoster Virus reactivation Affects Cranial Nerves 7 and 8Facial ParesisTinnitusHearing Loss and Vertigo
39 Dizziness Meniere’s Disease Very Overdiagnosed..Occurs as attacks Low Frequency Sensory Neural Hearing Loss is the HALLMARK Hearing Loss may fluctuateIncrease in the volume of Endolymph which has led to various therapeutic interventionsDistension of the Endolymphatic SystemSevere Vertigo Nausea Vomiting with a peripheral pattern of NystagmusAttacks last minutes to hours, Ear fullness or painAbrupt Spells of Tumarkan Fall to the Floor!Usually unilateral but may be bilateral
40 Dizziness Acoustic Neuroma Slow Unilateral Hearing Loss and Tinnitus Schwanoma of the acoustic nerveBegins on vestibular portion but affects hearing firstSlow growth is the reason vertigo rarely developsCranial nerves 5 and 7 This is the classic cerebello-pontine angle lesion
42 Pre-Syncope Simple Faint Usually Needs to be differentiated from a seizurePost Episode Confusion RareNo tongue bitingNo incontinenceNo shaking
43 DisequibiriumPatient feels unsteady, they feel like they are going to fall.Usually after a sudden change in position particularly when they have lost visual cues.Loss of sensory inputMotor weakness subtle affecting balanceExtrapyramidal Disease Parkinsons!Visual Impairment with NeuropathyArthritis when it is severeLong standing Diabetes or HIV
44 Lightheadedness Vague Difficult to characterize Most common in a dizziness clinicMost important issue is that this is usually non neurologic and usually not a sign of severe significant diseaseFloating sensationDepersonalization a psych issue (anxiety,depression)Hyperventilation
45 Evaluation Patient may be uncooperative due to illness Vital Signs Orthostatic BP Changes supine and standing and look for a change in pulseComplete HEENT and Neuro ExamsNystagmusEOM’sPupilsFundus exclude PapiledemaTympanic Membranes are CRUCIAL! (Scars,Fluid,Pus)Weber Rinne after Gross Hearing
46 Evaluation Cardiac Exam Emboli Carotid Bruits Emboli Neuro Exam Gait Romberg is keyIf you can’t stand with your feet together with eyes open it is a cerebellar issue if it is only with eyes closed there is a sensory input issue.
47 Evauation Dix-Hallpike Maneuver Diagnose BPPV Turn Head 45 degrees to the side being testedRapidy lower head to a position hanging below the examing tableEyes open (nustagmus and Vertigo)After a short latency a positive test is denoted by the eyes having a burst of nystagmus with the eyes beating towards the ground (fast phase component of nystagmus)Lasts a minute or soPosterior Canal Variant of BPPV
48 Dizziness Always hyperventilate the patient if need be to dx Reproducing the syomtoms is the key to understanding whats wrong in non obvious cases
49 Evaluation Labs Not Helpful Diagnosing Vertigo CBC (anemia) Chem Profile (eletrolytes)(dehydration BUN)Thyroid TestsGlucose Tolerance Test (hypoglycemia)EKG afib or arrythmia of other type ???echo
50 Evaluation Electronystagmography Records eye movements to look for nystagmusIn response to vestibular,visual, cervical,caloric, rotational,positional stimulations to assess vestibular functionAudiogram KEY Meniere’s Low Frequency Sensorineural Hearing Loss