Dizziness Prof. H. Almuhaimed

Objective to be addressed: Difference between dizziness and vertigo. Difference between dizziness and vertigo. Treatment Considerations. Characteristics of central vertigo. Characteristics of peripheral vertigo. Diagnostic approach to True vertigo.

Patients refer to Dizziness as: “out-of-it” Imbalanced Giddy Faintness Light headedness Light headedness

Most dizzy patients can be placed in to one of four categories: Most dizzy patients can be placed in to one of four categories: 1- True Vertigo (50%)

2-Pre-syncope: Transient sensation that a faint in about to occur. Transient sensation that a faint in about to occur. Transient. May present as nausea,weakness, or change in vision.

3-Dysequilibrium: A sensation of imbalance when standing or walking. A sensation of imbalance when standing or walking. No sense of faintness. No illusion.

4-Vague lightheadedness: Holds the reminder of symptoms of dizziness (which can’t fit to the other categories) Holds the reminder of symptoms of dizziness (which can’t fit to the other categories) 1.Psychiatric disorders, 2.Hyperventilation syndrome 3.Encephalopathies

What is Vertigo?

True vertigo: Defined as an “illusion” or “hallucination” of movement. Defined as an “illusion” or “hallucination” of movement. Both vertigo and dysequilibrium imply a loss of balance, but vertigo involves a sense of motion.

How do we maintain equilibrium?

Visual input Proprioceptiual input Vestibular input labyrinths. equilibrium

Anatomy: Semicircular canals Semicircular Canals (SCC) Semicircular Canals (SCC) Horizontal Horizontal Anterior Anterior Posterior Posterior Cupula Cupula End organ receptors End organ receptors Endolymph Endolymph

Anatomy: Utricle Utricle Utricle Connected to SCC Connected to SCC Contains endolymph Contains endolymph Otoliths (otoconia) Otoliths (otoconia) Calcium carbonate Calcium carbonate Attached to hair cells Attached to hair cells Macule (end organ) Macule (end organ)

Vestibular system Tells brain which way the head moves without looking Tells brain which way the head moves without looking SCC: angular acceleration SCC: angular acceleration Utricle: linear acceleration Utricle: linear acceleration

How can we clinically evaluate the patient with vertigo?

labyrinth CN VIII (Vestibular portion) Vestibular nuclei Brainstem Vertigo Cerebellum

Vertigo Centralperipheral

Key points in History: Is true vertigo present? Are there associated neurologic symptoms? What is the pattern of onset ? What is the duration of the symptoms? Have there been auditory symptoms?

Are there other associated symptoms? What medications is the patient taking? What is the patient’s past medical history? Any recent or remote head or neck injury?

Key points in the physical examination: Vital signs Ear exam Eye exam Positional testing Neurological exam (including gait)

SPINNED Sudden (Onset) Sudden (Onset)Yes Slow, gradual Positional YesNo Intensity Severe Ill defined Nausea/Diaphoresis FrequentInfrequent Nystagmus Torsional/horizontalVertical Ear (hearing loss) Can be present Absent Duration ParoxysmalConstant CNS signs Absent Usually present PERIPHERALCENTRAL Carvalho et al. CTU, Oct, 2004

Peripheral vertigo: Approximation 85% of ED patients with vertigo. Due to dysfunction of one of vestibular organs. Asymmetry of input Sensation of rotation Associated with nausea, pallor and diaphoresis.

Differential Diagnosis Benign paroxysmal positional vertigo (BPPV) (50%) Benign paroxysmal positional vertigo (BPPV) (50%) Vestibular neuritis Vestibular neuritis Labyrinthitis (suppurative, serous, toxic, chronic) Labyrinthitis (suppurative, serous, toxic, chronic) Meniere’s disease Meniere’s disease FB in ear canal FB in ear canal A cute otitis media A cute otitis media Perilymphatic fistula. Perilymphatic fistula.

BPPV Benign Paroxysmal Positional Vertigo Benign Paroxysmal Positional Vertigo Age (F:M 2:1) Age (F:M 2:1) Head trauma Head trauma

Characteristic story Turn head Turn head After a few seconds delay, vertigo occurs After a few seconds delay, vertigo occurs Resolves within 1 minute if you don ’ t move Resolves within 1 minute if you don ’ t move If you turn your head back, vertigo recurs in the opposite direction If you turn your head back, vertigo recurs in the opposite direction

“ B PPV” “ B” = Benign “ B” = Benign Not a brain tumor Not a brain tumor Can be severe and disabling Can be severe and disabling

“B P PV” “P” = Paroxysmal “P” = Paroxysmal Episodic, not persistent Episodic, not persistent Helpful feature in the differential diagnosis Helpful feature in the differential diagnosis

“BP P V” “P” = Positional “P” = Positional Occurs with position of head Occurs with position of head Turning over in bed Turning over in bed Looking up Looking up Bending over Bending over

“BPP V ” “V” = Vertigo “V” = Vertigo An illusion of motion An illusion of motion “The room is spinning” “The room is spinning” Other descriptions Other descriptions Rocking Rocking Tilting Tilting Somersaulting Somersaulting Descending in an elevator Descending in an elevator

Pathophysiology of BPPV Otoliths become detached from hair cells in utricle Otoliths become detached from hair cells in utricle Inappropriately enter the posterior semicircular canal Inappropriately enter the posterior semicircular canal. Parnes LS, McClure JA. Laryngoscope 1992;102:

Physiology Normal situation Normal situation As one turns head to the right As one turns head to the right Endolymph moves  SCC receptors fire  “head turning right” Endolymph moves  SCC receptors fire  “head turning right” Stop turning head  endolymph stops moving  SCC receptors stop firing  “head has stopped moving” Stop turning head  endolymph stops moving  SCC receptors stop firing  “head has stopped moving”

Pathophysiology of BPPV BPPV BPPV Stop turning head  otoliths keep moving  drag endolymph  receptors continue to fire inappropriately  “head is still moving” Stop turning head  otoliths keep moving  drag endolymph  receptors continue to fire inappropriately  “head is still moving” Eyes  “head is NOT moving” Eyes  “head is NOT moving” Brain  room must be spinning in the opposite direction Brain  room must be spinning in the opposite direction

Dix-Hallpike Maneuver The diagnosis of BPPV is generally from the history. Can confirm the diagnosis of BPPV First described by Dix and Hallpike in BárányBárányAlso called the Nylen-Bárány, Bárány, Nylen, or Hallpike maneuver

Dix-Hallpike Maneuver They include: 1- Nystagmus 2- Provocative head position 3- Brief latency to symptoms after change in position 4- Short duration of attack 5- Fatigability of nystagmus on repeat testing 6-Reverse of nystagmus on returning to upright position.

Lab studies In a straightforward case, no lab studies are needed! In a straightforward case, no lab studies are needed! Hemoglobin Hemoglobin Fingerstick glucose Fingerstick glucose Electrolytes if prolonged vomiting Electrolytes if prolonged vomiting

Epley Maneuver: Randomized controlled trials reported success rates ranging from Randomized controlled trials reported success rates ranging from 44% - 88% 44% - 88% Froehling et al. Mayo clin proc Jul 2000 Wolf et al. Clin otolaryngol feb 1999 Asawarichianginda et al. ENT J Sep 2000

Epley maneuver Canalith repositioning maneuver Canalith repositioning maneuver 5 step head hanging maneuver 5 step head hanging maneuver Moves otoliths out of the posterior semicircular canal and back into utricle where they belong Moves otoliths out of the posterior semicircular canal and back into utricle where they belong

Epley maneuver 1. Repeat Hallpike 1. Repeat Hallpike Previously performed diagnostic Hallpike test tells you the starting position (right or left) Previously performed diagnostic Hallpike test tells you the starting position (right or left)

Epley maneuver 2. Turn head 90 degrees in the other direction 2. Turn head 90 degrees in the other direction

Epley maneuver 3. Patient rolls onto shoulder, rotates head and looks down towards floor 3. Patient rolls onto shoulder, rotates head and looks down towards floor

Epley maneuver

Repeating the Epley maneuver Repeating the Epley maneuver Post procedure Post procedure Remain upright for 8-24 hours Remain upright for 8-24 hours

The Epley Maneuver Contraindications Contraindications Unstable heart disease Unstable heart disease High grade carotid stenosis High grade carotid stenosis Severe neck disease Severe neck disease Ongoing CNS disease (TIA/stroke) Ongoing CNS disease (TIA/stroke) Pregnancy beyond 24 th week gestation (relative) Pregnancy beyond 24 th week gestation (relative) Furman JM, Cass SP. N Engl J Med 1999;341:

Complications Vomiting Vomiting Converting to horizontal canal BPPV Converting to horizontal canal BPPV

Labyrinthitis and Vestibular neuronitis A cute unilateral loss of peripheral vestibular function A cute unilateral loss of peripheral vestibular function Associated with vertigo, N/V, and nystagmus Associated with vertigo, N/V, and nystagmus Worsened by head movement Worsened by head movement Occurs in healthy young to middle-aged adults Occurs in healthy young to middle-aged adults Often after respiratory infections Often after respiratory infections self-limiting self-limiting

Perilymphatic fistula: Due to a traumatic “fistula” at the round or oval window. Due to a traumatic “fistula” at the round or oval window. After forceful cough, sneeze, scuba diving or direct blow to the ear. After forceful cough, sneeze, scuba diving or direct blow to the ear. Recurrence of vertigo with pneumo- otoscopy (Hennebert’s sign) Recurrence of vertigo with pneumo- otoscopy (Hennebert’s sign) Self-limiting Self-limiting

Meniere’s disease: Characterized by triad of: Characterized by triad of: vertigo vertigo tinnitus tinnitus hearing loss (sensorineural) hearing loss (sensorineural) Chronic relapsing illness (? familial) Chronic relapsing illness (? familial) Due to a build-up of endolymphatic pressure in the labyrinth. Due to a build-up of endolymphatic pressure in the labyrinth. Treatment: vestibular suppressants. Treatment: vestibular suppressants.

Meniere’s disease

Central vertigo May include disorders with significant potential morbidity. May include disorders with significant potential morbidity. Warrants the initiation of further work-up. Warrants the initiation of further work-up.

SPINNED Sudden (Onset) Sudden (Onset)Yes Slow, gradual Positional YesNo Intensity Severe Ill defined Nausea/Diaphoresis FrequentInfrequent Nystagmus Torsional/horizontalVertical Ear (hearing loss) Can be present Absent Duration ParoxysmalConstant CNS signs Absent Usually present PERIPHERALCENTRAL Carvalho et al. CTU, Oct, 2004

Differential Diagnosis: Vertebral-basilar circulation events: Vertebral-basilar circulation events: 1. Vestibular nuclei (TIA or stroke) 2. Cerebellar infarction or hemorrhage 3. Lateral medullary infarction (Wallenberg’s syndrome)

4. Vertebral artery dissection Migraine Migraine Post concussive syndrome. Post concussive syndrome. Tumors (acoustic reuromas) Tumors (acoustic reuromas) Multiple sclerosis Multiple sclerosis Infection (encephalitis, meningitis) Infection (encephalitis, meningitis)

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