1. A Patient Complaint That Can Make the Doctor’s Head Spin.
Dizziness
A Patient Complaint That Can Make the Doctor’s Head Spin.

2. What Is Dizziness ?
A non-specific term used to describe a number of signs and symptoms
Unsteadiness
Giddiness
Light-headed
Disequilibrium
Vertigo

3. Focus of Diagnostic Workup
Vertigo – auditory and Vestibular system
Near-faint dizziness– cardiovascular system
Psychophysiological dizziness - psychiatric
Hypoglycemic dizziness- metabolic assessment
Disequilibrium – peripheral nerves, spinal cord, inner ear, vision, CNS
Dizziness, Hearing Loss, and Tinnitus/ Baloh,R.W 1998,F.A.Davis Co

4. Vertigo An illusion of movement in space Rotation (most common) Linear
Tilt

5. History of the Dizzy Patient
Detailed description of dizziness
Differentiate vertigo from non-vertigo
Determine onset, length, and if recurrent
Associated neurological or systemic signs
Any hearing loss?
Current medications
Differentiate Peripheral vs. Central cause

6. Peripheral or Central Cause?
Labyrinth or vestibular nerve dysfunction
Recurrent
Nystagmus-horizontal
Position change
Moderate to severe vertigo
Central
Cerebellum or brain stem dysfunction
Continuous
Nystagmus-vertical
Mild vertigo
Non-positional
Differential Diagnosis and Management for the Chiropractor, Aspen Publishers, Inc 2001

7. Peripheral Vestibular Disorders
BPPV
Labrynthitis
Meniere’s disease
Acoustic Neuroma
Motion sickness
Cervicogenic
Perilymphatic fistula
Vestibular neuronitis
Semicircular canal infection
Semicircular canal water penetration
Assessment of the dizzy patient, Australian Family Physician Vol. 31, No. 8, August 2002

8. Central Vestibular Disorders
Brain stem lesion
Basilar artery migraine
TIA
Stroke MS
Cerebellar lesions
Metastatic Tumor
Meningioma
Assessment of the dizzy patient, Australian Family Physician Vol. 31, No. 8, August 2002

9. Anatomic and Physiologic Components of Balance
Vestibular – labyrinth, vestibular nuclei
Visual – CN III, IV, VI
Proprioceptive – upper cervical ms and joints

10. Types of Vertigo Subjective vertigo Objective vertigo
The patient feels that they are spinning
Objective vertigo
The patient feels still but objects appear to be moving around them

11. Causes of Vertigo Ear disease
Toxic conditions (alcohol, food poisonings)
Postural hypotension
Infectious disease
Cervicogenic
Disease of the eye or brain
Psychological

12. Schimp D. A diagnostic algorithm for the dizzy patient Chiropractic Technique, vol 6(4) Nov 1994

14. Benign Paroxysmal Positional Vertigo (BPPV) 20%
Brief episodes – recurrent
Moderate to severe
Associated with head position
Gradually diminishes over a month or two
No hearing loss
Latency or delayed onset of S/S
Positive Nylen-Barany maneuver
Caused by otoconia (debris) floating in PSC

15. Nylen-Barany AKA Dix-Hallpike
Patient seated, head turned 45 degrees
Patient quickly lays supine
Latency period, then horizontal or rotational nystagmus
Nystagmus decreases after seconds
Affected ear is the side head is turned toward when nystagmus and vertigo occurs

16. Nylen-Barany Maneuver
Dizziness, Hearing Loss, and Tinnitus R.W. Baloh, F.A. Davis Company 1998

17. Treatment Options for BPPV
Epley’s
Sermont’s
Habituation exercises (Brandt-Daroff)
Cervical adjusting

18. Modified Epley’s Maneuver
Patient placed supine with head turned 45 degrees toward the affected ear (30 sec.)
Dr. turns head 90 degrees so affected ear is up. (30 sec.)
Patient rolls on to side, head looking toward the floor (30 sec.)
Patient is lifted into sitting position
Procedure is repeated until no nystagmus

19. Modified Epley Maneuver
Dizziness,Hearing Loss, and Tinnitis R.W. Baloh, F.A. Davis Company 1998

20. Sermont’s Maneuver Patient can be instructed to do this at home.
Patient turns head 45 degrees away from the affected side
Quickly lays down maintaining head position (4 minutes)
Brought up and placed on other side with same head position. (4 min) Sit up normal

21. Archives Otolaryngol Head Neck Surgery, Vol 119, p452, 1993
Sermont’s Maneuver
Archives Otolaryngol Head Neck Surgery, Vol 119, p452, 1993

22. Post Maneuver Instructions
Patient waits 10 min. before leaving office.
Other person drives them home.
Sleep half-reclined 2-3 days.
Avoid laying on bad side.
Avoid extreme head extension for 2-3 days

23. Cervicogenic Vertigo Hx of neck trauma, muscle spasm
Limited cervical ROM
Positive chair rotation test (Fitz-Ritson)
Patients may complain of dysequilibrium (tilt) more than rotational vertigo
Overstimulation of upper cervical proprioceptors
May overlap BPPV or Meniere’s disease

24. Vertebrobasilar Insufficiency TIA’s
Vertigo with associated Neurological signs
Diplopia
Ataxia
Drop attacks
Dysarthria
Paralysis/weakness/Numbness
Headache
Risk factors (HTN, Diabetes, Coronary Disease)

26. Meniere’s Disease
Sudden and recurrent (paroxysmal) attack of severe vertigo (4th leading cause)
Low-tone hearing loss
Low-tone tinnitis
Sense of fullness in the ear
Vertigo lasts for hours to a day then burn out
Hearing loss may progress

27. Cause of Meniere’s Overproduction or retention of endolymph
Possible autoimmune etiology
Head trauma
Previous infection
Pregnant females are more prone

28. Management of Meniere’s
Salt-restriction diet
Diuretic therapy
Cervical adjusting (overlaps with cervicogenic vertigo

29. Perilymphatic Fistula
Hx of barometric pressure changes (airplane or weight lifting)
Opening develops between middle and inner ear (oval window rupture)
Rare cause of vertigo
Bearing down reproduces s/s
Tx - surgical

31. Labyrinthitis Sudden severe vertigo that last days to weeks
Maybe nausea and vomiting
Viral infection - no hearing loss
Bacterial infection hearing loss

32. Acoustic Neuroma Mild but constant hearing loss
Dizziness with possible tinnitis
Gradual onset
Benign schwannoma of 8th CN
Other CN findings as tumor grows
Surgical excision

33. Cerebral Hemorrhage Sudden vertigo and nausea
Vomiting associated with a headache
Inability to stand
Nystagmus, nuchal rigidity, facial paralysis, ataxia, dysrythmia, small reactive pupils
Hx of HTN in 2/3 of patients

34. When to refer to a specialist
Serious vertigo that is disabling
Ataxia out of proportion to vertigo
Vertigo longer than 4 weeks
Changes in hearing
Vertical nystagmus
Focal neurological signs
Systemic disease or psychological origin
Australian Family Physician Vol. 31, No 8, August 2002