1 DIZZINESS AND VERTIGO JOSHUA F. SMITH, PA-C
2 Disclosures I am the chair of the NCAPA Professional Development Review Panel. I am a paid speaker for the NCAPA.
3 Learning Objectives 1. Understand the components needed for balance 2. Be able to perform a competent history and physical exam on a dizzy patient 3. Understand how timing and the duration of symptoms can help you narrow your differential diagnosis 4. Develop a working differential diagnosis list for the chief complaint of dizziness 5. Understand the different treatments for the different causes of dizziness
4 Case Report 77 year old female with dizziness presents to ED I felt all swimmy-headed, just.dizzy. Multiple tests are performed including: CT head EKG Cardiac enzymes and other labs Finally after hours in the ED, she was diagnosed with Vertigo. She was given a prescription for meclizine and told to follow up with her local ENT. DIAGNOSIS VERTIGO
5 Dizziness 1. You must take a thorough history. 2. You MUST take a thorough history. 3. It is appropriate to rule out serious causes first. 4. Vertigo is a SYMPTOM, not a diagnosis. 5. Meclizine will likely make your patient MORE dizzy, and should hardly ever be prescribed. 6. There is not one treatment for dizziness. Each individual condition has a unique treatment plan.
6 Epley Maneuvers Lifestyle Adjustment Rehab BPPV Adjust BP meds Fluids Cardio Multisensory Dizziness Orthostatic Hypotension Low Salt Diuretics Surgery Meniere's Dizziness Labyrinthitis Vestibular Rehab Cardiac Arrhythmia Acoustic Neuroma or Tumor Vestibular Migraine Rate control Ablation Surgery Radiation Triptan Beta Blocker Neuroleptic
7 BALANCE VESTIBULAR SYSTEM THE MECHANISM OF BALANCE
8 The Vestibular System
9 Components of Balance Vestibular system Visual input Peripheral nervous system Central nervous system Motor output
10 Each balance component relies on the others CNS Proprioception Vestibular Vision Somatosensory Peripheral Neuropathy Stroke Parkinson s Vestibular Meniere s Labyrinthitis Neuroma Visual Cataracts Retinopathy Macular Degeneration
11 Vestibular Suppressants Meclizine, Diazepam, Scopolamine Block neurotransmitters which carry signal from peripheral organ to the central nervous system Only for acute vertigo which last at least 1-2 hours NOT indicated for lightheadedness, disequilibrium or brief episodes of vertigo Long-term use impedes the compensation process and recovery is much longer Interferes with vestibular testing
12 WHAT IS DIZZINESS? LIGHTHEADEDNESS DISEQUILIBRIUM VERTIGO
13 Dizziness The complaint of dizziness is very non-specific. Many people experience dizziness in a different way and have a hard time describing their symptoms. It is important to try to the sensation that the patient is really experiencing: Lightheadedness Disequilibrium Vertigo
14 Lightheadedness The feeling that you are about to faint Usually occurs after sitting up or standing up If no loss of consciousness pre-syncope If loss of consciousness syncope Usually a sign of cardiovascular dysfunction
15 Disequilibrium The sensation of being unable to walk straight Feeling like you are going to fall over Generalized imbalance without vertigo Intolerance to quick movements
16 Vertigo A hallucinatory sensation of motion Rotational spinning Elevator moving up or down Ground rocks back and forth
17 DIFFERENTIAL DIAGNOSIS OF DIZZINESS NEUROLOGIC CARDIOVASCULAR OTOLOGIC
18 Differential Diagnosis Cardiologic Orthostatic hypotension Arrhythmia CAD Neurologic Stroke/TIA Parkinson s Peripheral Neuropathy Migraine Brain tumor Hematologic Anemia Psychologic Panic Attack Metabolic/Endocrine Hypothyroid Menopause Hormone induced migraines Orthopedic Cervical disc disease Arthritis (back, hips, knees) Geriatric Loss of vision Loss of proprioception Loss of strength Loss of center of balance Otologic BPPV Meniere s Disease Vestibular Neuronitis Labyrinthitis Vestibular concussion Perilymphatic Fistula Superior Semi-circular canal dehiscence Acoustic neuroma Pharmacologic Polypharmacy/side effects
19 CARDIOLOGIC DIZZINESS ORTHOSTATIC HYPOTENSION VASOVAGAL SYNCOPE CARDIAC ARRHYTHMIA
20 Orthostatic Hypotension Occurs when patient stands up too fast Blood pressure changes 20mmHg drop in systolic pressure 10mmHg drop in diastolic pressure Sudden onset of dizziness Pre-syncope/lightheadedness Tachycardia Tunnel vision Can lead to actual syncope
21 Vasovagal Syncope Recurrent lightheadedness and syncope caused by a specific trigger Vasodilation and/or decreased heart rate leads to hypotension which decreases blood flow to brain. The patient will pass out and fall, thus restoring blood flow to the brain. Symptoms: Lightheadedness, nausea, hot/cold sensation, sweating, tinnitus, tunnel vision Treatment: Avoid triggers Increase pressure in impending syncope Avoid anti-hypertensives Increase fluids and sodium before impending trigger.
22 Cardiac Arrhythmia Atrial fibrillation SVT, PVCs, many more Symptoms: Lightheadedness Dizziness Fluttering Pounding Chest Shortness of breath Chest discomfort Pre-syncope/Syncope Cardiology consult
23 NEUROLOGIC DIZZINESS VESTIBULAR MIGRAINE MULTI-SENSORY DIZZINESS
24 Vestibular Migraines Migraine with aura Vasoconstriction phase leads to neurologic symptoms: Vertigo Photophobia Nausea Tinnitus Vasodilation phase causes headache (of any severity)
25 Multi-sensory Dizziness Often seen in elderly or diabetic patients Due to peripheral neuropathy, vision loss and/or vestibular dysfunction Will feel constantly off-balance, difficulty making quick movements Proprioception CNS Vestibular Vision Falls at night Treat with PT, vision correction if possible, use of cane or walker, lots of patient education
26 OTOLOGIC DIZZINESS BPPV MENIERE S LABYRINTHITIS ACOUSTIC NEUROMA
27 Benign Paroxysmal Positional Vertigo Caused by displaced otoliths Episodic vertigo lasting <30 seconds Provoked with head movements, rolling in bed, looking up or bending over Positive Dix-Hallpike Treated with Epley maneuvers
28 Meniere s Disease Not well defined disorder, possibly due to increased endolymphatic fluid pressure Classic symptoms: Vertigo with: Episodic low frequency SNHL Tinnitus Treatment: Aural fullness and pressure Low sodium diet ( mg/day) Diuretic Diazepam or meclizine for vertigo
29 Vestibular Neuronitis Acute Labyrinthitis Viral infection of the inner ear Vestibular neuronitis: vertigo only Labyrinthitis: vertigo and SNHL Vertigo is severe, lasting hours After vertigo, severe imbalance for 1 week Several weeks to months of gradually improving imbalance Treat sudden SNHL with prednisone Treat imbalance with physical therapy
30 Acoustic Neuroma Rare, slow growing benign tumor Arises from Schwann cells of vestibular nerve. Symptoms: Asymmetric SNHL Asymmetric tinnitus Chronic worsening imbalance Diagnosed with MRI of internal auditory canal Treatment: Stereotactic radiation Surgical excision
31 TAKING A PROPER HISTORY OF A DIZZY PATIENT
32 Pointers. Allow the patient an opportunity to briefly explain their symptoms. Start at the onset and work towards today. Quality: Vertigo vs. Lightheadedness vs. Disequilibrium Vertigo duration and frequency (more on this later) Medications (HTN, Prostate, Vestibular Suppressants) Associated symptoms: Hearing loss or tinnitus associated? Is there any positional influence? Headache, photophobia, nausea Palpitations Near-syncope or Syncope
33 Precipitating Symptoms Rolling over in bed, tilting head up Standing up too fast Loud noises Medication use Darkness/eyes closed Mechanical fall
34 DURATION OF SYMPTOMS FLEETING SECONDS MINUTES HOURS DAYS CONSTANT
35 Duration/Frequency of Dizziness This is the most important question to ask and understand. You want to know how long the patient experiences sustained vertigo. This one piece of information will help to cut your large differential diagnosis into easier to manage fractions. It is important to understand when associated symptoms occur in time with the dizziness.
36 Fleeting With head movements: Old vestibular weakness Paroxysmal: Heart palpitations With standing: Orthostatic hypotension
37 Seconds Usually BPPV Provoked by head movements Lasts less than 30 seconds 10 Severity Asymptomatic 0 1 Week 4 Weeks 1 year
38 Minutes 5-20 minutes of vertigo usually indicates either: Migraine symptom Transient ischemic attack Severity minutes Headache Photophobia Nausea Scotomata Tinnitus Hyperacusis Slurred speech Facial paralysis Loss of vision 1 week
39 Hours Usually caused by Meniere s Symptoms last anywhere from 20 minutes to 24 hours Usually 2-8 hours Severity Vertigo Hearing Loss Tinnitus Aural fullness Vertigo Hearing Loss Tinnitus Aural fullness Vertigo Hearing Loss Tinnitus Aural fullness Hours 1 month 2 months 3 months
40 Days Vertigo lasting hours is usually an inner ear infection: Acute labyrinthitis Vestibular Neuronitis The next week will have severe disequilibrium Severity Vertigo Severe Disequilibrium Gradual Resolution hours 1 week??
41 Constant Patients who complain of persistent vertigo longer than 48 hours usually are not actually having constant vertigo. Usually they have: Severe disequilibrium or multi-sensory dizziness Episodic vertigo (like BPPV or migraines) occurring multiple times a day Severity Months Years
42 PHYSICAL EXAM GAIT AND BALANCE EARS EYES CRANIAL NERVES ORTHOSTATIC PRESSURE
43 Vital Signs For dizziness, the most important vital signs are: Blood pressure Does the patient have resting hypotension? Orthostatic blood pressures if indicated Pulse Tachycardia or bradycardia? Regular Rhythm?
44 Gait and Balance Watch patient walk into the room Unsteadiness Inability to walk a line Wheelchair? Romberg Testing Proprioception Vision Vestibular function
45 Ear exam Usually, inspection of the EAC and TMs are normal Dix-Hallpike can have a good yield if you suspect BPPV based on history
46 Neurologic exam Evaluate extra ocular mobility Look for spontaneous nystagmus Evaluate for sustained gaze evoked nystagmus Cranial nerve testing will help you determine the presence of: Tumor TIA/CVA
47 DIAGNOSTIC TESTING
48 Audiogram An audiogram shows cochlear function which can give an insight into the health of the vestibulo-cochlear system. Look for asymmetric SNHL or low-frequency asymmetric SNHL.
49 Videonystagmography Objective test which can determine if dizziness is vestibular or central in origin. The VNG will compare relative vestibular strength between ears using a cold/hot water stimulation, aka caloric testing. Additional tests include optokinetic and occulomotor testing, positional testing, evoked myopotential and rotary chair.
50 Magnetic Resonance Imaging Studies show that the use of CT brain scan in the emergency setting for the complaint of dizziness has an extremely low yield of finding the cause of the symptoms. MRI Brain with contrast has a much higher yield and can effectively evaluate for: Tumor of IAC, cortex and cerebellum Acute and chronic stroke Demyelinating disorders Chronic brain atrophy
51 CASE REPORTS
52 Case Report Audiogram 56 year old female Complaint of vertigo when lying down and rolling to the left or looking up Symptoms last 30 seconds and resolve Normal hearing on audiometric testing Dix-Hallpike LEFT BENIGN PAROXYSMAL POSITIONAL VERTIGO
53 Case Report 79 year old man Complains of positional vertigo Worse when sitting up in bed or when standing up Better when lying down No hearing loss Upon further questioning, feels lightheaded, no vertigo Dix-Hallpike Negative Orthostatic Blood Pressures Supine: 145/90 Sitting: 140/90 Standing: 115/80 ORTHOSTATIC HYPOTENSION
54 Case Report 35 year-old male Episodic vertigo for 6 hours Associated hearing loss in left ear and tinnitus Videonystagmogram Right ear warm caloric Audiogram Left ear warm caloric MENIERE S DISEASE
55 Case Report 49 year old female Complains of vertigo, every day, lasting 15 minutes Had severe migraines as a youth, but now says symptoms aren t consistent with that Has daily mild headache, photophobia and nausea Videonystagmogram Normal Vestibular Function Audiogram CT Head and Sinus No intracranial or sinus disease MIGRAINE HEADACHES
56 Case Report 65 year-old male 1 day ago had acute onset of severe, constant vertigo Unable to function Associated left tinnitus and ear fullness Audiogram Videonystagmogram ACUTE LABYRINTHITIS
57 Case Report Videonystagmogram 36 year old male Complaint of vertigo when lying down and looking straight back Symptoms last 30 seconds and resolve Generalized disequilibrium Normal hearing on audiometric testing MRI Brain w/ contrast CNS TUMOR: CEREBELLAR MASS LATER FOUND TO BE PILOCYTIC ASTROCYTOMA
58 THANK YOU
59 REFERENCES practice/monograph/73/diagnosis/step- by- step.html vestibular- disorder/human- balance- system hearing.org/disorders/acoustic- neuroma/ tests Wasay M, Dubey N, and Bakshi R. Dizziness and yield of emergency CT scan: Is it cost effective? Emerg Med J. April 2005; 22(4): arrhythmias/ drugs.html
60 REFERENCES Hypotension- And- General- Principles- In- Antihypertensive- Therap vgn/ anatomy- models.com/shop/3d- male- nervous- model vertigo- and- lightheadedness- a- discussion- of- possible- causes/ cranial- nerves- and- their- areas- of- innervation review/atrial- gibrillation/ Hearing/How- Read- Audiogram.htm vestibulara/ and- dizziness- tests/what- to- expect- during- a- videonystagmography- vng- test/ and- balance.com/disorders/tumors/acoustic_neuroma.htm