Dizziness. Eric Kraus, MD!!
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1 Dizziness Eric Kraus, MD!!
2 Dizziness: General Common complaint! Open-ended questions! Categorize!» Dysequilibrium - Unsteady!» Lightheaded - As if you might pass out!» Vertigo - Sensation of movement!
3 Dizziness: Differential Vertigo! Dysequilibrium! Lightheaded! Peripheral!!!Abnormal sensory input!!vasovagal! Physiologic!! Visual loss or distortion!!orthostatic hypotension!! Benign positional vertigo! Vestibular/cochlear!!Cardiopulmonary! Vestibular neuronitis!! Peripheral neuropathy!!chf! Recurrent vestibulopathy! Spinal cord disease!!arrhythmia! Meniere s!!!abnormal central integration!valvular stenosis! Labyrinthine trauma!! Dementia!!!Subaortic stenosis(ihss)! Labyrinthine infarct!! Degenerative disease!!angina equivalent! C-P angle tumor!! Metabolic encephalopathy!tamponade! Otosclerosis!! Drug effects!!anemia/blood loss! Herpes zoster oticus!! Space occupying lesions!atrial myxoma! Cholesteatoma!! Temporal lobe epilepsy!!pulmonary embolism!! Perilymph fistula!! Postconcussive syndrome!pulmonary hypertension! Aminoglycoside ototoxicity! Vascular etiology!!hyperventilation syndrome! Central!!! Somatization disorder!!psychiatric!! Vertebrobasilar TIA!! Panic attack!!somatization disorder!! Cerebellar stroke!! Hyperventilation syndrome!panic attack!!! Brainstem stroke!!abnormal motor response!!carotid sinus sensitivity! Subarachnoid hemorrhage! Pyramidal tract disease!!glossopharyngeal neuralgia! Basilar migraine!! Extrapyramidal disease!!vertebrobasilar disease! Posterior fossa mass!! Cerebellar disease!!subclavian steal syndrome! Demyelinating disease!! Spinal cord disease!!vertebrobasilar TIA! Hyperventilation!! Peripheral neuropathy!!systemic mastocytosis! Vertiginous epilepsy!!!!!hypoglycemia!
4 Dizziness: Dysequilibrium Unsteadiness!» Usually standing! Cause!» Multifactorial!» Age!» Sensory, motor, or central integration! Treatment!» Correct cause?!» Medication review!» Balance exercises!» Walking aid!
5 Dizziness: Lightheaded Many of the causes result in low cerebral blood flow (presyncope)! Cause!» Cardiopulmonary!» Hypoglycemia!» Psychiatric!» Cerebrovascular insufficiency! Assoc. symptoms!» SOB!» Chest pain!» Tingling!» Tunnel vision!» Diaphoresis!» Pale color!» Gen weakness!» Nausea!
6 Dizziness: Vertigo Spinning! Vestibular system!» Nystagmus!» Constant vs positional!» Central vs peripheral! Work-up!» Exam!» Electronystagmogram!» MRI! Treatment!» Drugs! Benzodiazepine! Scopolamine! Other!» Repositioning!» Surgery!
7 Semicircular Canals
8 Vestibulo-ocular System Excitatory projections by canal Anterior! Posterior! Horizontal!
9 Dizziness: Vertigo Spinning! Vestibular system!» Nystagmus!» Constant vs positional!» Central vs peripheral! Work-up!» Exam!» Electronystagmogram!» MRI! Treatment!» Drugs! Benzodiazepine! Scopolamine! Other!» Repositioning!» Surgery!
10 Dizziness: Vertigo!Constant!Positional! Duration!>15 mins.!< 2 mins.! Movement!Worse!Worse!!!!!!
11 Dizziness: Vertigo!Peripheral!Central! Nystagmus!Uni-directional!Uni- or multi-directional!! (Horiz, horiz/rot, vert/rot)! Vertical only!no!yes! Rotational only!no!yes! Assym of eyes!no!yes! Pendular!No!Yes! N/V!Yes!Yes! Central features!no!yes! Tinnitus/hearing!Sometimes!Unusual! Fixation!Inhibits nystag!no change! Head thrust!correction!no correction usually!! (ipsilateral)!!!
12 Head Thrust Head Thrust Video! v=bmncehn61gm&feature=related!
13 Flow Chart Vertigo Constant Positional Peripheral Central Peripheral Central Physiologic Vestibular neuritis Meniere s Vascular Demyelinating Migraine Hyperventilation Trauma BPPV Trauma Demyelinating Vascular
14 Dizziness: Vertigo Spinning! Vestibular system!» Nystagmus!» Constant vs positional!» Central vs peripheral! Work-up!» Exam!» Electronystagmogram!» MRI! Treatment!» Drugs! Benzodiazepine! Scopolamine! Other!» Repositioning!» Surgery!
15 Case!A 27 year-old male complains of dizziness starting 3 hours ago that is becoming more severe. He describes spinning. Your exam is remarkable for horizontal nystagmus to the right no matter which way he looks. There are no other findings.!! A. Vestibular neuritis! B. Benign positional vertigo! C. Meniere s disease! D. Central vertigo (e.g. stroke, MS)!
16 Acute Peripheral Vestibulopathy Vestibular neuritis!» Without auditory symptoms! Labyrinthitis!» With auditory symptoms! Clinical!» Sudden onset!» Constant!» Unidirectional nystag!» Fixation helps!» Days to weeks! Viral?!» Valacyclovir* not helpful! Treatment!» Steroids* acutely! Prednisone 120mg qd with 3 wk taper!» Valium!» Scopolamine!» Anti-emetics! *Strupp, et. al. NEJM 2004;351:354!
17 Case!A 67 year-old female complains of recurrent spinning that lasts 2-12 hours. She also has tinnitus and hearing loss in the right ear. Your exam in the office does not reveal nystagmus while she is asymptomatic. There are no other findings.!! A. Vestibular neuritis! B. Benign positional vertigo! C. Meniere s disease! D. Central vertigo (e.g. stroke, MS)!
18 Meniere Disease Clinical!» Fluctuating/progressive hearing loss!» Fluctuating tinnitus!» Episodic vertigo! Minutes to hours! May result in baseline dysequilibrium!» Aural fullness!» Sudden falls w/o loss of consciousness Otolithic catastrophe of Tumarkin!» Unilateral usually. Bilateral 20-40%!
19 Meniere Disease Pathophysiology!» Endolymphatic hydrops!» Endolymph and perilymph mix! Audiogram!» Low frequency hearing loss! ENG!» Reduced vestibular response on the affected side! Imaging!» MRI can rule out rare acoustic neuromas, MS and Chiari malformation!
20 Meniere Disease Treatment!» Low salt diet!» Avoid caffeine, alcohol, nicotine!» Diuretics!» Steroids!» Valium, anti-nausea drugs!» Surgery (various)!
21 Case!A 32 y.o. male feels dizzy several times a day when he moves his head to the left. He describes a spinning sensation that lasts 1 minute with the environment moving from left to right. The exam reveals nystagmus with head maneuvers. There are no other findings.!! A. Vestibular neuritis! B. Benign positional vertigo! C. Meniere s disease! D. Central vertigo (e.g. stroke, MS)!
22 Benign Positional Vertigo Etiologies!» Head injury!» Viral!» Idiopathic! Canalolithiasis!» Calcium deposit in a semicircular canal!» 90% posterior canal! Clinical!» Positional nystagmus!» Hallpike maneuver! Treatment!» Epley maneuver!
23 Utricle and Otoliths
24 Cupula
25 BPV: Canal Type Canal! Posterior!Freq!Nystagmus!!90%!Geotropic torsional upbeat! Horizontal!6%!Horizontal direction changing! Anterior!4%!Ageotropic torsional downbeat!
26 Hallpike-Dix disorders/bppv/dix%20hallpike.htm!
27 Left Posterior Canal BPV Hallpike maneuver! Nystagmus:!Geotropic torsional!!upbeat!
28 BPV Right ear BPV
29 Left Epley 4 positions! 1st position is Hallpike! 1! 2! secs. in each position! Nystagmus may be seen in any position.! 80% effective the first time. Repeat if fails.! Reverse for right ear! 3! 4!
30 BPV Epley Maneuver
31 Case!An 82 year-old male presents to the ER by ambulance after sudden onset left hemiparesis, dysarthria, right face numbness, and dizziness. He describes the feeling of falling forwards since onset about 30 minutes ago. Your exam demonstrates upbeat nystagmus in addition to weakness and numbness.!! A. Vestibular neuritis! B. Benign positional vertigo! C. Meniere s disease! D. Central vertigo (e.g. stroke, MS)!
32 Case!A 67 year-old male presents to the ER with acute onset dizziness, nausea, and vomiting since onset 30 minutes ago. PMH significant for HTN, DM, ASCVD, and hyperlipidemia. Your exam shows mild horizontal nystagmus to the right only, and inability to walk.!! A. Vestibular neuritis! B. Benign positional vertigo! C. Meniere s disease! D. Central vertigo (e.g. stroke, MS)!
33 Acute Ischemic Vestibular Syndrome Clinical!» Stroke risk factors!» Inability to walk!» Headache!» Fixation doesn t help!» Central features! **May not be present! Location!» Brain stem!» Cerebellum! Brain imaging!» MRI is best!
34 END
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