Doctor, I m Dizzy An Evidence-Based Approach to Diagnosing Dizziness Ronald H. Labuguen, M.D. Associate Clinical Professor Department of Family and Community Medicine University of California, San Francisco UCSF Annual Review of Family Medicine April 20, 2009 Objectives Be familiar with distinguishing clinical characteristics of common causes of dizziness Review elements of the history and physical examination that point to common causes of dizziness and vertigo Choose imaging studies helpful in the initial evaluation of dizziness and vertigo After this lecture participants will be able to Use an evidence-based approach to the workup of patients with dizziness Dizziness is... "a disturbed sense of relationship to space; a sensation of unsteadiness with a feeling of movement within the head." -Dorland s Medical Dictionary Dizziness: Common and Debilitating Common: 23% of all adults More common in older adults: 34% of adults 60+ yo Commonly debilitating: Persistent dizziness in 4% of all patients Severe incapacitation in at least 3% of all patients Nazareth I, Yardley L, Owen N, et al. Outcome of symptoms of dizziness in a general practice community sample. Fam Pract 1999; 16(6): 616-8. Kroenke K, Price RK. Symptoms in the community. Prevalence, classification, and psychiatric comorbidity. Arch Intern Med 1993; 153: 2474-80. Sloane P, Blazer D, George LK. Dizziness in a community elderly popluation. J Am Geratr Soc 1989; 37: 101-8 1
Most Common Causes Causes of Dizziness Peripheral vestibular disorders (35-55%) Benign positional paroxysmal vertigo (BPPV) Acute vestibular neuronitis (AVN) Labyrinthitis Ménière s disease Hoffman R, Einstadter D, Kroenke K. Evaluating dizziness. Am J Med 1999;107:468-478. Most Common Causes Psychiatric illness: anxiety (especially panic), depression Only cause in 9% of patients At least contributory in up to 25% Dizziness can be somatic complaint in depressed Asian patients Other Common Causes Central vestibular disorders (5%) Presyncope (2-16%) Dysequilibrium (1-15%) Prescription drug toxicity (2-10%) Sloane PD, Coeytaux RR, Beck RS, Dallara J. Dizziness: state of the science. Ann Intern Med 2001;134:823-832. Ardic FN, Atesci FC. Is psychogenic dizziness the exact diagnosis?. Eur Arch Otorhinolaryngol 2006; 263: 578-81. Lawson J, Fitzgerald J, Birchall J, et al. Diagnosis of geriatric patients with severe dizziness. J Am Geriatr Soc 1999; 47: 12-7. Hoffman R, Einstadter D, Korenke K. Evaluating dizziness. Am J Med 1999;107:468-478. Arnault DS, Kim O. Is there an Asian idiom of distress? Somatic Symptoms in Female Japanese and Korean Students. Arch Psychiatr Nurs. 2008 February ; 22(1): 27 38. Hoffman R, Einstadter D, Kroenke K. Evaluating dizziness. Am J Med 1999;107:468-478. 2
Less Common Causes Substance abuse Metabolic abnormalities Hepatic encephalopathy Electrolyte disturbances Systemic and upper respiratory infections Hypertension Trauma Anemia Alzheimer s disease Parkinson s disease Seizures Endocrine disorders Hoffman R, Einstadter D, Kroenke K. Evaluating dizziness. Am J Med 1999;107:468-478. Causes of Dizziness in Children Most common: Otitis media Chronic middle ear effusion Eustachian tube dysfunction Golz A, Angel-Yeger B, Parush S. Evaluation of balance disturbances in children with middle ear effusion. Int J Ped Otorhinolaryngol 1998; 43(1): 21-6 Less common: Benign paroxysmal positional vertigo of childhood Migraine Trauma Vestibular neuronitis Ménière s disease Bower CM, Cotton RT. The spectrum of vertigo in children. Arch Otolaryngol Head Neck Surg 1995; 121: 911-5 Many Patients have Multiple and/or Unknown Causes of Dizziness Multiple diagnoses are common, especially in older patients 10-25% remain undiagnosed Vertigo Overview of Common Causes Hoffman R, Einstadter D, Korenke K. Evaluating dizziness. Am J Med 1999;107:468-478. 3
Vertigo is...... a false sense of motion Usually rotatory, may be linear Half of all dizziness complaints Extensive differential diagnosis Most cases in primary care fall under relatively few diagnoses Kroenke K, Lucas CA, Rosenberg ML, Scherokman B, Herbers JE, Wehrle PA et al. Causes of persistent dizziness: a prospective study of 100 patients in ambulatory care. Ann Int Med 1992;117:898-904. Most Common Causes of Vertigo 93% of peripheral vertigo: Benign paroxysmal positional vertigo (BPPV) Acute vestibular neuronitis (AVN) Ménière s disease Other causes Drug-induced Psychological Cerebrovascular disease Migraine Hanley K, O Dowd T. Symptoms of vertigo in general practice: a prospective study of diagnosis. Br J Gen Pract 2002;52:809-812. Benign Paroxysmal Positional Vertigo (BPPV) a.k.a. Benign Positional Vertigo (BPV) Most common cause of vertigo in primary care Cause: stimulation of vestibular sense organs by otolith Posterior semicircular canal Lateral semicircular canal Clinical Characteristics of BPPV Main complaint = rotatory illusion Timing/duration: Brief episodes (seconds to few minutes) Variable lengths of time between episodes Recurrent episodes may occur over days to weeks Severity: May affect social/occupational functioning 4
Clinical Characteristics of BPPV (cont d) Aggravating factors: Changes in head position provoked symptoms Associated symptoms: May have nausea, usually not vomiting No hearing loss Epidemiology: Typically middle aged and older patients Twice as many females as males Acute Vestibular Neuronitis (AVN) a.k.a. vestibular neuritis, epidemic vertigo Nomenclature can be confusing; often confused with acute/viral labyrinthitis Cause: inflammation/stimulation of vestibular nerve caused by viral infection Clinical Characteristics of AVN Main complaint = severe constant vertigo Timing/duration: Relatively sudden onset Symptoms may resolve slowly over a few days Sometimes shorter recurrent attacks over days or weeks Clinical Characteristics of AVN (cont d) Aggravating factors: Head movement can worsen symptoms Associated symptoms Nausea; half of patients with vomiting Epidemiology Affects patients at any age 5
Ménière s Disease a.k.a. Ménière s syndrome Cause: Not well understood Endolymphatic hydrops pathological finding Saeed SR. Diagnosis and treatment of Ménière s disease. BMJ 1998:316:368-372. Clinical Characteristics of Ménière s Disease Main complaints = Vertigo associated with Hearing loss Fluctuating course of low, then high frequency sensorineural hearing loss Eventually progresses to permanent hearing loss Tinnitus Aural fullness Timing/duration: Episodes last several minutes to hours Waxing/waning course long-term Clinical Characteristics of Ménière s Disease (cont d) Drugs That Can Cause Vertigo Severity: Waxing then waning course Associated symptoms: Nausea, vomiting Pallor Sweating Epidemiology: Onset in early to mid adulthood Alcohol Aminoglycosides Anticonvulsants Phenytoin Antidepressants Antihypertensives Barbiturates Cocaine Diuretics Furosemide Nitroglycerin Quinine Salicylates Sedative/hypnotics Froehling DA, Silverstein MD, Mohr DN, Beatty CW. Does this dizzy patient have a serious form of vertigo? JAMA 1994;271:385-388. 6
Psychological Causes of Vertigo Anxiety Disorders Panic disorder Agoraphobia Yardley L, Owen N, Nazareth I, et al. Panic disorder with agoraphobia associated with dizziness: characteristic symptoms and psychosocial sequelae. J Nerv Ment Dis 2001; 189(5): 321-7. Cerebrovascular Disease Transient Ischemic Attack, Stroke Suspect in patients with risk factors Tobacco use Hypertension Diabetes mellitus Hypercholesterolemia Advanced age Clinical Characteristics of Some Strokes That Can Cause Dizziness Basilar artery stroke may initially present as isolated dizziness Posterior cerebral circulation repeated TIA s usually cause other neurological symptoms as well Anterior inferior cerebellar artery occlusion can cause dizziness and sudden unilateral hearing loss Migraine Headaches usually accompanied by other characteristic symptoms 30% of patients with migraine suffer vertigo 12% with classical migraine report vertigo as part of their aura Vertigo lasts minutes to hours Basilar migraines mimic vertebrobasilar insufficiency Cass SP, Furman JM, Ankerstjerne JKP, Balaban C, Yetiser S, Aydogan B. Migrainerelated vestibulopathy. Ann Otol Rhinol Laryngol 1997;106:182-189. 7
Important Points Diagnosing Dizziness Be familiar with common presenting scenarios History alone diagnoses 75% of patients Distinguish between vertigo and other forms of dizziness Know key questions to ask to distinguish between different causes of dizziness Know key physical examination techniques and findings Recognize serious causes of dizziness History History of the Present Illness Distinguish between vertigo and other forms of dizziness Spinning sensation suggests vertigo Evans JG. Transient neurological dysfunction and risk of stroke in an elderly English population: the different significance of vertigo and non-rotatory dizziness. Age Ageing 1990;19:43-49. 8
History: 3 Key Questions Timing/duration Aggravating factors Presence of associated symptoms Hearing loss Pain Nausea and vomiting Neurological symptoms Psychological symptoms History: Timing/Duration/Onset When does dizziness occur? Vertigo upon awakening associated with peripheral vestibular disorders Sudden or gradual onset? Inner ear cause associated with more sudden onset of vertigo Does severity vary over time? AVN: initially severe, then lessen over few days Ménière s disease: attacks progressively become more severe, then lessen in late stages of disease History: Timing/Duration/Onset How long do episodes last? If vertigo, the longer symptoms last, the more likely a central cause Several seconds to few minutes BPPV Hours Ménière s disease Migraine Weeks Psychogenic History: Aggravating Factors Positional change think BPPV Turning over in bed Bending over at the waist and then straightening up Hyperextending the neck Recent URI think AVN Psychosocial stress 9
History: Associated Symptoms Hearing loss Nausea and vomiting Neurological symptoms Psychological symptoms Pain History: Associated Symptoms Hearing Loss Common Causes Ménière s disease Progressive, cumulative hearing loss with each episode Associated with tinnitus, aural fullness Acute labyrinthitis History: Associated Symptoms Hearing Loss: Other Serious Causes Acoustic neuroma Progressive, unilateral hearing loss Associated with aural fullness Anterior Inferior Cerebellar Artery TIA or Stroke Sudden onset of hearing loss, unilateral Associated with other neurological symptoms History: Associated Symptoms Hearing Loss: Other Causes Herpes zoster oticus Associated with pain, unilateral facial nerve palsy Cholesteatoma Associated with ear drainage Otosclerosis 10
History: Associated Symptoms Nausea and Vomiting AVN BPPV History: Associated Symptoms Psychological Symptoms Vertigo Fainting Agoraphobic behavior Occupational disability Yardley L, Owen N, Nazareth I, et al. Panic disorder with agoraphobia associated with dizziness: characteristic symptoms and psychosocial sequelae. J Nerv Ment Dis 2001; 189(5): 321-7. History: Associated Symptoms Neurological Symptoms Weakness Dysarthria Vision changes Paresthesia Altered level of consciousness Ataxia Other changes in sensory and motor function History: Associated Symptoms Pain Acute middle ear disease Invasive disease of the temporal bone Meningeal irritation 11
Past Medical History Past Medical History Risk factors for cerebrovascular disease Medications Trauma Exposure to toxins Psychiatric history Psychosocial stressors Physical Examination: Three Key Systems Physical Examination Head and neck Cardiovascular Neurological 12
Physical Examination: Head and Neck Pneumatic otoscopy Vesicles (Ramsay-Hunt syndrome) Cholesteatoma Otosclerosis Physical Examination: Cardiovascular Orthostatics (blood pressure/pulse) Most useful to diagnose Moderate or severe dehydration Autonomic dysfunction However: Wide range of normal About 50% of elderly patients have positive orthostatic measurements may not be reproducible McGee S, Abernethy WB, Simel DL. Is This Patient Hypovolemic? JAMA 1999;281(11):1022-1029. Physical Examination: Cardiovascular (cont d) Schellong Test (100% specific) (+) test = systolic BP falls at least 20 mmhg while patient stands 10-20 min Causes of positive test: Postural orthostatic tachycardia syndrome (61% sensitive) Neurocardiogenic syncope (31% sensitive) Physical Examination: Cardiovascular (cont d) Carotid sinus stimulation May document arrhythmia Low yield: reveals arrhythmia in 6% in patients >60 yo w/ unexplained dizziness Theoretically potentially dangerous, but danger not borne out in studies Winker R, Prager W, Haider A, et al. Schellong test in orthostatic dysregulation: a comparison with tilt-table testing. Wien Klin Wochenschr 2005; 117(1-2): 36-41. Evans JG. Transient neurological dysfunction and risk of stroke in an elderly English population: the different significance of vertigo and non-rotatory dizziness. Age Ageing 1990;19:43-49. Kumar NP, Thomas A, Mudd P, et al. The usefulness of carotid sinus massage in different patient groups. Age Ageing 2003; 32(6): 666-9. 13
Physical Examination: Neurological Cranial nerves Sensorineural hearing loss (Weber, Rinné) Nystagmus: Often suppressed by visual fixation if caused by a peripheral vestibular disorder Try funduscopic examination in the dark Spontaneous horizontal +/- rotatory is consistent with AVN Vertical = 80% sensitive for vestibular nuclear or cerebellar vermis lesions Physical Examination: Neurological (cont d) Romberg s sign Consistent with vestibular and/or proprioceptive problem Not particularly useful in distinguishing between causes of dizziness Fife TD, Tusa RJ, Furman JM, et al. Assessment: vestibular testing techniques in adults and children: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2000; 55(10): 1431-41. Herr RD, Zun L, Mathews JJ. A directed approach to the dizzy patient. Ann Emerg Med 1989:18:664-672. Physical Examination: Neurological Dix-Hallpike Maneuver Diagnoses posterior semicircular canal BPPV Patient sits upright, then head turned 30-45 Patient focuses on examiner as s/he lies supine quickly (within 2 seconds) Onset of nystagmus or vertigo within 2-20 seconds, lasting up to 30 seconds = (+) test Nystagmus reverses direction when pt sits upright again Intensity of induced symptoms wanes with repeated maneuvers Physical Examination: Neurological Dix-Hallpike Maneuver (cont d) Videos Claymation video Computer animation 14
Physical Examination: Neurological Dix-Hallpike Maneuver (cont d) Dix-Hallpike maneuver (cont d): PPV 83%, NPV 52% for BPPV May not be as sensitive in older patients Variations on Dix-Hallpike maneuver Supine roll test lateral semicircular canal BPPV Side-lying test Hanley K, O Dowd T. Symptoms of vertigo in general practice: a prospective study of diagnosis. Br J Gen Pract 2002;52:809-812. Hoffman RM, Einstadter D, Kroenke K. Evaluating dizziness. Am J Med 1999;107:468-78. Bhattacharyya N, Baugh RF, Orvidas L et al. Clinical practice guideline: Benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 2008;139:S47-S81. Supine Roll Test Fife TD, Iverson DJ, Lempert T et al. Practice parameter: therapies for benign paroxysmal positional vertigo (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2008;70:2067-74 Treatment of BPPV Particle Repositioning Maneuver (PRM)/Canalith Repositioning (CRP) Epley maneuver (better evidence) Semont maneuver Superior to Brandt-Daroff exercises Antihistamines/benzodiazepines not recommended Fife TD, Iverson DJ, Lempert T et al. Practice parameter: therapies for benign paroxysmal positional vertigo (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2008;70:2067-74. Bhattacharyya N, Baugh RF, Orvidas L et al. Clinical practice guideline: Benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 2008;139:S47-S81. Treatments for BPPV: Epley Maneuver 15
Treatments for BPPV: Semont Maneuver Physical Examination: Neurological Other Qualitative Tests Head thrust test Patient fixates on target, then rapidly rotates head to one side 45 deg Saccadic eye movements after head turning may rule in unilateral semicircular canal dysfunction PPV 100%, NPV 68% in one study Oliva M, Martin Garcia MA, Bartual J, Ariza A, Garcia Teno M. The head-thrust test (HTT): physiopathological considerations and its clinical use in daily practice. Acta Otorrinolaringol Esp 1998;49:275-279. Physical Examination: Neurological Other Qualitative Tests (cont d) Hyperventilation x 30 sec May distinguish physical vs. psychogenic cause Can rule out hyperventilation syndrome (PPV 19%, NPV 99%) History and Physical: Other Evidence Based Pearls Herr RD, Zun L, Mathews JJ. A directed approach to the dizzy patient. Ann Emerg Med 1989:18:664-672. 16
Serious Causes of Dizziness Older age (>70), neurological deficit or lack of vertigo predicts a serious cause of dizziness (86% sensitivity) Serious causes of dizziness = Adverse effect of medication Central nervous system disease such as seizure or cerebrovascular disease (stroke, transient ischemic attack, vertebrobasilar insufficiency) Cardiovascular disease (arrhythmia, hypertension, pericarditis) Herr RD, Zun L, Mathews JJ. A directed approach to the dizzy patient. Ann Emerg Med 1989:18:664-672. Peripheral Vestibular Disorders Vertigo, vomiting or both and (+) Dix-Hallpike maneuver suggests peripheral vestibular disorder Specificity 94% PPV 85%, LR(+)=7.6 NPV 68%, LR(-)=0.6 Herr RD, Zun L, Mathews JJ. A directed approach to the dizzy patient. Ann Emerg Med 1989:18:664-672. Tests Not as Useful in Older Patients Weber and Rinné tests Dix-Hallpike maneuver Orthostatics Lawson J, Fitzgerald J, Birchall J, et al. Diagnosis of geriatric patients with severe dizziness. J Am Geriatr Soc 1999; 47: 12-7 Causes of Peripheral Vertigo In patients with peripheral vertigo, this matrix is accurate 60% of the time: Episodic Vertigo Persistent Vertigo Hearing Loss Ménière s disease Labyrinthitis No Hearing Loss BPPV AVN Kentala E, Rauch SD. A practical assessment algorithm for diagnosis of dizziness. Otolaryngol Head Neck Surg 2003;128:54-59. 17
Qualitative vs. Quantitative Vestibular Tests No evidence on sensitivity/specificity of qualitative vestibular tests vs. quantitative vestibular testing techniques Dizziness Associated With Panic Patients with panic attacks Those with dizziness report higher rates of Vertigo Fainting Agoraphobic behavior Occupational disability Yardley L, Owen N, Nazareth I, et al. Panic disorder with agoraphobia associated with dizziness: characteristic symptoms and psychosocial sequelae. J Nerv Ment Dis 2001; 189(5): 321-7. No routine testing is indicated in all patients with dizziness Diagnostic Testing: Evidence Based Pearls Study of dizzy patients in ED concluded: Check glucose levels in diabetic patients (to diagnose reactive hypoglycemia) Monitor cardiac rhythm in patients > 45 yo Certain low yield tests may be performed when indicated Qualitative vestibular tests Carotid massage Herr RD, Zun L, Mathews JJ. A directed approach to the dizzy patient. Ann Emerg Med 1989:18:664-672. 18
When to Order Neuroimaging Consider neuroimaging studies if: CNS or invasive otologic disease suggested by exam acute vertigo and high risk for cerebrovascular disease based on age and risk factors progressive hearing loss w/ abnormal speech reception thresholds Turski PA, Seidenwurm DJ, Davis PC, et al, Expert Panel on Neurologic Imaging. Vertigo and hearing loss. http://www.guideline.gov/summary/summary.aspx?doc_id=9602&nbr=005123&string=dizziness. [online publication]. Reston (VA): American College of Radiology (ACR) 2006; : 8 p. MRI Preferred over CT MRI preferred over CT in patients with sensorineural hearing loss and acute or intermittent vertigo patients with vertigo but without hearing loss or neurological findings MRI/MRA may be useful in patients with new-onset episodic vertigo lasting hours to days Turski PA, Seidenwurm DJ, Davis PC, et al, Expert Panel on Neurologic Imaging. Vertigo and hearing loss. http://www.guideline.gov/summary/summary.aspx?doc_id=9602&nbr=005123&string=dizziness. [online publication]. Reston (VA): American College of Radiology (ACR) 2006; : 8 p. Audiometry May distinguish Ménière s disease from migraine-associated vertigo Saeed SR. Diagnosis and treatment of Ménière s disease. BMJ 1998:316:368-372. Battista RA. Audiometric findings of patients with migraine-associated dizziness. Otol Neurotol 2004; 25(6): 987-92. Arrhythmia Monitoring Patient-triggered event recorders with continuous automatic arrhythmia detection are superior to 24 hour Holter monitoring or patient-triggered event recorders alone 24 hr Holter monitoring will miss over 1/2 of relevant arrhythmias Patient-triggered event recorders capture only about 1/6 of clinically relevant arrhythmias Balmelli N, Naegeli B, Bertel O. Diagnostic yield of automatic and patient-triggered ambulatory cardiac event recording in the evaluation of patients with palpitations, dizziness, or syncope. Clin Cardiol 2003; 26(4): 173-6. 19
When to Refer If a vestibular disorder is suspected but not confirmed by the clinical examination, consider neurology, neurotology, or otolaryngology referral An Evidence-Based Algorithm for the Diagnosis of Dizziness and Vertigo 20
Take-Home Points Recognize serious causes of dizziness Patients >70 years old, Presence of neurological deficit, or Non-vertigo dizziness Serious causes of dizziness Medication-related Neurologic Cardiac 21
Take-Home Points Perform the Dix-Hallpike maneuver to diagnose patients with a peripheral vestibular disorder (posterior semicircular canal BPPV). Take-Home Points In patients with vertigo, determine whether symptoms are episodic or persistent, and whether hearing loss is present, in order to distinguish between benign paroxysmal positional vertigo, vestibular neuronitis, labyrinthitis, or Ménière s disease. Take-Home Points In patients with vertigo, determine whether symptoms are episodic or persistent, and whether hearing loss is present, in order to distinguish between benign paroxysmal positional vertigo, vestibular neuronitis, labyrinthitis, or Ménière s disease. Episodic Vertigo Persistent Vertigo Hearing Loss Ménière s disease Labyrinthitis No Hearing Loss BPPV AVN Take-Home Points No routine tests are indicated in the diagnosis of dizziness, although Glucose levels should be checked in diabetic patients Cardiac rhythm should be monitored in patients >45 years old 22
Take-Home Points Magnetic resonance imaging is preferred for neuroimaging when indicated in patients with dizziness. References Labuguen RH. Initial Evaluation of Vertigo. Am Fam Physician 2006;73:244-51, 254. Labuguen RH. Dizziness. Essential Evidence Plus (online), in press. 23