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“Doctor I feel Dizzy”
AIMGP Seminar 2004
Yash Patel
Objectives
Develop an approach to the evaluation of
“dizziness”
Review
Etiology
Prognosis
Diagnostic Evaluation
Treatment
Background
Acute Vestibular Syndrome NEJM 1998;
339:680-5
Vestibular Neuritis NEJM 2003; 348:102732
Benign Paroxysmal Positional Vertigo
NEJM 1999; 341:1590-96
Vertigo Lancet 1998; 352: 1841-46
“Take Home Message”
Dizziness is a common symptom
 Clinical History is very important in
determining the “Type” of dizziness
The Prognosis for most patients is good
Investigations are helpful only in selected
patients
Real Cases…
 Case A
 61 M
 Sudden onset
dizziness, sweating,
blurred vision
 Wobbling when
walking, holding on to
things
Case B
79 F
“Weak and dizzy”
Episodic dizziness and
“roaring in the ear”
 Felt unsteady on her
feet




Real Cases…
 Case A
 Nystagmus horizontal
gaze, no diplopia
 Broad based gait
 Positive Romberg sign
 Normal motor and
sensory exam
 CT head normal
 Case B
 CN II-XII normal
 Normal motor and
sensory exam
 Cerebellar testing
normal
 Gait was broad based
Background
 Dizziness is a non-specific term used by
patients to describe symptoms
 It is a common symptom
 7 million clinic visits/year in U.S.
 Dizziness can represent many different
overlapping sensations
 Caused by different pathophysiologic
mechanisms
Mechanism of Balance
 Visual receptors
provide a stable retinal image during movement
 Proprioceptive receptors
provide info on gravity, position, and motion of muscles
and joints
 Vestibular receptors
provide info on the direction and speed of motion
Mechanism of Balance
 Integration of receptor information at the
vestibular nuclei and cerebellum
 Perception of balance is the role of cortical
integration and interpretation of signals
 Dizziness results when a mismatch occurs
between these receptors or levels of the
balance system
Approach to Dizziness
History
 important to ask open-ended questions and listen to
the description of symptom
Symptom Based Approach
(Drachman and Hart, Neurology; 1972)
 Proposed a “complaint-oriented” approach to
classifying patients with dizziness
 Although symptoms are described differently by each
patient they can be classified into one of four
categories
Four symptom categories
A. Sensation of Motion (vertigo)
B. Sensation of Impending Faint (pre-syncope)
C. Sensation of Losing one’s balance (dysequilibrium)
D. Ill-Defined Lightheadedness (not A,B,C)
A. Vertigo
 Experience an illusion of motion between self
and environment.
 Perception that the world is moving or the body
is moving
 Usually accompanied with excessive autonomic
activity (Nx/Vx, pallor, diaphoresis)
 Disturbance of vestibular function
 “Central”: lesions of brainstem or cerebellum
 “Pheripheral”: lesions of labyrinth or VIIIth nerve
A. Vertigo
“Central”
(lesions of brainstem or cerebellum)
 Vertigo is NOT the dominant symptom
 Signs/symptoms of brainstem or cerebellar
involvement
Causes
Brainstem or cerebellar infarction
Posterior fossa tumors
Multiple sclerosis
A. Vertigo
“Peripheral”
(lesion of the labyrinth or VIII nerve)
 vertigo ± auditory symptoms
Causes
Benign Paroxysmal Positional Vertigo
Vestibular Neuronitis/Labyrinthitis
Meniere’s Syndrome
Post traumatic or Ototoxicity
A. Vertigo
Aids to differentiate Central vs Peripheral
Nausea Imbalance Hearing Neurologic Compensation
and
Loss
Symptoms
Vomiting
Peripheral
Severe
Mild
Common
Rare
Rapid
Central
Moderate
Severe
Rare
Common
Slow
A. Vertigo
BPPV
brief episodes of vertigo with position change
usually lasts < 30s
idiopathic, after viral infection or trauma
no hearing change
Vestibular Neuronitis
sudden onset severe vertigo with nausea and
vomiting
lasts hours to days
no hearing loss
A. Vertigo
Labyrinthitis
sudden onset severe vertigo with nausea and
vomiting
lasts hours to days
associated hearing loss or tinnitus
usually follows viral upper respiratory tract infection
Menieres
episodic vertigo
lasts hours
fluctuating hearing loss, tinnitus
A. Vertigo
 Vertigo lasting day or longer
 Vestibular neuritis, labyrinthitis
 Brainstem/Cerebellar infarction
 MS
 Vertigo lasting hours or minutes
 Meniere’s
 TIA or Migraine headache
 Vertigo lasting for seconds
 BPPV
B. Presyncope
 Involves the patient’s perception that they
are about to faint
 Can be associated with Nx, pallor,
diaphoresis, or narrowing of visual field
B. Presyncope
 No difference in the DDx of presyncope and
syncope
Cardiovascular (20%)
Arrhythmic
Obstruction to cardiac output
Noncardiovascular (45%)
Vasovagal
orthostatic
psychogenic
Unknown (35%)
C. Dysequilibrium
 Sensation of losing one’s balance without
a feeling of illusionary movement
 Typically patients do not report symptoms
sitting or lying, but notice unsteadiness
standing or walking
C. Dysequilibrium
Neurologic disorder
disruption in the integration of sensory inputs and motor output
 Causes
 Peripheral neuropathy
 alcohol, drugs, DM, B12
 Central




C-P angle or posterior fossa tumors
Cerebellar degeration
Extrapyramidal disorders (Parkinson’s)
Drugs (carbamazepine, phenytoin)
 Multiple sensory deficits (decreased vision and sensation)
D. Ill Defined Lightheadedness
 Vague sensation not characteristic of
vertigo, pre-syncope, or dysequilibrium
 Psychophysiologic dizziness
 impaired central integration of sensory signals
 Psychiatric disorders primary cause of
nonspecific dizziness
D. Ill Defined Lightheadedness
 Causes
 Major depression (25%)
 Generalized anxiety or panic disorders (25%)
 Somatization disorders
 Alcohol dependence
 Personality disorders
Focus of Evaluation
Type of Dizziness
Focus of Evaluation
A. Vertigo
Auditory and vestibular system
B. Presyncope
Cardiovascular system
C. Dysequilibrium
Visual, peripheral and central
nervous system
D. Ill-defined
Psychosocial issues
Physical Examination
A. Vertigo
B. Presyncope
Eyes for nystagmus
Assess hearing
Signs of brainstem involvement
Able to walk
Hallpike maneuver (see next slide)
Cardiac and vascular exam
Heart rhythm
Orthostatic blood pressure
Hallpike
Maneuver
Physical Examination
C. Dysequilibrium
Vision
Sensation and Position
Cerebellar testing
Gait
D. Ill-defined
No diagnostic physical signs
Special Tests
A. Vertigo
Central:
Peripheral:
neuroimaging of brainstem
audiometry, electronystagmography
B. Presyncope
Cardiac:
ECG, Holter, Echocardiogram
Noncardiac: Tilt table testing
Special Tests
C. Dysequilibrium
Visual testing
Neuroimaging
Nerve conduction studies
D. Ill-defined
Psychiatric evaluation
Treatment
 Treatment can be considered in terms of three
categories
1. Specific
Treat the underlying cause
2. Symptomatic
Control symptoms of vertigo, nausea and vomiting
Antihistamines (meclazine, diphenhydramine)
Phenothiazines (CPZ)
Anticholinergic (scopolamine)
Treatment
3. Rehabilitative
Vestibular exercises to stimulate “dizziness” is
necessary for compensation to occur
Physiotherapy
Etiology, Prognosis, and
Evaluation
(Hoffman, Am J Med. 1999)
Etiology (most common etiologies)
Peripheral vestibular (35-55 %)
Psychiatric (10-25 %)
Cerebrovascular disease (5 %)
Brain Tumors (< 1%)
History and Physical lead to diagnosis in 75 %
Etiology, Prognosis, and
Evaluation
(Hoffman, Am J Med. 1999)
Prognosis
Most symptoms were self limited
Persistent dizziness impaired quality of life
Diagnostic Testing
Routine lab testing as well as cardiovascular and
neurologic testing had a low yield in unselected
patients
Back to Cases…
 Case A
 61 M
 Sudden onset
dizziness, sweating,
blurred vision
 Wobbling when
walking, hold on to
things
Case B
79 F
“Weak and dizzy”
Episodic dizziness and
“roaring in the ear”
 Felt unsteady on her
feet




Back to Cases…
 Case A
 Nystagmus horizontal
gaze, no diploplia
 Broad based gait
 Positive Rhomberg sign
 Normal motor and
sensory exam
 CT head normal
 Dx: Vestibular Neuronitis
 Case B
 CN II-XII normal
 Normal motor and
sensory exam
 Cerebellar testing
normal
 Gait was broad based
 Dx: Menieres
Approach to Dizziness
Veritigo
(sensation
of motion)
Presyncope
(sensation
of fainting)
Disturbance
of vestibular
function
Decreased
cerebral perfusion
“I am
dizzy”
Dysequilibrium
(unstedy gait)
Ill-defined
Neurologic
disorder
Psychosocial
disorder
Central
Brainstem/Cerebellar infarction
Posterior fossa tumors
MS
Peripheral
BPPV/Vestibular neuritis
Labyrinthitis/Meniere’s
Post traumatic vertigo
Cardiac
Arrhythmia
Aortic stenosis/HOCM
Noncardiac
Vasovagal
Orthostatic
Peripheral
neuropathy
Alcohol
DM/B12
Drugs
Central
Cerebellar disease
Posterior fossa tumors
Extrapyramidal disorders
Drugs
Depression
Anxiety or Panic disorder
Personality disorder
Hyperventilation
“Take Home Message”
 Dizziness is a common symptom
 Clinical History is very important in
determining the “Type” of dizziness
 The Prognosis for most patients is good
 Investigations are helpful only in selected
patients