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King Khalid University College of medicine Department of family & community medicine Dizziness Prepared by : - Abdullah Alshehri - Fahd Alshehri -Mazen Alshahrani -Ali Almater -Abdurrahman Al qahtani - Abdullah Alammar - Khalid Aldossari Supervised by : Prof. Khalid S. Al-Gelban Clinical scenario . Mona Mohd. , a 43 old woman, she is housewife came to PHCC with chief complaint … Mona : dr. I sometimes felt dizzy in the last 2 months DR. : When you have dizzy spells, did you feel light-headed or do you see the world spin around you ? Mona : I feel the world spin over around me . DR : tell me about onset, frequency& severity .. Mona : well doctor, it started gradually before 2 months , and I feel dizzy 1 to 2 times a day , and it is not so severe . DR :for how long this dizzy reaming ? Mona : 2-3 hours . DR : any aggravating or relieving factor ? Mona : yes , aggravated by head movement and Relieved by bed rest . DR : tell me about the associated complaints ? Mona : sometimes .. Nausea and vomiting ? DR : is it associated with tinnitus or headache ? Mona : yes , tinnitus in my Rt. Ear , and no headache . DR: is it associated with any sort of deafness ? Mona : only a little pit I feel that in my Rt. Ear . DR; any ear discharge or feeling fullness in the ear ? Mona : No Any migraine headache ? Mona : No Any recent upper respiratory infection or fever ? Mona : No . Any head or ear trauma ? Mona : no Any sleep disturbance , loss of appetite , loss of interest ? Mona : No . Any previous angina , MI ? Mona : No Are you HTN , D.M. , smoker ? Mona : No Any medicine you use ? Mona : Sometimes Paracetamol . Any similar condition in your family ? Yes , my father complain from the same problem before one year , and now he is O.K. How to approach to the patient with dizziness ? Objectives Definition . Epidemiology . Classification ( according to patient history ) . Causes . DDx. Hx. Physical examination . Investigations Management Referral . Objectives Definition . Epidemiology . Classification ( according to patient history ) . Causes . DDx. Hx. Physical examination . Investigations Management Referral . Dizziness is defined as perception or sensation of oneself or one`s environment is moving or room spinning . It also refers to sensation of lightheadedness or faintness to spinning or a feeling of imbalance . Objectives Definition . Epidemiology . Classification ( according to patient history ) . Causes . DDx. Hx. Physical examination . Investigations Management Referral . Dizziness is common in : Elderly . Middle aged . Females . Psychiatric patients . Patients on drugs . Patients suffering from chronic diseases such diabetes and hypertension. 1- 5 % of the total visits to primary health care setting is due to dizziness. 15-25% of patients come to emergency departments with dizziness are admitted to hospitals . 5% of patients presented to primary health care with dizziness are referred to hospitals . Majority of the patients presenting to primary health care settings with dizziness are self-limited. Approximately , 33% of people suffer from dizziness by the age of 65 years and 50% of them will suffer from dizziness by the age of 80 years . Most of the patients presenting with vertigo to primary health care are due to peripheral causes . Objectives Definition . Epidemiology . Classification ( according to patient history ) . Causes . DDx. Hx. Physical examination . Investigations Management Referral . 1- vertigo : The main causes of vertigo are benign paroxysmal positional vertigo, Meniere disease, vestibular neuritis, and labyrinthitis . 2- disequilibrium : Parkinson disease and diabetic neuropathy should be considered with the diagnosis of disequilibrium 3- presyncope : Many medications can cause presyncope, and regimens should be assessed in patients with this type of dizziness . 4- lightheadedness : Psychiatric disorders, such as depression, anxiety, and hyperventilation syndrome, can cause vague lightheadedness Cause category of dizziness Pathophysiology Diagnostic criteria Benign paroxysmal positional vertigo Vertigo Loose otolith in semicircular canals causing a false sense of motion . Positive findings with Dix-Hallpike maneuver; episodic vertigo without hearing loss . Hyperventilation syndrome Lightheadedness Hyperventilation causing respiratory alkalosis; underlying anxiety may provoke the hyperventilation . Symptoms reproduced with voluntary hyperventilation . Meniere disease Vertigo Increased endolymphatic fluid in the inner ear . Episodic vertigo with hearing loss . Cont.. cause category of dizziness pathophysiology Diagnostic criteria Migrainous vertigo (vestibular migraine) vertigo Uncertain; one hypothesis is that trigeminal nuclei stimulation causes nystagmus in persons with migraine . Episodic vertigo with signs of migraine, plus photophobia, or aura during at least two episodes of vertigo . Orthostatic hypotension Presyncope Drop in blood pressure on position change causing decreased blood flow to the brain, adverse effect of multiple medications Systolic blood pressure decrease of 20 mm Hg, diastolic blood pressure decrease of 10 mm Hg, or a pulse increase of 30 beats per minute . Parkinson disease Disequilibrium Dysfunction in gait causing imbalance and falls Shuffling gait with reduced arm swing and possible hesitation Cont.. cause Category of dizziness pathophysiology Diagnostic criteria Peripheral neuropathy Disequilibrium Decreased tactile Decreased sensation response when in lower extremities, walking causes particularly the feet . patient to be unaware when feet touch the ground, leading to imbalance and falls . VERTIGO Otologic or vestibular causes of vertigo are the most common causes of dizziness, and include benign paroxysmal positional vertigo (BPPV), vestibular neuritis (viral infection of the vestibular nerve), labyrinthitis (infection of the labyrinthine organs), and Meniere disease (increased endolymphatic fluid in the inner ear). An estimated 35 percent of adults 40 years and older have vestibular dysfunction. Vertigo with hearing loss is usually caused by Meniere disease or labyrinthitis, whereas vertigo without hearing loss is more likely caused by BPPV or vestibular neuritis Episodic vertigo tends to be caused by BPPV or Meniere disease, whereas persistent vertigo can be caused by vestibular neuritis or labyrinthitis . Vertigo Central Peripheral Central No hearing loss No tinitus Causes : - cerbrovascular causes - MS . - Drugs (Vertebro-basillar insufficiency: severe vertigo hiccoughs dysphagia Dx: MRI ) Peripheral Associated with hearing loss and tinnitus. Mostly due to 8th cranial nerve etiology. Causes : - Benign Paroxysmal Positional Vertigo BPPV - Acoustic neuroma - Labyrinthitis - Menier’s disease - Perilymph fistula BPPV ONLY symptom is: VERTIGO. No hearing loss, No tinnitus. Comes when patient is getting up. Mostly due to otoliths ‘ear stones’. Dx: Dix-Hallpike test Rx: Positional maneuvers to dislodge the otoliths. The Epley maneuver. This maneuver is used to treat benign positional vertigo by returning displaced otoliths to the utricle. If vertigo occurs during any of the positions, that position is held until the vertigo subsides. Acoustic Neuroma Shwanoma of the 8th cranial nerve. Not related to patient’s position. Unilateral hearing loss Unilateral Tinnitus. ATAXIA. Dx: CT, MRI Rx: Surgery Labyrinthitis Not related to patient’s position. Hearing loss. Tinnitus. SINGLE episode. Recent VIRAL illness. Rx: self limited. Menier’s Disease Over-production of endolymph. Not related to patient’s position. Hearing loss. Tinnitus. MULTIPLE RECURRENT episodes. Rx: Low salt diet. Diuretics. Surgery. Perilymph Fistula Not related to patient’s position. Hearing loss. Tinnitus. Hx. of TRAUMA. Rx: Resolves spontaneously. Surgical repair. Migrainous vertigo or , vestibular migraine ,, is another underlying cause of vertigo that affects about 3 percent of the general population and about 10 percent of persons with migraine Diagnosis of migrainous vertigo is established in patients with a history of episodic vertigo with a current migraine or history of migraine and one of the following symptoms during at least two episodes of vertigo: migraine headache, photophobia, phonophobia, or aura. PRESYNCOPE Cardiovascular causes of dizziness include arrhythmias, myocardial infarction, carotid artery stenosis, and orthostatic hypotension. Of patients with supraventricular tachycardia, 75 percent experience dizziness and about 30 percent experience syncope. Symptoms brought on by postural changes suggest a diagnosis of orthostatic hypotension. Cardiac syncope MI: ECG & cardiac enzymes. Aortic stenosis: Echocariography. Arrhythmia: ECG . DISEQUILIBRIUM There are many underlying conditions that may cause a sense of imbalance. Stroke is an important and life-threatening cause of dizziness that needs to be ruled out when the dizziness is associated with other symptoms of stroke. However, other neurologic findings are generally present. In a population-based study of more than 1,600 patients, 3.2 percent of those presenting to an emergency department with dizziness were diagnosed with a stroke or transient ischemic attack (TIA), but only 0.7 percent presenting with isolated dizziness were diagnosed with stroke or TIA. Poor vision commonly accompanies a feeling of imbalance, leading to falls. The physician should inquire about a history of other problems that may cause imbalance, such as Parkinson disease, peripheral neuropathy, and any musculoskeletal disorders that may affect gait. Use of benzodiazepines and tricyclic antidepressants increase the risk of ataxia and falls in older persons. LIGHTHEADEDNESS Psychiatric causes of lightheadedness are common, particularly anxiety; therefore, questions about anxiety and depression should be included in the patient history. In one study, about 28 percent of patients with dizziness reported symptoms of at least one anxiety disorder. In another study, one in four patients with dizziness met criteria for panic disorder. Up to 60 percent of patients with chronic subjective dizziness have been reported to have an anxiety disorder. Depression and alcohol intoxication have also been found to overlap with dizziness. Hyperventilation syndrome is an important cause of lightheadedness. Although the condition can be associated with anxiety disorders, many patients without anxiety experience hyperventilation. Hyperventilation is defined as breathing in excess of metabolic requirements, causing a respiratory alkalosis and lightheadedness. Patients may sigh repeatedly and may have associated symptoms, such as chest pain, paraesthesias, bloating, and epigastric pain. Objectives Definition . Epidemiology . Classification ( according to patient history ) . Causes . DDx. Hx. Physical examination . Investigations Management Referral . what are the DDx. do you think ? Differential Diagnosis Acute life threatening : a. Cerebral hemorrhage (stroke). b. Myocardial infarction . c. Cardiac arrhythmia . Infectious : a. Acute neurolabyrinthitis. b. Acute vestibular neuritis. c. Neuro-syphilis. Serious: a. Brain tumors b. Drug overdose c. Severe depression. d. Aortic stenosis. e.Acoustic neuroma Metabolic: a. Hyperglycemia. b. hypoglycemia. c. hypothyroidism Psychiatric: a. depression. b. Anxiety c. Stress d. Panic attacks Ear causes: a. Benign positional vertigo b. otitis media c. Acute labyrinthitis d. meniere`s disease e. Acoustic neuroma. f. peri-lymphatic fistula . Central nervous system : a. stroke. b. Multiple sclerosis. c. Brain tumors. d. migraine. e. epilepsy. Objectives Definition . Epidemiology . Classification ( according to patient history ) . Causes . DDx. Hx. Physical examination . Investigations Management Referral . Identify • patient’s name • Age • Job • Marital status Explore chief complaint Clarify the complaint Is it true vertigo? Is it light headedness? Is it pre-syncope? Ask the patient , describe your feelings !? Is it disequilibrium? Vertigo: The patient feels perception or sensation of himself or his environment is moving or room is spinning (False sense of motion, possibly spinning sensation) . Light headedness: It is a vague floating sensation (feeling disconnected with the environment ) Pre-syncope: Feeling of an impending fainting but no loss of consciousness. Disequilibrium: An ability to keep balance usually associated with unsteady gait. Duration ? (second, minutes, hours, days) Frequency ? (acute, recurrent, chronic) Intensity ? (mild, moderate, severe) Aggravating factors ? (sitting, standing, rolling over, bending over) Relieving factors ? (sitting, standing, rolling over) Ask about the associated symptoms .. Neurological symptoms: o Headache (migraine) ? o Numbness, tingling ? o Blurring of vision ? o Body weakness ? o Par aesthesia ? • Ear symptoms: o Hearing loss (Deafness) ? o Tinnitus ? o Ear pain ? o Ear discharge ? Head & Neck: o Neck pain ? o Head trauma ? Cardiovascular & Pulmonary symptoms: o Chest pain ? o Palpitation ? o Dyspnea ? o Chronic cough ? General symptoms: o Fever ? o Weight loss ? o Nausea ? o Vomiting ? Assess for Risk factors Head trauma ? Age <60 years Coronary heart disease (CHD) ? Diabetes Mellitus ? Hypertension ? Drugs ? Sexuality ? Past history Similar attacks ? Head trauma ? Chronic Otitis Media ? Spondylosis ? Recent respiratory infections ? Head and neck surgery ? Family history Similar problem in the family ? Drug history Using drugs ? (What are they, dose, why?) Abusing drugs ? (What are they, dose, why?) Cardiac medications Alpha blockers (e.g., doxazosin [Cardura], terazosin) Alpha/beta blockers (e.g., carvedilol [Coreg], labetalol) Angiotensin-converting enzyme inhibitors Beta blockers Clonidine (Catapres) Dipyridamole (Persantine) Diuretics (e.g., furosemide [Lasix]) Hydralazine Methyldopa Nitrates (e.g., nitroglycerin paste, sublingual nitroglycerin) Reserpine Central nervous system medications Antipsychotics (e.g., chlorpromazine, clozapine [Clozaril], thioridazine) Opioids Parkinsonian drugs (e.g., bromocriptine [Parlodel], levodopa/carbidopa [Sinemet]) Skeletal muscle relaxants (e.g., baclofen [Lioresal], cyclobenzaprine [Flexeril], methocarbamol [Robaxin], tizanidine [Zanaflex]) Tricyclic antidepressants (e.g., amitriptyline, doxepin, trazodone) Urologic medications Phosphodiesterase type 5 inhibitors (e.g., sildenafil [Viagra]) Urinary anticholinergics (e.g., oxybutynin [Ditropan]) Psychosocial history Idea: What is the patient’s idea about dizziness? Concern: What is the patient afraid of? Expect: What are the expectations of the patient from his doctor to do? Effect: What are the effect of dizziness on sleep? Daily activity and work? Depressed mood: (take detailed history for depression) Stressed patient: (explore the reasons) Anxious: (look for reasons) Other hidden agenda Afraid of malignancy ? Wants sick leave ? Want further investigation such as MRI ? Objectives Definition . Epidemiology . Classification ( according to patient history ) . Causes . DDx. Hx. Physical examination . Investigations Management Referral . Physical Examination Aims: * To determine the diagnosis. * To reassure the patient. * To assess the severity of the condition. The main goal of the physical examination is to reproduce the patient's dizziness in the office General Examination * Blood Pressure: (supine, sitting, standing) look for postural hypotension. ( blood pressure should be measured while the patient is in a supine position and again at least one minute after the patient stands. A systolic blood pressure decrease of 20 mm Hg, diastolic blood pressure decrease of 10 mm Hg, or pulse increase of 30 beats per minute is indicative of orthostatic hypotension ) * Pulse: look for arrhythmia. * Temperature: high grade fever may indicate intracranial infections. • Signs of anemia and polycythemia pallor and congested face. Cardiovascular System * Bruit atherosclerosis. * Signs of aortic stenosis. * Arrhythmia. Ear, Nose and Throat: * Ear wax. * Hearing tests (Weber & rinne’s). Eyes: * Visual activity. * Nystagmus. Nervous System * Gait. * Coordination. * Muscle tone & power. * Reflexes. * Romberg test. * Finger-nose test. * Cranial nerves (2nd,3rd,4th,6th,7th). Head & Neck: * Head & neck local tenderness. * Cervical spine tenderness and range of movement. Special tests: * Forced hyperventilation test (20-25 breath/minute for 2 minutes). * Positional testing for benign positional vertigo (Dix-Hallpike maneuver). Dix-Hallpike maneuve A person is brought from sitting to a supine position, with the head turned 45 degrees to one side and extended about 20 degrees backward. Once supine, the eyes are typically observed for about 30 seconds. If no nystagmus ensues, the person is brought back to sitting. There is a delay of about 30 seconds again, and then the other side is tested. A positive Dix-Hallpike tests consists of a burst of nystagmus (jumping of the eyes Objectives Definition . Epidemiology . Classification ( according to patient history ) . Causes . DDx. Hx. Physical examination . Investigations Management Referral . Investigations: Asking for investigations will depend upon the probable diagnosis. * CBC (if you suspect anemia, polycythemia). * Fasting & random plasma sugar (hyper/hypoglycemia). * ECG (to rule out arrhythmia). * Audiometry (to rule in or rule out Menier’s disease). * Calori test (to confirm benign positional vertigo). * Plain x-rays (to rule out cervical spondylosis). * CT scan or MRI (stroke & brain tumers). * EEG (epilepsy). Audiometer Objectives Definition . Epidemiology . Classification ( according to patient history ) . Causes . DDx. Hx. Physical examination . Investigations Management Referral . Management of common conditions that present with dizziness # Acute vestibulopathy. # Benign paroxysmal positional vertigo (BPPV). # Menier’s disease. # Acute vestibulopathy: *usually preceded by viral upper respiratory tract infectoins. * Acute onset of vertigo. * Last hours to days. * Improves gradually. * No hearing loss or tinnitus. Cont. * Acute phase is associated with horizontal nystagmus. * Lie on the affected ear will limit the sensation of vertigo. * Has benign self limited course: No need for any treatment except reassurance. Diphenhydramine 50 mg every 4-6 hourly. # Benign paroxysmal positional vertigo (BPPV). * Affects all ages (mainly the elderly). * F > M. * Reccurs frequently for several days. * Attacks usually brief (lasts < 1 minute). * Not associated with nausea, vomiting, hearing loss or tinnitus. * The hearing test is normal. * Diagnosis is confirmed by Dix-Hallpike maneuver. Cont. * Recovery is common & will take place within a week. * Treatment includes: - Explanation. - Reassurance. - Positional vestibular exercise. - Drugs are not recommended. Menier’s disease * Occurs due to accumulation of endolymph. * Age: 30 – 50 years. * Triad of diagnosis are: vertigo, vomiting, and tinnitus. * Additional feature: progressive neurosensory deafness. * Acute onset. * Patients do not like head movement. * Nystagmus occurs during attacks. Cont. * Audiometry: reveals sensori-neural deafness (low tone). * Treatment includes: - Reassurance & explanation. - Reduce salt intake, coffee, tobacco. - Betahistidine 8 mg orally TID. - Hydrochlorothiazide 12.5 mg orally OD. - Surgery may be needed in special cases. Objectives Definition . Epidemiology . Classification ( according to patient history ) . Causes . DDx. Hx. Physical examination . Investigations Management Referral . Referral of patients with dizziness: Vertigo of uncertain diagnosis. Suspicion of tumor. Suspicion of stroke. Suspicion of chronic otitis media. Vertigo following head trauma. Menier’s disease. Benign positional vertigo that does not improve with home. Suspected cardiac causes.