“doctor i feel dizzy” aimgp seminar 2004 yash patel
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“Doctor I feel Dizzy”
AIMGP Seminar 2004Yash Patel
Objectives
Develop an approach to the evaluation of “dizziness”
Review EtiologyPrognosisDiagnostic EvaluationTreatment
Background
Acute Vestibular Syndrome NEJM 1998; 339:680-5
Vestibular Neuritis NEJM 2003; 348:1027-32
Benign Paroxysmal Positional Vertigo NEJM 1999; 341:1590-96
Vertigo Lancet 1998; 352: 1841-46
“Take Home Message”
Dizziness is a common symptomClinical 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 receptorsprovide a stable retinal image during movement
Proprioceptive receptorsprovide info on gravity, position, and motion of muscles and joints
Vestibular receptorsprovide 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
CausesBrainstem or cerebellar
infarctionPosterior fossa tumorsMultiple sclerosis
A. Vertigo
“Peripheral” (lesion of the labyrinth or VIII nerve)
vertigo ± auditory symptoms
CausesBenign Paroxysmal Positional
VertigoVestibular Neuronitis/LabyrinthitisMeniere’s SyndromePost traumatic or Ototoxicity
A. Vertigo
Aids to differentiate Central vs Peripheral
Nausea
and Vomiting
Imbalance
Hearing
Loss
Neurologic Symptoms
Compensation
Peripheral Severe Mild Common Rare Rapid
Central Moderate Severe Rare Common Slow
A. Vertigo
BPPVbrief episodes of vertigo with position
changeusually lasts < 30sidiopathic, after viral infection or traumano hearing change
Vestibular Neuronitissudden onset severe vertigo with nausea
and vomitinglasts hours to daysno hearing loss
A. Vertigo
Labyrinthitissudden onset severe vertigo with nausea
and vomitinglasts hours to daysassociated hearing loss or tinnitususually follows viral upper respiratory tract
infection
Menieresepisodic vertigolasts hoursfluctuating 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%)ArrhythmicObstruction to cardiac output
Noncardiovascular (45%)Vasovagalorthostaticpsychogenic
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 disorderdisruption 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. VertigoEyes for nystagmusAssess hearingSigns of brainstem involvementAble to walkHallpike maneuver (see next
slide)
B. PresyncopeCardiac and vascular examHeart rhythmOrthostatic blood pressure
Hallpike Maneuver
Physical Examination
C. Dysequilibrium
VisionSensation and PositionCerebellar testingGait
D. Ill-defined
No diagnostic physical signs
Special Tests
A. VertigoCentral: neuroimaging of brainstemPeripheral: audiometry,
electronystagmography
B. PresyncopeCardiac: ECG, Holter, EchocardiogramNoncardiac:Tilt table testing
Special Tests
C. DysequilibriumVisual testingNeuroimagingNerve conduction studies
D. Ill-definedPsychiatric evaluation
Treatment
Treatment can be considered in terms of three categories1. Specific
Treat the underlying cause
2. SymptomaticControl symptoms of vertigo, nausea and
vomitingAntihistamines (meclazine,
diphenhydramine)
Phenothiazines (CPZ)
Anticholinergic (scopolamine)
Treatment
3. RehabilitativeVestibular 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)
PrognosisMost symptoms were self limitedPersistent dizziness impaired quality of life
Diagnostic TestingRoutine 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
“I am dizzy”
Veritigo (sensation of motion)
Presyncope (sensation of fainting)
Dysequilibrium
(unstedy gait)
Ill-defined
Disturbance of vestibular function
Central
Peripheral
Decreased cerebral perfusion
Cardiac
Noncardiac
Neurologic disorder
Psychosocial disorder
Peripheral neuropathy
Central
Brainstem/Cerebellar infarctionPosterior fossa tumorsMS
BPPV/Vestibular neuritisLabyrinthitis/Meniere’sPost traumatic vertigo
ArrhythmiaAortic stenosis/HOCM
VasovagalOrthostatic
AlcoholDM/B12Drugs
Cerebellar diseasePosterior fossa tumorsExtrapyramidal disordersDrugs
DepressionAnxiety or Panic disorderPersonality disorderHyperventilation
Approach to Dizziness
“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
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