dizziness

Heba Al-thuwaini – Bayan AlsultanGroup : 1

dizziness

Learning objectives

• What is vertigo and dizziness ?

• What are the causes of dizziness?

• What is the approach to reach the diagnosis?

• Mention steps and findings in examination of dizziness case ?

• Mention the investigation for a dizziness case?

• What is the treatment in the above case?

Case summary

A 45 years old female

presents with the primary

complaint of being “ dizzy ”

• Dizziness is the feeling of being lightheaded,

woozy, or unbalanced.

Dizziness

Types Of Dizziness

Vertigo 54% Disequilibrium

Pre-syncope

syncope

• Vertigo: sensation of movement either of the patient or of the surroundings.

• Disequilibrium: sensation of imbalance.

• Pre-syncope : Sense of impending fainting .

• Syncope: sudden transient loss of consciousness with

concurrent loss of postural tone .

Types Of Dizziness

Causes of dizziness

Vertigo Disequilibrium

Pre-syncope syncope

Systems That Maintain Balance

vision

proprioceptors

Vestibular labyrinth

Causes of vertigo

Peripheral Causes of vertigo

• Benign paroxysmal positional  vertigo (BPPV) :

20%

• vestibular neuronitis (labyrinthitis):15%

• Meniere’s disease:10%

• Drugs (aminoglycosides)

Benign paroxysmal positional vertigo (BPPV)

• BPPV is caused by particles in the semicircular canals which alter endolymph flow

• It may be due to minor  head injury  or because of repetitive head movement

• symptoms sometimes occur at night during movement whihe asleep

•   vertigo = Less than one minute

• BPPV is common in women than men.

Vestibular neuritis : 

• This is inflammation of the vestibular nerve, possibly due to viral infection.

• This inflammation disrupts the transmission of sensory information from the ear to the brain.

• Vertigo Associated with severe nausea and vomiting

• vertigo = Longer than one day. 

Meniere’s disease : 

• It caused by increased volume of endolymph in the semicircular canals.

• psychological factors such as  stress can act as a trigger  mechanism for an  attacks.

• Vertigo = less than one day and more than one minute.

• Associated symptoms : 

• Tinnitus

•   fluctuating hearing loss (  unilateral )

• Nausea & vomiting 

Central causes of vertigo

• Vascular disease ( vertebrobasilar insufficiency): 50% of central causes

• Demyelinating (Multiple sclerosis)

• Drugs (anticonvulsants, alcohol, hypnotics)

Vertebrobasilar Insufficiency

• Is a condition where there is an insufficient delivery of blood flow via the vertebral and/or basilar arteries to the brain.

• The vertebrobasilar system supports the occipital lobes, which are responsible for vision, and the  cerebellum, which is responsible for balance and coordination.

Multiple Sclerosis (MS):

•  Is an immune system disease that affects the central nervous system. 

• A lesion or lesions in the brain stem or  cerebellum, the area of the brain that controls balance & coordinate visual, spatial and other input to the brain needed to produce and maintain equilibrium, May cause vertigo.

 

Causes of Disequilibrium

• Common in the elderly people.

• caused by Multisensory disorder due to any combination of:

•peripheral neuropathy

•visual impairment

•musculoskeletal disorder interfering with gait

•vestibular disorder

Causes of Pre-syncope

• Caused by psychiatric disorders:

•Major depression 25%

•Generalized anxiety or panic disorder 25%

•Somatization disorder

•Alcohol dependence

•Personality disorder

•Hyperventilation

Causes of Syncope

• Drop in blood pressure (orthostatic hypotension).

• Inadequate output of blood from the heart.

• Dehydration

• Low blood sugar

The approach to reach the diagnosis

• History alone reveals the diagnosis in roughly three out of four patients complaining of dizziness

1- Taking History

What to ask!

1- ask patient what he mean by “ I’m dizzy” ?

2- Or ask the patient questions to identify the type of dizziness.

What to ask!

3- When did the dizziness occur and the duration of it?( Help to differentiate between the types of vertigo ).

4- Was is it associated with other symptoms? (Tinnitus, hearing loss , nausea and vomiting.)

5- Are there certain body position that cause the dizziness?

6- Did it occur after performing certain activates ?

What to ask!

Medical history

1. Determine if the patient has a condition such as:

• Vascular disease • Multiple sclerosis • Cardic disease• Hypertntion• Or recent viral upper repiratory infection.

2- Ask the patient about the drug history.

3- Determine if the patient had an ear surgery.

• Family history .

Physical examination

• Review of vital signs : BP (supine and standing), HR, presence of fever, irregular pulse.

• Ear examination : Examine the tympanic membrane for vesicles

or cholesteatoma.

Weber’s test

Hearing tests:

Rinne test

Rinne Test

Weber’s test

Romberg test Gait test Dix-Hallpike maneuver

Examining Vestibular system :

Fukuda test Finger-nose test Tandem walking

•Electronystagmography (ENG) - tests vestibular function by using electrodes to detect nystagmus.

•Frenzel goggles

Examining eye function

• Patients with sudden ongoing attacks, should have:

pulse oximetry Glucose test Pregnancy test

Investigation

Further investigations include

ECG MRI Audiological

evaluation

• Laboratory tests tests such as electrolytes, glucose, blood counts, and thyroid function tests are rarely helpful.

• Except for patients with chronic vertigo and bilateral hearing loss.

Treatment and Management

• Treatment is directed at the cause, including

stopping, reducing, or switching any

causative drugs.

• If a vestibular disorder is present and thought to

be secondary to active Meniere disease or

vestibular neuronitis or labyrinthitis, the most

effective vestibular nerve suppressants are

(diazepam). Antibiotics are rarely needed.

• Meniere disese diuretics & low salt diet.

• vestibular rehabilitation therapy – for recurrent vertigo secondary to unilateral vestibular weakness

• Vertigo associated with (BPPV) is treated with the Epley maneuver (otolith repositioning).

Complication

• Patients with frailty are at significant risk of falling with consequent fractures;

• their fear of moving and falling often significantly decreases their ability to do daily activities.

Dizziness is neither predictable nor preventable. However, we have some guidelines:

• Avoid reading while traveling if it makes you feel sick.

• Relaxation techniques can help ward tension and anxiety that can cause dizziness.

• Changes to the diet can also cut down on episodes of dizziness.

• People with menier’s disease may avoid episodes of vertigo by cutting salt, alcohol and caffeine out of their diets.

Prevention

Simple self-care tips that can lower you dizziness:

•Dizziness is always a symptom of danger and it is

better to consult the doctor immediately.

•Drink plenty of fluids.

•Have regular meals.

•Get plenty of rest.

•Practice relaxation by yoga or meditation.

Summary

Reference

www.merckmanuals.comwww.ncbi.nlm.nih.govwww.aan.comwww.dizziness-and-balance.com

Any QUISTIONS !!