“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