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A. Categories Related to Dizziness [2] navigator

  1. True Dizziness (Vertigo, rotational sensation)
  2. Light-Headedness (near-syncope, presyncope, impending faint)
  3. Imbalance (Disequilibrium)
  4. Psychogenic Dizziness
  5. Dizziness is a general term for a sense of disorientation
  6. Over 5 million clinic visits in USA in 1989 related to dizziness
  7. Nurse-based primary care vestibular training can substantially reduce chronic dizziness [3]

B. Vertigo (True Dizziness) [4,5] navigator

  1. Characteristics
    1. Episodic sense (illusion) of movement when none present
    2. Usually has rotational component, such as room spinning while sitting
    3. Manifestation of vestibular dysfunction
    4. Typically rotational, but may be illusion of tilting to one side or swaying
    5. Must be distinguished from brainstem or cerebellar ischemic syndromes
  2. Accompanying Symptoms
    1. Nystagmus nearly always present
    2. Tinnitus (buzzing or ringing) in ear - unilateral or bilateral
    3. Vertigo is usually accompanied by nausea (± vomiting)
    4. Hearing loss may occur
    5. Autonomic instability frequently accompanies true, acute vertigo
    6. Autonomic abnormalities doe not typically occur with other types of dizziness
  3. Pathophysiology
    1. Afferent inputs from otolith organs and semicircular canals of inner maintain balance
    2. Normally, these inputs are continuous firings onto the vestibular nuclei
    3. Asymmetrical alteration of the baseline continuous firings leads to vertigo
    4. Slow unilateral losses or bilateral loss typically does not produce vertigo
    5. Rapid head movements commonly induce vertigo by accentuating asymmetry
    6. Lesions of Vestibular Nerve
    7. Lesions of Labyrinth are usually with hearing deficits
    8. Symptoms also caused by inferior cerebellar or brainstem ischemia / stroke
  4. Distinguish causes by time course, duration, and recurrence of illusion of movement
  5. Common Causes of Prolonged Spontaneous Vertigo [5]
    1. Otomastoiditis - recurrent infections, ear pain
    2. Vestibular neuritis (neuronitis) - previous viral symptoms are common
    3. Labyrinthine concussion
    4. Lateral medullary infarction - usually with Horner's syndrome
    5. Cerebellar infarction
  6. Common Causes of Recurrent Vertigo [5]
    1. Meniere's Disease (see below)
    2. Autoimmune inner-ear disease
    3. Perilymph fistula
    4. Migraine
    5. Vertebrobasilar Insufficiency
    6. Benign positional vertigo [8]
  7. Vertigo Lasting One Day or Longer
    1. Usually vestibular neuritis
    2. Begins over period of few hours
    3. Peaks in 24 hours
    4. Improves within days to a week
    5. Recurrent, usually less severe, episodes may come and go
    6. Complete resolution in weeks to a month
    7. Preceded or associated with viral illness in <50% of patients
  8. Vertigo Lasting Several Days to Weeks
    1. When cerebellar or brainstem ischemia or infarction involved, disabling vertigo persists over days to weeks without clear peak
    2. Resolution of infarction related symptoms takes many months and may be incomplete
    3. Nearly all cases with stroke associated with other evidence of vertebrobasilar disease
    4. Includes diplopia, reduced vision, dysarthria, dysphagia, focal neurological deficits
    5. Inferior cerebellar infarctions, however, may have limited associated symptoms
    6. Multiple sclerosis can also produce vestibular syndrome
    7. Careful evaluation of nystagmus can help differentiating causes of vertigo
    8. However, MRI evalation is required to clearly differentiate malignant causes of vertigo
  9. Vertigo Lasting for Hours or Minutes
    1. Meniere's Syndrome and Transient Ischemic Attacks (TIA) are most common causes
    2. In Meniere's Syndrome, vertigo usually preceded or accompanied by other symptoms
    3. Typical symptoms include reduced hearing, tinnitus, and feeling of pressure in ear
    4. Attacks usually recur in Meniere's Syndrome
    5. Abrupt onset of vertigo lasting for minutes is typical of TIA
    6. Angiographic (MRA) evaluation is generally indicated in these patients
  10. Vertigo Lasting for Seconds
    1. Abrupt onset of vertigo for seconds after rapid change in head position is BPV
    2. BPV (benign positional vertigo) is most common type of vertigo [8]
    3. BPV is caused by clot of free-floating debris, usually in posterior semi-circular canal
    4. Diagnosis is confirmed by induction of paroxysmal vertigo and nystagmus during physical
    5. This head tiling maneuver is described below

C. Causes of Vertigo navigator

  1. Peripheral - related to disorders of the vestibular end organ
    1. Benign Paroxysmal Positional Vertigo (BPV) - most common type of true vertigo [8]
    2. Motion Sickness
    3. Vestibular Neuronitis - also called viral vestibular neuritis
    4. Labyrinthitis - with acute hearing loss (also called neurolabyrinthitis)
    5. Meniere's Disease
    6. Post-Traumatic
    7. Labyrinthine Imbalance
    8. Autoimmune inner ear disease - Cogan Syndrome, others
  2. Central
    1. Brainstem Ischemia - especially from middle cerebral artery
    2. Inferior cerebellar stroke
    3. Multiple Sclerosis
    4. Posterior Fossa Tumors
    5. Basilar Migraine
    6. Acoustic Neuroma
  3. Acute Vestibular Syndrome [4]
    1. Severe vertigo
    2. Nausea and vomiting
    3. Spontaneous nystagmus
    4. Postural instability
    5. Most commonly casued by vestibular neuronitis, labyrinthitis, inferior cerebellar stroke

D. Treatment of Vertigo [5] navigator

  1. See below for additional evaluation
  2. Otomastoiditis - antibiotics, surgical removal of infection or cholesteatoma
  3. Vestibular neuritis (neuronitis)
    1. 3-week course of high dose glucocorticoids [9]
    2. Anticholinergics of symptomatic benefit but may delay healing
  4. Labyrinthine concussion - vestibular rehabilitation
  5. Lateral medullary infarction - control vascular disease risk factors aggressively
  6. Cerebellar infarction - heparin, control risk factors
  7. Meniere's Disease - diuretics, surgery, neurotoxin blockade
  8. Autoimmune inner-ear disease - high dose glucocorticoids
  9. Perilymph fistula - bed rest; surgical exploration
  10. Migraine - prophylaxis including ß-blockers, tricyclics, calcium blockers
  11. Vertebrobasilar Insufficiency - ticlopidine 250mg po bid, clopidogrel, warfarin

E. Light-Headedness navigator

  1. Near-syncope and syncope
    1. Cardiac - ECG must be checked (especially arrhythmias)
    2. Cerebrovascular Disease - especially postero-basilar insufficiency (though uncommon)
    3. Idiopathic Orthostatic Intolerance
    4. Central Nervous System Lesion - pupillary responses and optic disc exam
  2. Orthostatic Vital Signs [6]
    1. Volume Depletion - fluid and/or blood loss
    2. Autonomic Insufficiency
    3. Pulse increase >30 beats/min is specific but not very sensitive
    4. Capillary refill time and skin turgor are of no use in adults
    5. Serum electrolytes, renal function tests, and urine studies are most helpful
  3. Low Hematocrit
    1. Blood Loss - Stool Guaiac must be checked
    2. Production Problems
  4. Drug Effects
    1. Anti-hypertensives
    2. Anti-cholinergic agents
    3. Sedatives
  5. Idiopathic Orthostatic Intolerance
    1. Autonomic disorder
    2. Defined as >30 beats per minute increase in heart rate on standing, with symptoms, but with no change in blood pressure
    3. Mainly affects women in second to third decade of life
    4. Cerebral hypoperfusion appears to be present in all patients with this condition
    5. Abnormal vasoconstriction of cerebral blood vessels likely plays a role
    6. Adrenergic blockers may be effective in treating this disorder

F. Imbalance (Dysequilibrium)navigator

  1. Multiple Sensory Deficit
  2. Posterior fossa tumor
  3. Cerebellar Degeneration
  4. Abnormal vestibular system

G. Change in Mental Statusnavigator

  1. Patient reports, "I just don't feel good."
  2. Drug Effects
    1. Toxin Screens - both blood and urine
    2. Complete neurological examination (especially pupillary reflexes)
  3. Metabolic Disorders
    1. Hypoglycemia
    2. Hypoxemia
    3. Electrolyte Abnormalities
    4. Endocrine Abnromalities
    5. Renal and Liver Dysfunction
    6. B12 / Folate deficiency
  4. Infection
    1. Urinary Tract Infection - especially in elderly
    2. Meningitis
    3. Pneumonia

H. Psychogenic Dizziness navigator

  1. Often associated with psychiatric disorders
    1. Major Depression
    2. Anxiety Disorder
    3. Somatization Disorder
  2. Psychogenic dizziness is diagnosis of exclusion
  3. Hyperventilation which is often present in patients with psychogenic dizziness

I. Evaluation [1] navigator

  1. An attempt should be made to classify the patient into one of the FOUR categories
    1. True Dizziness (Vertigo)
    2. Light-Headedness (near-syncope)
    3. Imbalance (Disequilibrium)
    4. Psychogenic Dizziness
  2. History
    1. When does dizziness occur ? What is the duration ?
    2. Inquire about associated Neurologic and Otologic symptoms
    3. Symptom patterns - during activities, meals, urination, etc.
    4. Psychiatric evaluation with focus on depression or anxiety is essential
    5. The medical history provides probable diagnosis in ~75% of patients
  3. Vertigo should be separated from other causes [2]
    1. Is the dizziness present when standing ?
    2. Vertigo, near syncope (low cerebral perfusion) or disequilibrium: check blood pressure
    3. Unsteady while walking implies disequilibrium
    4. To distinguish disequilibrium from vertigo, check peripheral neuropathy, visual acuity,
    5. Always evaluate gait for ataxia
    6. Dizziness when turning head implies true vertigo
  4. Physical Exam
    1. Detailed Neurological and Ear examination
    2. Spontaneous Nystagmus - always abnormal
    3. Head-Hanging (Hallpike or Dix-Hallpike) Maneuver - positional nystagmus
    4. The Hallpike maneuver provides probable diagnosis in ~15% of patients with dizziness
  5. Dix-Hallpike Maneuver [8]
    1. Patient in sitting position, gazing at examiner's forehead
    2. Examiner firmly graps patient's head
    3. Patient should quickly (within 2 seconds) lie supine, head turned 30°, about 30° below exam table
    4. Observe patients eyes for 5-15 seconds to determine whether nystagmus has been induced on side of affected ear down
    5. Repeat on other side
    6. Sensitivity ~75% for benign positional vertigo
  6. Recommended Initial Laboratory
    1. Overall, laboratory tests are NOT helpful for evaluation of dizziness
    2. Of 4538 dizzy patients evaluated for etiologic causes, the following were found:
    3. Glucose disorders (11/4538), anemia (11/4538), electrolyte disorders (3/4538)
    4. Electrolyte panel with glucose
    5. Complete blood count (CBC) - particularly for hematocrit
    6. Cardiac evaluation should be performed to rule out arrhythmias - electrocardiogram
    7. Optional toxin screen
  7. Specialized Testing
    1. Audiograms - for dizzy patients with hearing complaints
    2. Can detect hearing loss in Menier's Disease and acoustic neuromas
    3. Electronystagmography - electrodes to detect nystagmus, high sensitivity, specificity
    4. Cardiovascular testing should be performed with near-syncope
    5. Non-invasive carotid artery testing is crucial as well in syncope, light-headedness
    6. Electroencephalography (EEG) should be considered if no underlying cause found
  8. Neuroimaging
    1. Generally indicated when a central cause of vertigo is suspected or focal signs found
    2. Brain stem or long tract signs
    3. Rotatory or vertical nystagmus
    4. Atypical Headache
    5. MRI is generally preferable to CT Scan
    6. Careful evaluation for atherosclerotic cerebrovascular disease is generally indicated
  9. Primary-care (nurse-) based vestibular training can significantly reduce chronic dizziness [3]

References navigator

  1. Hoffman RM, Einstadter D, Kroenke K. 1999. Am J Med. 107(5):468 abstract
  2. Drachman DA. 1998. JAMA. 280(24):2111 abstract
  3. Yardley L, Donovan-Hall M, Smith HE, et al. 2004. Ann Intern Med. 141(8):598 abstract
  4. Hotson JR and Baloh RW. 1998. NEJM. 339(10):680 abstract
  5. Baloh RW. 1998. Lancet. 352(9143):1841 abstract
  6. Jacob G, Atkinson D, Jordan J, et al. 1999. Am J Med. 106(1):59 abstract
  7. McGee S, Abernethy WB III, Simel DL. 1999. JAMA. 281(11):1022 abstract
  8. Furman JM and Cass SP. 1999. NEJM. 341(21):1590 abstract
  9. Strupp M, Zingler VC, Arbuscow V, et al. 2004. NEJM. 351(4):354 abstract