Medical Approach to Dizzy Patients

Bastaninejad, Shahin, MD, Otolaryngologist & Head and Neck Surgeon

Presentation Outlines Introduction

History Physical Examination Para-clinical issues Differential Diagnosis

–

Non-systematized Dizziness

–

Vertigo

• •

Peripheral Central

Introduction

• Dizziness is the third most common complaint among all outpatients.

• The single most common among patients older than 75 yrs.

complaint • Encompasses: neurologic weakness, impairment, presyncope, vertigo, visual disturbance, and psychologic illness.

Presentation Outlines

Introduction

History

Physical Examination Para-clinical issues Differential Diagnosis

–

Non-systematized Dizziness

–

Vertigo

• •

Peripheral Central

History

• Does the patient experience a spinning sensation? This sensation is classic for true vertigo (vestibular end vestibular nerve, vestibular nuclei).

organs, • Is the patient experiencing vomiting ?

(usually have disease) • Are any associated present?

nausea and labyrinthine auditory symptoms

• What is the timing of the dizziness? Does it completely resolve between attacks?

• Are any neurologic symptoms the dizziness? (also visual) associated with • Drug history.

• Past medical, surgical, family, psychiatric history and social history.

– Vascular problems, such as coronary artery disease or carotid artery disease, suggest certain causes of dizziness.

– Headaches dizziness … may suggest migraine-associated

• Central Vs. Peripheral Vertigo: – Vertigo, which is peripheral in origin, often presents as severe, intense attacks that last several seconds to minutes.

– A central etiology is more concerning in patients who describe mild symptoms that are gradual in onset and last several weeks to months.

Presentation Outlines

Introduction History

Physical Examination

Para-clinical issues Differential Diagnosis

–

Non-systematized Dizziness

–

Vertigo

• •

Peripheral Central

Physical Examination

• Blood pressure (check for orthostatic) & PR and Heart Rhythm (ECG).

• Ear  otoscopy, audiogram.

• Eye  fundoscopy, iris reactivity, motion, Saccadic and persuade examination.

• Complete cranial nerve (CN) evaluation.

• Auscultate the heart and carotids.

• Evaluate the balance function: – Head-thrust and head-shake tests – Dix-Hallpike maneuver (A positive result is suggestive  BPPV) – Fistula test (perilymph fistulas) – Cerebellar function should be assessed (finger-to-nose and heel-to-shin, Gait should be observed) – Romberg test (proprioceptive)

Maneuver:

Presentation Outlines

Introduction History Physical Examination

Para-clinical issues

Differential Diagnosis

–

Non-systematized Dizziness

–

Vertigo

• •

Peripheral Central

Para-clinical Issues

• hemoglobin and hematocrit levels.

• thyroid function tests (T4 and TSH).

• antinuclear antibodies.

• fasting glucose.

• cholesterol levels.

• rheumatoid factor.

• tests for syphilis (FTA-ABS and VDRL).

• Radiographic imaging: – in patients with suspected retrocochlear abnormalities – in patients who demonstrate equivocal results in other studies – all patients who have new-onset vertigo or neurologic findings (although not indicated in younger patients who have a clear peripheral cause)

MRI +/- Gd, Brain CT, …

• Audiometery : in all patients.

• Electronystagmography ( ون روتساپ ) – It’s standard of objective assessment of vestibular function.

– ENG provides the examiner with information regarding the site of the lesion – If the patient’s nystagmus is worsened by fixation , a central focus of a pathologic condition should be suspected.

ENG

– Although direction-fixed positional nystagmus is nonlocalizing, it is more likely to represent peripheral vestibular disease than central vestibular disease.

– Direction-changing positional nystagmus is nonlocalizing; it can present with either central disease or peripheral disease – Electronystagmography does, however, have limitations.

It fails vestibulospinal tracts .

to assess the

• Rotational testing – The rotary chair is large and expensive, making it impractical for many otolaryngologists.

• Computerized dynamic posturography: – this is primarily a test of functional abilities rather than a test to determine site of lesion.

– Can be done in the clinic with the Romberg test.

Presentation Outlines

Introduction History Physical Examination Para-clinical issues

Differential Diagnosis

–

Non-systematized Dizziness

–

Vertigo

• •

Peripheral Central

Differential Diagnosis

• Nonsystematized dizziness • Vertigo – Peripheral – Central Vertigo: …Sense of motion. These symptoms are generally brought on by disturbance to the vestibular end organs and the retrocochlear pathways

Presentation Outlines

Introduction History Physical Examination Para-clinical issues Differential Diagnosis

–

Non-systematized Dizziness

–

Vertigo

• •

Peripheral Central

Nonsystematized dizziness

• Proprioceptive system abnormalities – Pt. May have Ataxia too • chronic alcoholism • Vitamin deficiencies due to malnutrition • Pernicious anemia • Syphilis (tabes dorsalis)

• Eye abnormalities – If visual compromise is suspected, tests for visual acuity should be performed – Complaints of diplopia should be investigated – In glaucoma often complain of dizziness is secondary to visual change

• Cerebral anoxia – complain of lightheadedness (not while sitting or lying down) – Anemia – Arteriosclerosis – Orthostatic hypotension: • Shy-Drager syndrome (which classically has associated autonomic changes).

• Drug induced (e.g., atenolol).

• Infection – meningitis or encephalitis also syphilis • Tumors: – Tumors affecting the cochlea and retrocochlear pathways may present with whirling symptoms (vertigo) – Tumors in other parts of the CNS often present with nonspecific dizziness

• Trauma – Labyrinthine concussion – Blasts – Barotrauma • Metabolic abnormalities – thyroid dysfunction – pregnancy – Menstruation – Exogenous hormones – Hypoglycemia

• Migraines – Often, migraine headaches are associated with auras of dizziness or also vertigo .

– Acetazolamide has been particularly effective in prophylactic treatment of the patients who have vestibular symptoms associated with migraine.

• Epilepsy – Generalized absence seizures

• Psychogenic (chronic anxiety): – Complaints are often vague, numerous , and out of proportion to the physical findings.

– In other patients, panic attacks manifest as sudden intense fear or discomfort and reach a crescendo within 10 minutes.

– They are frequently associated with brief episodes of dizziness, nausea, shortness of breath, chest tightness, paresthesias, and diaphoresis.

– Physical examination findings in patients who have psychogenic disorders are often dramatic.

Presentation Outlines

Introduction History Physical Examination Para-clinical issues Differential Diagnosis

–

Non-systematized Dizziness

–

Vertigo

• •

Peripheral Central

Peripheral Vertigo

• Foreign bodies and cerumen in the external ear • Otitis media with effusion • Acute suppurative otitis media – These patients are at risk for hearing loss (Toxic Labyrinthitis) • Eustachian tube dysfunction • Cholesteatoma

• Benign paroxysmal positional vertigo (BPPV) – patients report attacks caused by turning in bed or watching traffic while sitting in a car.

– This condition is fatigable . generally have a positive Hallpike maneuver .

– Antihistamines tend to decrease the symptoms but should be used minimally because they delay the process of fatigue.

% successful

• Vestibular neuritis – a complication of an upper respiratory tract infection.

– The virus is postulated to affect the vestibular nuclei and causes sudden and severe vertigo, nausea, and vomiting.

– The attacks are sudden and generally resolve after a couple of weeks.

Auditory symptoms are absent.

– treatment centers around bedrest and pharmacologic suppression of the vestibular symptoms and Cotricosteroids .

• Vascular causes (inner ear)  Vestibular artery and/or Common Cochlear artery.

Anterior – sudden, debilitating vertigo.

– Vascular occlusion or hemorrhage is often accompanied by tinnitus and sudden hearing loss.

• Endolymphatic hydrops – The most common form of endolymphatic hydrops is

Meniere ’s disease

.

Meniere ’s

– Classic triad of tinnitus, fluctuant sensorineural hearing loss, and vertigo.

fullness Aural is another classic complaint in these patients.

– Most of these patients initially have vertigo ; the other symptoms may develop later.

– The vertigo attacks may progress over the course of minutes to an hour for up to several hours.

and may persist – The associated sensorineural hearing loss generally demonstrates a lowfrequency deficit on audiometry, which is characteristic for this condition.

– Although the disease starts unilaterally, up to 40% of patients may develope bilateral auditory symptoms.

– Medical Treatment: Greater than 90% of patients with Meniere ’s disease respond well to medical management: • restrict daily salt intake to 1.5 g/d • Avoid Smoking and caffeine • Diuretics • Vestibular suppressants (dimenhyrinate,…) • Acute attacks: Hospitalization, Diazepam, Antiemetics, rehydration.

Promethazine,

most common causes of otogentic vertigo

Presentation Outlines

Introduction History Physical Examination Para-clinical issues Differential Diagnosis

–

Non-systematized Dizziness

–

Vertigo

• •

Peripheral Central

Central Vertigo

• Cerebellar hemorrhage: – hemorrhage in posterior fossa can lead to rapid compression and compromise of vital medullary functions, obstructive hydrocephalus, or herniation of the medullary tonsils.

• Brainstem ischemia: – AICA: lateral cerebellum, the pons, and the labyrinth – PICA: medulla cerebellum  Wallenberg and the dorsolateral ’s Syndrome

• Vertebrobasilar insufficiency: – most commonly visual disturbance, drop attacks, unsteadiness, or weakness and also central vertigo.

• Management of Vertigo (algorithm) : Algorithm