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Kirsten Bonnin, M.M.S., PA-CASAPA Fall Conference
October 5, 2019
Head Spinning??Evaluation of Dizziness
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Learning Objectives
Describe the pathophysiology of vertigo
Discuss the etiologies of vertigo
Compare and contrast peripheral and central vertigo
Discuss the diagnostic studies used in the evaluation of vertigo
Discuss clinical presentation and management of various causes of vertigo
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Presenting Problem
Dizziness
Whirling
Twisting
Turning
Rotating
Tilting
Moving
Rocking
Disequilibrium
Imbalance
Unsteadiness
Wooziness
Floating
Lightheadedness
Disorientation
Nearly blacked out
Presyncope
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Vertigo
• Vertigo is a symptom
• Defined as a sensation of motion, when there is no motion or exaggerated sense of movement
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May be associated with nystagmus and postural
instability
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Differential Diagnosis for Vertigo
o Anxiety disorder
o Arrhythmia
o Benign paroxysmal positional vertigo (BPPV)
o Cardiogenic (heart failure, tamponade, aortic stenosis)
o Cerebellar degeneration, hemorrhage, or tumor
o Cerebrovascular ischemia or stroke
o Dehydration
o Eustachian tube dysfunction/middle ear effusion
o Hypoglycemia
o Herpes zoster oticus
o Labyrinthine concussion
o Medication-induced
o Ménière disease
o Motion sickness/disembarkmentsyndrome
o Multiple sclerosis
o Neurocardiogenic (neurally mediated syncope, postural tachycardia syndrome)
o Orthostatic hypotension
o Ototoxicity (medication)
o Perilymphatic fistula
o Parkinson disease
o Peripheral neuropathy
o Syphilis
o Vestibular migraine
o Vestibular neuritis
Etiologies of Vertigo
40% Peripheral vestibular dysfunction
10% Central brainstem vestibular dysfunction
15% Psychiatric disorder
25% Other (presyncope, disequilibrium)
10% Uncertain
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UpToDate
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Peripheral causesImplies vestibular (otologic) dysfunction
Central causesImplies central (brainstem) dysfunction
Vestibular system: Vestibular apparatus in the
inner ear Vestibular nerve Nucleus within medulla Connections to/from vestibular
portions of cerebellum
Central vestibular dysfunction: Vestibular nuclei (superior,
inferior, lateral, medial)
Synapse with numerous pathways (cerebellar, oculomotor, posterior column, proprioceptive, vestibulospinal)
Peripheral vs. Central causes
Pathophysiology of Vertigo
Illusion of motion (most commonly spinning)
Asymmetry of the vestibular system
Visual-vestibular conflict
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https://en.wikipedia.org/wiki/Semicircular_canals
Clinical presentation: Peripheral vs. Central
Peripheral
o Usually sudden, acute onset; may be severe
o Associated ear symptoms Hearing loss, tinnitus
o Nystagmus can be horizontal and/or torsional (rotary)
o Neurologic symptoms are absent
Central
o May be gradual and progressive
o Rare to have associated ear symptoms
o Nystagmus can occur in any direction; can be dissociated in the two eyes (often vertical, nonfatigable)
o Neurologic symptoms are present Diplopia, ataxia, dysarthria
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Clarify what the patient means by “dizziness”
Vertigo: sensation of abnormal movement; often spinning +/- sense of tumbling, falling forward/backward
Disequilibrium: sense of imbalance (i.e. losing balance without
sensation of movement); +/- gait difficulty Usually multifactorial
Explore contributing factors (e.g. visual acuity changes, peripheral neuropathy, degenerative joint disease)
Lightheadedness: vague and nonspecific dizziness May be associated with psychiatric disorders (e.g. anxiety, depression,
stress reaction); hyperventilation
Presyncope: feeling of impending faint or LOC (no true syncope)
Generally associated with cardiac etiology
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Evaluating the “Dizzy” Patient: Symptoms
o Hearing
o Reduced acuity, hyperacusis, fluctuation, distortion, tinnitus
o Gait/balance
o Imbalance, falls, ataxia, retropulsion
o Autonomic symptoms
o Nausea, vomiting, diarrhea, diaphoresis, palpitations, presyncope/syncope
o General symptoms
o Headache, neck pain/stiffness, hydration status
o Neurologic symptoms
o Focal weakness/numbness/tingling, visual field reduction, mental status changes, photo/phonophobia, visual aura
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Cleveland Clinic
Additional Pertinent History
o Past medical history
Head trauma, diabetes, hypertension, migraines, recent URI or illness
Psychiatric hx: anxiety, depression, or panic disorder
Medications, OTC
o Social history
Occupational exposures
Alcohol use
Substance use
Stressors
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Drugs Associated with Vertigo
• Aspirin
• Amiodarone
• Aminoglycosides
• ⍺-/β-blockers
• Cocaine
• Diuretics (e.g. furosemide)
• Ethanol
• Insulin excess
• Muscle relaxants
• Nitrates
• Phosphodiesterase inhibitors
• Sildenafil (Viagra)
• Psychotropic agents
Antipsychotics Antidepressants Anxiolytics Anticonvulsants Mood stabilizers
• Quinine
• Urologic medications
Evaluating the “Dizzy” Patient: Signs
o Nystagmus: spontaneous, gaze-evoked, post-head-shake, positioning (Dix-Hallpike test)
o Auditory: Weber and Rinne tests
o Vestibular: Romberg, head-thrust test
o Gait: base, stability, ataxia, arm-swing
o Cervical spine: ROM (flexion/extension, rotation, lateral bend), tenderness/pain, spasm, weakness
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Cleveland Clinic
Diagnostic Studies
o Dix-Hallpike maneuver Most helpful for BPPV
o Electronystagmography (ENG) or videonystagmography (VNG) Assessment of vestibular function/ocular motility
• Record eye movements in response to visual, positional or rotational stimuli
o Caloric testing Vestibular paresis
• Impaired or absent thermally induced fast nystagmus indicates pathology in the labyrinth on the irrigated side
o Audiometry Sensorineural vs. conductive hearing loss
o Imaging studies: MRI
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http://www.newhealthadvisor.com/images/1HT04788/dix-hallpike.jpeg
http://www.aopo.org/wp-content/uploads/2014/12/BrainDeath-3.png
Caloric Testing
Used to test the vestibulo-ocular reflex
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Caloric Testing: Normal
o Mnemonic: 'COWS' can be used to remember the normal response
Direction of the fast beating nystagmus response
o Cold water: eyes deviate ipsilateral and nystagmus beats away to the Opposite side
o Warm water: eyes deviate contralateral and nystagmus beats toward the Same side
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ColdOppositeWarmSame
Benign Paroxysmal Positional Vertigo (BPPV)
o Most common cause of vertigo
o Associated with otoconia in the semicircular canals
o Transient (<1 minute) episodes of vertigo
o Associated with changes in head position
o No associated changes in hearing
o Physical exam: normal
Dix-Hallpike test can reproduce vertigo & nystagmus; symptoms fatigue with repetition
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BPPV: Management
o Patient education/reassurance
Condition is fatigable & self-limited
o Particle repositioning maneuvers
o Vestibular rehabilitation
Occupational therapy/positional exercises
o Anti-vertigo meds +/- effective
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Vestibular Neuritis
o Aka vestibular neuronitis, acute peripheral vestibulopathy
o Vestibular neuritis swelling of branch of vestibulocochlear nerve affecting balance
o Labyrinthitis (neurolabyrinthitis) involves both branches affecting balance & hearing
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Vestibular Neuritis: Clinical Presentation
o Single attack of severe vertigo, associated with a viral URI Nausea, vomiting, and gait instability
o No associated tinnitus or hearing loss (pure)
If hearing loss present, called labyrinthitis
o May see nystagmus
o Positive head thrust test
o No CNS deficits
o Caloric testing will show vestibular paresis
o Self-limited course Symptomatic treatment (bed rest, vestibular suppressants, anti-
emetics prn, prednisone taper over 10 days)
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Ménière Disease: Clinical Presentation
Triad: Episodic Vertigo Tinnitus Fluctuating hearing loss
o Attacks come on suddenly Last 20 minutes to 24 hours
o Associated aural fullness, nausea & vomitingo Progressive hearing loss progresses; eventually irreversibleo Lose low tones first, then high tones; speech
discrimination is preserved until lateo Attacks of vertigo stop when deafness is completeo Clinical diagnosis
o Audiogram: sensorineural hearing loss
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Ménière Disease: Management
oAcute attack Bed rest
Symptomatic care:
Anti-emetics
Vestibular suppressants
oProphylactic management Low salt diets (1.5 gm/day)
Limit caffeine, nicotine, alcohol, MSG
Diuretics (e.g., HCTZ)
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Vestibular Suppressants*
o Anticholingerics *
Scopolamine (Trans-Derm Scop)
o Antihistamines *
Meclizine (Bonine), dimenhydrinate (Dramamine)
o Phenothiazines
Prochlorperazine (Compro), promethazine (Phenergan)
o Benzodiazepines
Diazepam (Valium), lorazepam (Ativan), alprazolam (Xanax)
* First line medications
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Ménière Disease: Refractory Management
o 90% of patients respond to medical therapy, but if refractory…
o Surgical management:
Intratympanic corticosteroid injections
Endolymphatic sac decompression
Vestibular ablation
o Transtympanic gentamicin
o Vestibular nerve section
o Surgical labyrinthectomy
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Circulation-related Causes of Vertigo
oReduced cerebral perfusion
Low CO states:
Heart failure
Cardiac tamponade
Aortic stenosis
Arrhythmia
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Cleveland Clinic
Subclavian Steal Syndrome
o Stenosis of subclavian artery near origin
o See flow reversal in ipsilateral vertebral artery causing decreased cerebral perfusion
o May see diplopia, vertigo, dysarthria, ataxia, syncope
o Look for symptoms with arm exertion
Lightheadedness, syncope
o Look for difference in pulses in the upper extremities
Lawrence, PF (2000). Essentials
Of General Surgery, 5th Ed.
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oNeurocardiogenic
Orthostatic hypotension
Postural tachycardia syndrome
Neurally mediated syncope
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Cleveland Clinic
Circulation-related Causes of Vertigo
Orthostatic (Postural) Hypotension
Causes:
Autonomic and peripheral neuropathies
Diabetic polyneuropathy
Parkinson Disease
Volume depletion
Aging/debilitation
Medications (e.g. anti-hypertensives, tricyclic antidepressants)
Sxs can be immediate (common) or delayed
Delayed: a few moments to several min after standing is more worrisome
Malnutrition, anemia, blood loss, and adrenal insufficiency all worsen orthostatic hypotension
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Orthostatic Hypotension: Management
oAvoid volume depletion
oMedication adjustment
oBehavior modification
Slow changes in position
Dorsiflexion of the feet or handgrip exercises prior to standing
Jobst stockings
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Presyncope/Syncope Prodrome
o Uneasiness or apprehension
o Lightheadedness
o Facial pallor
o Diaphoresis
o Nausea
o Visual blurring
o Chest pain or SOB
o HA or focal neurologic symptoms
Consistent with vasovagal syncope
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Perilymphatic Fistula
Abnormal connection between the perilymph and the middle ear
Canal through which inner ear fluid may leak into middle ear (via round or oval window)
Causes:
Barotrauma: trauma, airplane descent, scuba diving, weight lifting, vigorous coughing
Erosion
Congenital
Hearing loss, tinnitus, +/- vertigo
May confirm presence with fistula test with pneumatic otoscopy
Abnormal to see eye movements with changes in pressure; may see nystagmus
Management: bedrest, hydration, symptomatic, surgery
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Labyrinthine Concussion
Following head trauma
Vertigo
Nausea, vomiting, imbalance
Hemotympanum
Sensorineural hearing loss
Symptoms are maximal at onset and improve over days to months
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Semicircular Canal Dehiscence Syndrome
o Thin/absent bone overlying superior aspect of superior semicircular canal bone, pressure transmitted to inner ear
o Vertigo provoked by coughing, sneezing, Valsalva
Tullio phenomenon: loud sound induces vertigo
o CT of temporal bone
o Surgical repair
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Vestibular Migraine
o Current or past history of migraine
o Vestibular symptoms last minutes to hours
Vertigo +/- headache
Phonophobia, tinnitus, aural fullness, subjective hearing impairment
o Clinical diagnosis
o Treatments for migraine and/or vertigo
Avoid triggers
Acute attacks: vestibular suppressants
Prophylactic: B-blockers, TCAs, topiramate
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Brainstem/Cerebellar Ischemia
Continuous vertigo/dizziness
Normal head impulse test (head thrust) on both sides
Direction-changing nystagmus
Skew deviation
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Red Flags in Vertigo
Neurologic deficit
Ipsilateral hearing loss
Gait abnormality
Direction changing nystagmus
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5MinuteConsult
Symptoms that help distinguish between common causes of Vertigo
Aural fullness: acoustic neuroma, Ménière disease
Ear/mastoid pain: acoustic neuroma, acute middle ear disease (AOM, herpes zoster oticus)
Facial weakness: acoustic neuroma, herpes zoster oticus
Focal neurologic findings: cerebellar tumor, CVD, MS
Headache: acoustic neuroma, migraine
Hearing loss: Ménière disease, acoustic neuroma, otosclerosis, labyrinthitis, herpes zoster oticus, transient ischemic attack (TIA), cholesteatoma, perilymphatic fistula
Imbalance: acute vestibular neuritis (moderate), cerebellar tumor (severe)
Phonophobia/photophobia: migraine
Rash: herpes zoster oticus
Tinnitus: acute labyrinthitis, acoustic neuroma, Ménière disease
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5MinuteConsult
Provoking factors that help distinguish different causes of Vertigo
Changes in head position: acute labyrinthitis, BPPV, cerebellar tumor, MS, perilymphatic fistula
Spontaneous episodes/no clear provoking factors: vestibular neuritis, TIA/CVA, Ménière disease, migraine, MS
Recent URI: vestibular neuritis
Stress: psychogenic causes, migraine
Immunosuppression: herpes zoster oticus
Changes in ear pressure, trauma, loud noises: perilymphatic fistula
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5MinuteConsult
Duration of Typical Vertiginous Episodes
Auditory Symptoms Present
Auditory Symptoms Absent
Seconds Perilymphatic fistula Positioning vertigo (cupulolithiasis), vertebrobasilar
insufficiency, migraine-associated vertigo
Hours Endolymphatic hydrops (Ménière syndrome,
syphilis)
Migraine-associated vertigo
Days Labyrinthitis, labyrinthine concussion, autoimmune
inner ear disease
Vestibular neuronitis, migraine-associated
vertigo
Months Acoustic neuroma, ototoxicity
Multiple sclerosis, cerebellar degeneration
Current Medical Diagnosis & Treatment 2018, Table 8-3
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Summary: Vertigo & Auditory Symptoms
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https://5minuteconsult-com.mwu.idm.oclc.org/data/GbosContainer/33/clin_algo_dizziness_print.jpeg
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https://5minuteconsult-com.mwu.idm.oclc.org/data/GbosContainer/33/clin_algo_syncope_print.jpeg
References
Papadakis, MA, McPhee SJ, Rabow, MW (2018). Current Medical Diagnosis & Treatment, 57th Ed., McGraw-Hill Education.
5MinuteConsult UpToDate Lawrence, PF (2013). Essentials of General Surgery, 5th Ed., Lippincott,
Williams & Wilkens: Philadelphia. Bader R, Sartini S (2016) Risk Stratification of Syncope in the Emergency
Department, Clinical Decision Rules or Clinical Judgment?. Emergency Med 6:313. doi:10.4172/2165-7548.1000313
Dizziness. Cleveland Clinic Center for Continuing Education.http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/neurology/dizziness/. Accessed October 2, 2019.
Approach to the Patient with Dizziness. UpToDate. https://www-uptodate-com.mwu.idm.oclc.org/contents/approach-to-the-patient-with-dizziness?search=dizziness&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1. Accessed October 2, 2019.
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