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Kirsten Bonnin, M.M.S., PA-C ASAPA Fall Conference October 5, 2019 Head Spinning?? Evaluation of Dizziness 1

Head Spinning?? · 5 Differential Diagnosis for Vertigo o Anxiety disorder o Arrhythmia o Benign paroxysmal positional vertigo (BPPV) o Cardiogenic (heart failure, tamponade, aortic

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Page 1: Head Spinning?? · 5 Differential Diagnosis for Vertigo o Anxiety disorder o Arrhythmia o Benign paroxysmal positional vertigo (BPPV) o Cardiogenic (heart failure, tamponade, aortic

Kirsten Bonnin, M.M.S., PA-CASAPA Fall Conference

October 5, 2019

Head Spinning??Evaluation of Dizziness

1

Page 2: Head Spinning?? · 5 Differential Diagnosis for Vertigo o Anxiety disorder o Arrhythmia o Benign paroxysmal positional vertigo (BPPV) o Cardiogenic (heart failure, tamponade, aortic

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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Page 3: Head Spinning?? · 5 Differential Diagnosis for Vertigo o Anxiety disorder o Arrhythmia o Benign paroxysmal positional vertigo (BPPV) o Cardiogenic (heart failure, tamponade, aortic

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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Page 4: Head Spinning?? · 5 Differential Diagnosis for Vertigo o Anxiety disorder o Arrhythmia o Benign paroxysmal positional vertigo (BPPV) o Cardiogenic (heart failure, tamponade, aortic

Vertigo

• Vertigo is a symptom

• Defined as a sensation of motion, when there is no motion or exaggerated sense of movement

4

May be associated with nystagmus and postural

instability

Page 5: Head Spinning?? · 5 Differential Diagnosis for Vertigo o Anxiety disorder o Arrhythmia o Benign paroxysmal positional vertigo (BPPV) o Cardiogenic (heart failure, tamponade, aortic

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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

Page 7: Head Spinning?? · 5 Differential Diagnosis for Vertigo o Anxiety disorder o Arrhythmia o Benign paroxysmal positional vertigo (BPPV) o Cardiogenic (heart failure, tamponade, aortic

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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

Page 8: Head Spinning?? · 5 Differential Diagnosis for Vertigo o Anxiety disorder o Arrhythmia o Benign paroxysmal positional vertigo (BPPV) o Cardiogenic (heart failure, tamponade, aortic

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

Page 9: Head Spinning?? · 5 Differential Diagnosis for Vertigo o Anxiety disorder o Arrhythmia o Benign paroxysmal positional vertigo (BPPV) o Cardiogenic (heart failure, tamponade, aortic

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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Page 10: Head Spinning?? · 5 Differential Diagnosis for Vertigo o Anxiety disorder o Arrhythmia o Benign paroxysmal positional vertigo (BPPV) o Cardiogenic (heart failure, tamponade, aortic

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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Page 11: Head Spinning?? · 5 Differential Diagnosis for Vertigo o Anxiety disorder o Arrhythmia o Benign paroxysmal positional vertigo (BPPV) o Cardiogenic (heart failure, tamponade, aortic

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

Page 12: Head Spinning?? · 5 Differential Diagnosis for Vertigo o Anxiety disorder o Arrhythmia o Benign paroxysmal positional vertigo (BPPV) o Cardiogenic (heart failure, tamponade, aortic

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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Page 13: Head Spinning?? · 5 Differential Diagnosis for Vertigo o Anxiety disorder o Arrhythmia o Benign paroxysmal positional vertigo (BPPV) o Cardiogenic (heart failure, tamponade, aortic

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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

Page 14: Head Spinning?? · 5 Differential Diagnosis for Vertigo o Anxiety disorder o Arrhythmia o Benign paroxysmal positional vertigo (BPPV) o Cardiogenic (heart failure, tamponade, aortic

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

Page 15: Head Spinning?? · 5 Differential Diagnosis for Vertigo o Anxiety disorder o Arrhythmia o Benign paroxysmal positional vertigo (BPPV) o Cardiogenic (heart failure, tamponade, aortic

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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Page 16: Head Spinning?? · 5 Differential Diagnosis for Vertigo o Anxiety disorder o Arrhythmia o Benign paroxysmal positional vertigo (BPPV) o Cardiogenic (heart failure, tamponade, aortic

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http://www.newhealthadvisor.com/images/1HT04788/dix-hallpike.jpeg

Page 17: Head Spinning?? · 5 Differential Diagnosis for Vertigo o Anxiety disorder o Arrhythmia o Benign paroxysmal positional vertigo (BPPV) o Cardiogenic (heart failure, tamponade, aortic

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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Page 18: Head Spinning?? · 5 Differential Diagnosis for Vertigo o Anxiety disorder o Arrhythmia o Benign paroxysmal positional vertigo (BPPV) o Cardiogenic (heart failure, tamponade, aortic
Page 19: Head Spinning?? · 5 Differential Diagnosis for Vertigo o Anxiety disorder o Arrhythmia o Benign paroxysmal positional vertigo (BPPV) o Cardiogenic (heart failure, tamponade, aortic

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

Page 20: Head Spinning?? · 5 Differential Diagnosis for Vertigo o Anxiety disorder o Arrhythmia o Benign paroxysmal positional vertigo (BPPV) o Cardiogenic (heart failure, tamponade, aortic

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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Page 21: Head Spinning?? · 5 Differential Diagnosis for Vertigo o Anxiety disorder o Arrhythmia o Benign paroxysmal positional vertigo (BPPV) o Cardiogenic (heart failure, tamponade, aortic

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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Page 22: Head Spinning?? · 5 Differential Diagnosis for Vertigo o Anxiety disorder o Arrhythmia o Benign paroxysmal positional vertigo (BPPV) o Cardiogenic (heart failure, tamponade, aortic

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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Page 23: Head Spinning?? · 5 Differential Diagnosis for Vertigo o Anxiety disorder o Arrhythmia o Benign paroxysmal positional vertigo (BPPV) o Cardiogenic (heart failure, tamponade, aortic

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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Page 24: Head Spinning?? · 5 Differential Diagnosis for Vertigo o Anxiety disorder o Arrhythmia o Benign paroxysmal positional vertigo (BPPV) o Cardiogenic (heart failure, tamponade, aortic

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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Page 25: Head Spinning?? · 5 Differential Diagnosis for Vertigo o Anxiety disorder o Arrhythmia o Benign paroxysmal positional vertigo (BPPV) o Cardiogenic (heart failure, tamponade, aortic

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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Page 26: Head Spinning?? · 5 Differential Diagnosis for Vertigo o Anxiety disorder o Arrhythmia o Benign paroxysmal positional vertigo (BPPV) o Cardiogenic (heart failure, tamponade, aortic

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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Page 27: Head Spinning?? · 5 Differential Diagnosis for Vertigo o Anxiety disorder o Arrhythmia o Benign paroxysmal positional vertigo (BPPV) o Cardiogenic (heart failure, tamponade, aortic

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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Page 28: Head Spinning?? · 5 Differential Diagnosis for Vertigo o Anxiety disorder o Arrhythmia o Benign paroxysmal positional vertigo (BPPV) o Cardiogenic (heart failure, tamponade, aortic

Circulation-related Causes of Vertigo

oReduced cerebral perfusion

Low CO states:

Heart failure

Cardiac tamponade

Aortic stenosis

Arrhythmia

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Cleveland Clinic

Page 29: Head Spinning?? · 5 Differential Diagnosis for Vertigo o Anxiety disorder o Arrhythmia o Benign paroxysmal positional vertigo (BPPV) o Cardiogenic (heart failure, tamponade, aortic

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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Page 30: Head Spinning?? · 5 Differential Diagnosis for Vertigo o Anxiety disorder o Arrhythmia o Benign paroxysmal positional vertigo (BPPV) o Cardiogenic (heart failure, tamponade, aortic

oNeurocardiogenic

Orthostatic hypotension

Postural tachycardia syndrome

Neurally mediated syncope

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Cleveland Clinic

Circulation-related Causes of Vertigo

Page 31: Head Spinning?? · 5 Differential Diagnosis for Vertigo o Anxiety disorder o Arrhythmia o Benign paroxysmal positional vertigo (BPPV) o Cardiogenic (heart failure, tamponade, aortic

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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Page 32: Head Spinning?? · 5 Differential Diagnosis for Vertigo o Anxiety disorder o Arrhythmia o Benign paroxysmal positional vertigo (BPPV) o Cardiogenic (heart failure, tamponade, aortic

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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Page 33: Head Spinning?? · 5 Differential Diagnosis for Vertigo o Anxiety disorder o Arrhythmia o Benign paroxysmal positional vertigo (BPPV) o Cardiogenic (heart failure, tamponade, aortic

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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Page 34: Head Spinning?? · 5 Differential Diagnosis for Vertigo o Anxiety disorder o Arrhythmia o Benign paroxysmal positional vertigo (BPPV) o Cardiogenic (heart failure, tamponade, aortic

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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Page 35: Head Spinning?? · 5 Differential Diagnosis for Vertigo o Anxiety disorder o Arrhythmia o Benign paroxysmal positional vertigo (BPPV) o Cardiogenic (heart failure, tamponade, aortic

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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Page 36: Head Spinning?? · 5 Differential Diagnosis for Vertigo o Anxiety disorder o Arrhythmia o Benign paroxysmal positional vertigo (BPPV) o Cardiogenic (heart failure, tamponade, aortic

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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Page 37: Head Spinning?? · 5 Differential Diagnosis for Vertigo o Anxiety disorder o Arrhythmia o Benign paroxysmal positional vertigo (BPPV) o Cardiogenic (heart failure, tamponade, aortic

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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Page 38: Head Spinning?? · 5 Differential Diagnosis for Vertigo o Anxiety disorder o Arrhythmia o Benign paroxysmal positional vertigo (BPPV) o Cardiogenic (heart failure, tamponade, aortic

Brainstem/Cerebellar Ischemia

Continuous vertigo/dizziness

Normal head impulse test (head thrust) on both sides

Direction-changing nystagmus

Skew deviation

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Page 39: Head Spinning?? · 5 Differential Diagnosis for Vertigo o Anxiety disorder o Arrhythmia o Benign paroxysmal positional vertigo (BPPV) o Cardiogenic (heart failure, tamponade, aortic

Red Flags in Vertigo

Neurologic deficit

Ipsilateral hearing loss

Gait abnormality

Direction changing nystagmus

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5MinuteConsult

Page 40: Head Spinning?? · 5 Differential Diagnosis for Vertigo o Anxiety disorder o Arrhythmia o Benign paroxysmal positional vertigo (BPPV) o Cardiogenic (heart failure, tamponade, aortic

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

Page 41: Head Spinning?? · 5 Differential Diagnosis for Vertigo o Anxiety disorder o Arrhythmia o Benign paroxysmal positional vertigo (BPPV) o Cardiogenic (heart failure, tamponade, aortic

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

Page 42: Head Spinning?? · 5 Differential Diagnosis for Vertigo o Anxiety disorder o Arrhythmia o Benign paroxysmal positional vertigo (BPPV) o Cardiogenic (heart failure, tamponade, aortic

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

Page 43: Head Spinning?? · 5 Differential Diagnosis for Vertigo o Anxiety disorder o Arrhythmia o Benign paroxysmal positional vertigo (BPPV) o Cardiogenic (heart failure, tamponade, aortic

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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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