Dizziness
L. Jay Turkewitz MD
Dizziness
• One of the most common complaints in all
practice
• Affects 20-30% of the population
• I have been hospitalized twice in my life with
severe vertigo and uncontrolled vomiting
Dizziness
• Makes up a tremendous number of ER and
Urgent Care visits.
• True persistent dizziness can lead to falls, and
subsequent injuries and substantial day to day
dysfunction of daily activities.
• Balance related falls leads to death in the
elderly—i.e. hip fracture and subsequent blood
clots and pulmonary embolus or subdurals but
rarely are these falls due to VERTIGO
Dizziness
• Nonspecific when the patient walks in and
says I am dizzy
• Your job is to figure out what the patient
means by dizziness
• The key issue is whether the patient has true
Vertigo a sense of rotation.
Dizziness
• There is a specific “Dizziness” clinic at Mayo’s
• Classic paper by Daniel Drachman on the % of
patients with various symptoms who complain
of dizziness
• True Neurological vertigo is RARE
Dizziness
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Vertigo Neurologic
Presyncope NON Neurologic
Disequilibrium Often Neurologic
Lightheadedness Rarely Neurologic
VERTIGO
• VERTIGO
Dizziness
• Vertigo, The illusion or sense of a spinning rotation of
the room BUT it may be the patient who feels they are
doing the spinning BUT there is a sense of rotation!
• Peripheral vs Central
• Peripheral is a reflection of disorders of the
semicircular canals, utricle –the Vestibular End Organs
or the 8th Nerve (ENT Docs say 8th nerve vertigo is
central!)
• Central Vertigo implies dysfunction of the Vestibular
Nuclear Connections or Cerebellum (less likely)
• The book is misleading on this point
Dizziness
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Peripheral Vertigo
Prominent Nausea and Vomiting
Unidirectional Nystagumus
Sudden Onset
Auditory Issues such as Hearing Loss or Tinnitus
May be positional
Very Disabling
Delay anf fatigue
Dizziness
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Central Vertigo
Nystagmus is variable
Less prominent nausea and vomiting
May not be disabling
Variable onset
No hearing issues
Other brainstem findings
Dizziness
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Presyncope
The sensation that one is about to faint
“feel faint”
Nausea
Dimming of Vision
Sweating
Tremor
Cardiovascular, Metabolic or much less likely
Hematologic in nature
Disequilibrium
• The sense one is about to fall
• Motor weakness may cause this
• Loss of sensory input from neuropathy may
cause this
• Balance and gait are the issues!
Dizziness
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Lightheadedness
Non specific
Hyperventilation is the classic
Psych issues
Meds
Altered Sensorium
Non specific
My 8th grade auditorium
Dizziness
• Vertigo
• Central Vertigo always requires immediate
evaluation including neuro imaging
• Must eliminate the possibility of a posterior
fossa mass pressing on the brainstem or
primary brainstem pathology.
Dizziness
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Peripheral Vertigo
Sudden Brief Attacks
Fall to the ground
Spells of Tumarken
No pre-syncope
No seizure stigmata
Nausea, vomiting and uni-directional nystagmus
Peripheral Nystagmus (Horizontal with a Rotatory
Component) Dampens with Fixation!
Dizziness
• Central Vertigo
• Often a more gradual onset
• They may not be able to walk but this may
reflect other issues including hemiparesis
• Vertical Nystagmus is always of central origin
• Unlike peripheral nystagmus central
nystagmus may persist beyond 48 hours.
• Peripheral Vertigo always compensates over
time
Dizziness
• Brainstem Lesions Which Cause Vertigo
• Always involves other tracts, motor, sensory or
other cranial nerve nuclei so look for signs of
other deficits on Neuro exam
• Wallenberg’s Syndrome in the distribution of
the Posterior Inferior Cerebellar Artery BUT
usually due to vertebral occlusive disease is
the classic brainstem syndrome causing
vertigo
Dizziness
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Wallenberg’s
Infarction of Vestibular Nuclei
Ipsilateral Horner’s Sundrome
Ipsilateral Facial Numbness
Contralateral Limb Numbness
Dyphagia
Dysarthria
Diplopia
Dizziness
• Cerebellar Lesions Causing Vertigo
• Cerebellar Infarcts (Medical Emergency)—
Swell and compress the brainstem (posterior
Fossa Herniation Syndrome)
• Cerebellar signs- Past pointing, dysmetria,
dysdiadokinesis (rapid alternating
movements)
Dizziness
• Vertigo associated with transient Brainstem
Ischemia
• Vertebrobasilar Insufficiency---diplopia,
transient homonomous visual defects,
dyarthria
• Drop Attacks VBI but patient does not lose
consciousness
Dizziness
• Brainstem Stroke has a myriad of features!
• Any stroke’s findings is a reflection of the affected
artery and it’s collateral blood flow
• Opthalmoplegia
• Hearing Loss
• Visual Field Defects
• Sensory Loss
• Ataxia
• MONOCULAR BLINDNESS IS ANTERIOR CIRCULATION
Dizziness
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Cerebellar Bleeds
Headache
Nausea Vomiting
Nystagmus
Ataxia of Gait
Depressed Level of Consciousness
EMERGENCY SURGERY!
Prevent Herniation of Cerebellum into the Brainstem
Dizziness
• Multiple Sclerosis
Dizziness
• Peripheral Causes of Vertigo Much More
Common than Central Causes…Statistically
whenever you see someone with severe
Vertigo is usually peripheral.
Dizziness
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BPPV (Benign Paroxysmal Positional Vertigo)
Most common cause of vertigo
Usually elderly
Positional One side or the other DOWN on the Pillow
Latency
Fatigue with repetitive episodes, Lasts 60 seconds per episode
Cupulolitiasis----Debris from the Utricle flowing freely in the
semi-circular canals endolymph
• This acts as a plug like a plunger causing a push and pull effect
on the cupula creating asymetric neural impulses from the
ears WHICH IS THE MECHANISM of Peripheral Vertigo and
Nystagmus!
• Rolling Over in Bed much more often than LOOKING UP!
Dizziness
• Vestibular Neuronitis
• Probably akin to the same mechanism as Bell’s Palsy
(reactivation of latent Herpes Virus BUT affecting the
vestibular portion of the 8th nerve)
• Often after a viral infection
• May be a viral infection of the vestibular apparatus this is not
like the book says NUCLEAR this is PERIPHERAL NOT CENTRAL
• Lasts weeks but the acute vertigo is over after about 48 hours
and the patient then feels disequilibrium for about 6-8 weeks.
The vertigo can be recurrent during that time frame.
Dizziness
• Labyrinthitis
• By definition there is a decrease in hearing
unlike vestibular neuronitis
• The Labyrinthe is affected
• Can be viral or bacterial or spirochetal
• The end organ of hearing is involved by
definition
• Otitis Media bacterial spread through a
ruptured membrane or a perilymph fistula
Dizziness
• These patients with labyrinthitis usually
appear quite ill and have fever.
• Unlike vestibular neuronitis where fever is
uncommon
• If you have Labyrinthitis there must be hearing
loss and usually vertigo with nausea vomiting
a peripheral pattern of nystagmus
• ENT Emergency
Dizziness
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Ramsay Hunt Syndrome
Varicella Zoster Virus reactivation
Affects Cranial Nerves 7 and 8
Facial Paresis
Tinnitus
Hearing Loss and Vertigo
Dizziness
• Meniere’s Disease
• Very Overdiagnosed..Occurs as attacks
• Low Frequency Sensory Neural Hearing Loss is the HALLMARK
Hearing Loss may fluctuate
• Increase in the volume of Endolymph which has led to various
therapeutic interventions
• Distension of the Endolymphatic System
• Severe Vertigo Nausea Vomiting with a peripheral pattern of
Nystagmus
• Attacks last minutes to hours, Ear fullness or pain
• Abrupt Spells of Tumarkan Fall to the Floor!
• Usually unilateral but may be bilateral
Dizziness
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Acoustic Neuroma
Slow Unilateral Hearing Loss and Tinnitus
Schwanoma of the acoustic nerve
Begins on vestibular portion but affects
hearing first
• Slow growth is the reason vertigo rarely
develops
• Cranial nerves 5 and 7 This is the classic
cerebello-pontine angle lesion
Evaluation
• MRI
Pre-Syncope
• Simple Faint
• Usually Needs to be differentiated from a
seizure
• Post Episode Confusion Rare
• No tongue biting
• No incontinence
• No shaking
Disequibirium
• Patient feels unsteady, they feel like they are going to
fall.
• Usually after a sudden change in position particularly
when they have lost visual cues.
• Loss of sensory input
• Motor weakness subtle affecting balance
• Extrapyramidal Disease Parkinsons!
• Visual Impairment with Neuropathy
• Arthritis when it is severe
• Long standing Diabetes or HIV
Lightheadedness
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Vague
Difficult to characterize
Most common in a dizziness clinic
Most important issue is that this is usually non
neurologic and usually not a sign of severe significant
disease
• Floating sensation
• Depersonalization a psych issue (anxiety,depression)
• Hyperventilation
Evaluation
• Patient may be uncooperative due to illness
• Vital Signs Orthostatic BP Changes supine and
standing and look for a change in pulse
• Complete HEENT and Neuro Exams
• Nystagmus
• EOM’s
• Pupils
• Fundus exclude Papiledema
• Tympanic Membranes are CRUCIAL! (Scars,Fluid,Pus)
• Weber Rinne after Gross Hearing
Evaluation
• Cardiac Exam Emboli
• Carotid Bruits Emboli
• Neuro Exam
• Gait Romberg is key
• If you can’t stand with your feet together with
eyes open it is a cerebellar issue if it is only
with eyes closed there is a sensory input issue.
Evauation
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Dix-Hallpike Maneuver
Diagnose BPPV
Turn Head 45 degrees to the side being tested
Rapidy lower head to a position hanging below the examing
table
Eyes open (nustagmus and Vertigo)
After a short latency a positive test is denoted by the eyes
having a burst of nystagmus with the eyes beating towards
the ground (fast phase component of nystagmus)
Lasts a minute or so
Posterior Canal Variant of BPPV
Dizziness
• Always hyperventilate the patient if need be
to dx
• Reproducing the syomtoms is the key to
understanding whats wrong in non obvious
cases
Evaluation
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Labs Not Helpful Diagnosing Vertigo
CBC (anemia)
Chem Profile (eletrolytes)(dehydration BUN)
Thyroid Tests
Glucose Tolerance Test (hypoglycemia)
EKG afib or arrythmia of other type ???echo
Evaluation
• Electronystagmography
• Records eye movements to look for nystagmus
• In response to vestibular,visual,
cervical,caloric, rotational,positional
stimulations to assess vestibular function
• Audiogram KEY Meniere’s Low Frequency
Sensorineural Hearing Loss
Evaluation
• ENG
Evaluation
• Audiogram
Evaluation
• ENG
Evaluation
• ENG
Evaluation
• MRI