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
complaint
among patients older than 75 yrs.
• Encompasses:
neurologic
weakness,
impairment,
presyncope,
vertigo,
disturbance, and psychologic illness.
visual
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 organs,
vestibular nerve, vestibular nuclei).
• Is the patient experiencing nausea and
vomiting? (usually have labyrinthine
disease)
• Are any associated auditory symptoms
present?
• What is the timing of the dizziness? Does it
completely resolve between attacks?
• Are any neurologic symptoms associated with
the dizziness? (also visual)
• 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
may
suggest
migraine-associated
dizziness…
• 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)
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
abnormalities
suspected
retrocochlear
– 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 (‫)پاستور نو‬
– 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
to
assess
the
vestibulospinal tracts .
• 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
associated autonomic changes).
• Drug induced (e.g., atenolol).
classically
has
• 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.
• 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) 
Anterior
Vestibular artery and/or Common Cochlear artery.
– 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. Aural
fullness 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 and may persist
for up to several hours.
– 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, Promethazine,
Diazepam, Antiemetics, rehydration.
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: cerebellum and the dorsolateral
medulla  Wallenberg’s Syndrome
• Vertebrobasilar insufficiency:
– most commonly visual
disturbance, drop
attacks, unsteadiness, or weakness and also
central vertigo.
• Management of Vertigo (algorithm):
Algorithm