By Meighan O’Connor, POPPF
DIZZINESS AND VERTIGO
DIZZINESS AND VERTIGO
Dizziness includes lightheadedness, motion
intolerance, imbalance, floating or vertigo.
 Vertigo is a type of dizziness defined as the illusion
of the environment or oneself spinning.
 Approximately 40 % of dizzy patients have
peripheral vestibular dysfunction; 10 % have a
central brainstem vestibular lesion; 15 % have a
psychiatric disorder; and 25 % have other
problems, such as presyncope and disequilibrium.
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CC: “DIZZINESS”
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HPI: 52 y/o female with h/o Ehlers Danlos type IV and
migraines complains of “dizziness.” She states that
earlier today she was walking into her living room and
suddenly started stumbling to the right and fell into the
floor. While she was lying on the floor she could not
focus on objects and the room would not stop spinning.
She denies nausea, vomiting, sweating, syncope,
numbness, tingling, weakness, other vision or hearing
changes, trouble speaking, new or severe h/a, or chest
pain. After two minutes the sensation went away and
she was left with 2/10 pain on the left side of her neck
and head that is still present. She said this has never
happened before.
Meds: Imitrex prn,
 PMHx: Ehlers Danlos Type IV diagnosed three
years ago, migraines for past 25 years.
 SHx:
Sigmoid colon perforation repair 30
years ago.
 SocHx: Denies using tobacco products or ETOH
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PE
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Vitals: BP 134/87 standing, 138/88 supine
Pulse 80; RR 14
HEENT: PERRLA, EOM intact BL; Tympanic membrane grey and
reflective BL, Weber and Rinne hearing test negative BL; Nasal
turbinates non-inflamed, pink and moist BL; Throat pink and
moist, no ulcers.
Cardio: No carotid bruits or murmurs auscultated BL, normal
rate
Neuro: CN II-XII intact BL, sensation was intact BL and DTR
were 2/4 BL, heel-toe walking was normal.
MSK: Full ROM of cervical spine BL, C2-C5FRLSL with
associated hypertonic paraspinals BL
Cranial: CRI at 16 cycles/minute
DDX
TIA
 CVA
 Vertebral Artery Dissection
 Brain Tumor
 BPPV
 Vestibular Neuronitis (mcc acute vertigo)
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COMMON CAUSES OF DIZZINESS:
Dizziness not including vertigo is more likely
due to central nervous system (CNS) such as
MS, cardiovascular such as CVA and orthostatic
hypotension, or systemic diseases such as
anemia where the symptoms are often gradual
and ill-defined.
 Cardiovascular disease is important to rule out
in the elderly, although dizziness at a late age
may have multiple etiologies.
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COMMON CAUSES OF VERTIGO
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Inner Ear Pathology:
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Vestibular Neuronitis is the most common cause of acute vertigo and
may result from a reactivation of HSV that affects the vestibular ganglion
nerves. Vertigo is without auditory or other CNS symptoms and lasts for
several days
Benign Paroxysmal Positional Vertigo is the second most common cause
of vertigo. Typically patients experience brief vertigo upon changing
head or body position. The mechanism of BPPV can be due to
canalithiasis (otoconia floating in the endolymph) or cupulolithiasis
(otoconia adherent to cupula).
Ménière Disease presents with symptoms of episodic vertigo, tinnitus,
and hearing loss. Untreated, severe hearing loss and unilateral
vestibular paresis are inevitable. The common pathophysiology is
disordered fluid homeostasis in the inner ear.
Other Pathology: TIA or Stroke, MS, post-traumatic
as with concussion, medicatons, migraines
MODIFIED EPLEY MANEUVER
EPLEY MANEUVER
CC: “DIZZINESS”
In order to r/o vertebral artery dissection, an MRA
was performed.
 The test showed a diminutive left vertebral artery
with a focal area of absent/decreased flow and
abnormal signal hyperintensity from the C1-2
through the C5-6 levels. These findings likely
represent dissection of a short segment of
vertebral artery.
 Patient was given intravenous heparin and then
switched to warfarin anticoagulation
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TX
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Medications:
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Canalith repositioning:
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An antihistamine, such as the prescription medicine meclizine, or nonprescription medicines like dimenhydrinate, or diphenhydramine.
Prescription anti-nausea medicines, such as promethazine,
metoclopramide, or ondansetron.
Prescription sedative medicines, such as diazepam, lorazepam, or
clonazepam
Maneuvers such as Epley Maneuver is a treatment that may be
recommended for people with benign paroxysmal positional vertigo (BPPV).
The purpose is to reposition any otoliths in the vestibular canals.
Balance rehabilitation:
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Most patients with vertigo prefer to keep their head still. However, staying
still and not moving the head can make it harder to cope with vertigo.
Rehabilitation can help people with vertigo that is caused by injury to the
vestibular system. The vestibular system includes parts of the inner ear and
nervous system, which controls balance.
The rehabilitation works by helping your brain adjust its response to
changes in the vestibular system. The therapy can also help train your eyes
and other senses to "learn" how to compensate. This therapy is most helpful
when it is started as soon as possible after you develop vertigo.
OMT
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Dizziness can be caused by a temporal bone dysfuncion specifically the bone becomes internally rotated,
compressing the vestibulochoclear nerve (CN VIII) which
can also cause tinnitis.
SCM hypertonicity especially when chronic can pull the
temporal bone and cause local tissue inflammation,
blocking the lymphatic flow. i.e. meniere's syndrome.
Otitis media can give vestibular symptoms that can be
treated using the raking the face maneuver.
Many case studies have been reported where treating
the cervical soft tissue and joints gave significant or
complete relief of dizziness. Somatic dysfunctions of the
cervical spine including OA, upper thoracics and cranium
should be treated.
REFERENCES
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Dizziness, Vertigo, and Imbalance
Author: Hesham M Samy, MD, PhD; Chief Editor: Robert A Egan, MD
http://emedicine.medscape.com/article/1159385-overview#a30;
Patient information: Dizziness and vertigo; Author Joseph M Furman, MD, PhD;
Section Editor Michael J Aminoff, MD, DSc; Deputy Editor Janet L Wilterdink, MD
http://www.uptodate.com.ezproxylocal.library.nova.edu/contents/patientinformation-dizziness-andvertigo?source=search_result&search=epley+maneuver&selectedTitle=2%7E4
A Case of Dizziness , http://www.ferne.org/Lectures/dizziness1001.htm#AB
Osteopathic Approach to Vertigo, Developed for OU-COM CORE by: Derek Stone,
DO. 2006.
http://www.ohiocore.org/gfx/media/contribute/Session9CranialPPT_000.pdf
Dizziness and Vertigo, Attorney & Physician Advisory Board, American Medical
Forensic Specialists, Inc. http://www.bailey-law.com/docs/dizziness-andvertigo.htm