Dizziness and Vertigo

PGI ECIJA, CLYDE JOSHUA A.

BACKGROUND
Background

● Dizziness - an imprecise symptom used to describe a variety of

sensations that include vertigo, light-headedness, faintness, and
imbalance.
● Vertigo - sense of spinning or other motion
○ Physiologic - during or after a sustained head rotation
○ Pathologic - vestibular dysfunction
● Light-headedness - presyncopal sensations due to brain
hypoperfusion
○ Disequilibrium and imbalance
Causes of Dizziness

● Vascular disorders
○ Cardiac dysrhythmia, orthostatic hypotension, medication
effects
● Vestibular causes
○ Vertigo or imbalance
○ Peripheral lesions affecting labyrinths or vestibular nerves
○ Involvement of central vestibular pathways
● Nonvestibular imbalance, gait disorders, and anxiety
Questions to consider

Is it dangerous?
Is it vestibular?
If vestibular, is it peripheral or central?
APPROACH TO PATIENT
General approach...

● History: first attack, duration, any prior episodes, provoking

factors, and accompanying symptoms

● Evaluation: TiTrATE
○ Timing, Triggers, And a Targeted Examination
Peripheral vs Central Vertigo
Characteristics Peripheral Central

Onset Sudden Gradual or sudden

Duration Seconds to minutes Variable

Intensity Severe Mild

Effect of Head Position Worsened Minimal

Direction of Nystagmus Unidirectional Horizontal, Vertical, Rotatory,

and Bidirectional

Neurologic Findings None Present

Auditory Findings Occasional None

Causes BPPV, Meniere’s disease, Meningitis, Encephalitis,

Vestibular neuritis, Labyrinthitis Tumors, Cerebellar
hemorrhage
DIFFERENTIAL DIAGNOSIS
Vestibular Neuritis
● An acute unilateral vestibular lesion causes constant vertigo, nausea, vomiting,
oscillopsia, and imbalance.

● If the head impulse test is normal, then the acute peripheral vestibular lesion is
unlikely.

● In older patients with vascular risk factors who present with acute vestibular
syndrome should be evaluated for the possibility of stroke even when there are no
specific findings that indicate a central lesion.

● Patients should resume a normal level of activity as soon as possible, and directed
vestibular rehabilitation therapy may accelerate improvement.
Vestibular Migraine

● In this, vertigo sometimes precedes a typical migraine headache but mostly occurs
without headache or with only a mild headache.

● The duration of vertigo may be from minutes to hours, but sometimes it can be more
prolonged periods of disequilibrium.

● Motion sensitivity and sensitivity to visual motion (e.g movies) is the common
presentation.

● Even in the absence of headache, other migraine features may be present, such as
photophobia, phonophobia, or a visual aura.
Vestibular Schwannoma

● Vestibular schwannomas are at the cerebellopontine angle cause slowly progressive

unilateral sensorineural hearing loss and vestibular hypofunction.

● In these patients typically do not have vertigo, because the gradual vestibular deficit
is compensated centrally as it develops.

● The diagnosis not made until there is sufficient hearing loss to be noticed.

● In the vestibular examination there will be a deficient response to the head impulse
test when the head is rotated toward the affected side, but nystagmus will not be
prominent.

● Patients with unexplained unilateral sensorineural hearing loss or vestibular

hypofunction require MRI of the internal auditory canals to look for a schwannoma.
Central Vestibular Disorder

● Typically involve vestibular pathways in the brainstem and/or cerebellum

● They may be due to discrete lesions, such as:
○ Ischemic or hemorrhagic stroke
○ Demyelination or
○ Tumors
● May be due to neurodegenerative conditions that include
vestibulocerebellum
● Acute central vertigo is an emergency
● All patients suspected with central vestibular disorder should undergo
brain MRI
● Patients should be referred for further evaluation
Benign Paroxysmal Positional Vertigo (BPPV)
● Episodes of brief (<1min and typically 15-20s) and are always provoked by changes in
head position relative to gravity.
● Attacks are caused by free floating otoconia that have been dislodged from the
utricular macula into the semicircular canal
● Usually involves the posterior canal
● When head position changes, gravity causes otoconia to move within the canal,
producing vertigo and nystagmus
● Posterior canal BPPV :
○ The nystagmus beats upward and torsionally
● Horizontal canal BPPV:
○ Horizontal nystagmus
● Superior canal involvement is rare
Meniere’s Disease

● Due to excess fluid (endolymph) in the inner ear

● Vertigo, hearing loss, pain, pressure/fullness
● Low frequency hearing loss and aura are key features
that distinguish it from other peripheral vestibulopathies
and from vestibular migraine
● Audiometry shows a characteristic asymmetric
low-frequency hearing loss
● Lasts from minutes- hours (2-3 hours)
Bilateral Vestibular Hypofunction
● Vestibular function is lost on both sides simultaneously so there is no
asymmetry of vestibular input
● Symptoms include loss of balance, oscillopsia during head movement
CAUSES
- Idiopathic and progressive
- Neurodegenerative disorder
- Iatrogenic due to medication ototoxicity
- Autoimmune Disease
- Infection or tumor
- Vestibular neuritis and Meniere’s Disease

● Examination findings: diminished dynamic visual acuity, abnormal

head impulse responses, Romberg sign
Psychosomatic and Functional Dizziness
- Psychological factors play an important role in chronic
dizziness
- Dizziness may be a manifestation of a psychiatric
condition
- Patients may develop anxiety or autonomic symptoms
as consequence of a vestibular disorder
Persistent- Postural Perceptual Dizziness
- Chronic fluctuating dizziness and disequilibrium present
at rest, worse while standing
- Neuro otologic and vestibular tests are normal
DIAGNOSTIC EXAMINATIONS
Focus should be given to the assessment of:
- Eye movements
- Vestibular function
- Hearing

DIAGNOSTIC EXAMINATIONS:
1. HEAD IMPULSE TEST
2. DIX-HALLPIKE MANEUVER
3. DYNAMIC VISUAL ACUITY
Head Impulse Test
- Most useful bedside test of peripheral vestibular function
- VOR is assessed with small amplitude (20 degrees) rapid head rotations
- Can identify BOTH unilateral and bilateral vestibular hypofunction

PROCEDURE POSITIVE
Dix-Hallpike Maneuver
- All patients with episodic dizziness, especially if provoked by positional
change should be tested with the Dix- Hallpike maneuver

PROCEDURE POSITIVE
Dynamic Visual Acuity Test
- Functional test that can be useful in assessing vestibular function
LABORATORY & ANCILLARY TESTING
● AUDIOMETRY
● ELECTRONYSTAGMOGRAPHY/ VIDEONYSTAGMOGRAPHY
● CALORIC TESTING
● ROTATING CHAIR TEST
● NEUROIMAGING
● ROUTINE BLOOD TESTS
MANAGEMENT & TREATMENT
Vestibular Neuritis

● Patients with vestibular neuritis recover spontaneously, but glucocorticoids can

improve outcome if administered within 3 days of symptom onset.

● Antiviral medications are given if there is evidence to suggest Ramsay Hunt

syndrome.
Benign Paroxysmal Positional Vertigo (BPPV)

● BPPV is treated with repositioning maneuvers that uses gravity to remove otoconia from
semicircular canal
● For posterior canal BPPV, the Epley maneuver is the most commonly used procedure.
● For more refractory cases of BPPV, patients can be taught a variant of this maneuver that
they can perform alone at home
EPLEY MANEUVER
Vestibular Migraine

● Vestibular migraine typically is treated with medications that are used for prophylaxis
of migraine headaches .

● Antiemetics may be helpful to relieve symptoms at the time of an attack.

Meniere’s disease

● Diuretics and sodium restriction are the initial treatments.

● If attacks persist, injections of gentamicin into the middle ear are typically the
next line of therapy.

● Full ablative procedures (vestibular nerve section, labyrinthectomy) are seldom

required.
Bilateral Vestibular Hypofunction

● Patients with bilateral vestibular hypofunction should be referred for vestibular

rehabilitation therapy.

● Vestibular suppressant medications should not be used, as they will increase the imbalance.

● Evaluation by a neurologist is important not only to confirm the diagnosis but also to
consider any other associated neurologic abnormalities that may clarify the etiology
Central Vestibular Disorders
● Acute central vertigo is a medical emergency, due to the possibility of life-threatening
stroke or hemorrhage

● All patients with suspected central vestibular disorders should undergo brain MRI, and
the patient should be referred for full neurologic evaluation.
Psychosomatic Dizziness & Vertigo
● Treatment with anti anxiety medications (selective serotonin reuptake inhibitors [SSRIs]) and
cognitive-behavioral therapy may be helpful.

● Vestibular rehabilitation therapy is also sometimes beneficial.

● Vestibular suppressant medications generally should be avoided.

● This condition should be suspected when the patient states, “My dizziness is so bad, I’m afraid to
leave my house” (agoraphobia).
REFERENCES

● Jameson, J. L., & Loscalzo, J. (2015). Harrison's principles of Internal Medicine (19th edition.). New York:
McGraw Hill Education.

● Post RE, Dickerson LM. Dizziness: a diagnostic approach. Am Fam Physician. 2010;82(4):361–368, 369.

● Anatomical and Physiological Considerations in Vestibular Dysfunction and Compensation: Semin Hear.
2009 ; 30(4): 231–241. doi:10.1055/s-0029-1241124