Differential Diagnosis of Dizziness

Sarah GuarinoIthaca College

What can cause dizziness?Vertigo

Benign Paroxysmal Positional Vertigo (BPPV): Brief and intense (10-20 seconds) sensation of spinning with rapid head movements due to displacement of inner ear crystals.

Infection Labyrinthitis: sudden hearing loss or vertigo from viral (ex: flu) or

bacterial irritation, a side effect of medication, allergies or ear infection that causes swelling of the inner ear.

Vestibular neuritis

Migraine Sometimes coupled with light and noise sensitivity

Meniere’s disease Episodes of vertigo (minutes to hours) caused by build up of fluid in

the inner ear. Hearing loss, tinnitus, feeling of a plugged ear

Blood pressure

Circulatory condition Cardiomyopathy, MI, heart arrhythmia, TIA or decrease in BV

Neurological condition PD, MS, stroke

Acoustic Neuroma Benign tumor on the vestibular nerve Tinnitus and gradual hearing loss; usually no vertigo

Medication Anxiety

Panic attacks can cause dizziness or lightheadedness Anemia

Coupled with fatigue, weakness and pale skin Hypoglycemia

DM (insulin dependent): coupled with sweating and anxiety Dehydration

Hyperthermia Especially with pts. with heart complications on heart medications

Orthostatic HypotensionA sudden drop in systolic BP causes lightheadedness often

when pt. stands up too quickly from sitting or laying down.Lasts seconds to minutes.

Blurred vision, weakness, confusion, nausea, faintness

Causes: dehydration, CV disease, NS disorders (PD, MS), endocrine problems (hypoglycemia), after eating meals

Risk factors: age, medications, disease, pregnancy, bed rest, disease, alcohol

Complications: falls, stroke, CV diseaseSystolic drop >20 mm HgDiastolic drop of >10 mm Hg

MedicationsAnti-seizureAntidepressants

PD

SedativesAntipsychoticsTranquilizers/ muscle

relaxantsErectile dysfunctionNarcotics

HBP meds (lower BP too much) Diuretics Alpha blockers Beta blockers ACE inhibitors Nitrates Calcium channel blockers

Cerebellar ~3% of pts who present to ED with vertigo actually have

cerebellar infarction. Misdiagnosis rate is as high as 35% Mortality rate can be as high as 40%

Symptoms reach maximal intensity at onset.Risk factors: hypertension and CV disease Exam:

Negative head thrust test Severe ataxia*

Inability to walk without support Multidirectional nystagmus*

Imaging: Hemorrhagic = CT and MRI are equally effective Ischemic = MRI has 83% sensitivity and CT has 26%

Vestibular NeuritisConstant vertigo due to a viral infection of the vestibular

nerve.Gradual onset that improves over days however full recovery

takes weeks to months.Symptoms are persistent and ongoing.

Nausea and vomiting Exam:

Normal neurological exam Normal limb coordination Positive head thrust test

Nystagmus: fast phase is towards affected ear Horizontal and torsional in a unidirectional manner Alexander’s Law: nystagmus is accentuated when looking away

from the affected ear.

Where do you start?Detailed history to rule out central involvement:Red Flags

Persistent vertigo Progressively worsening symptoms Vertical eye movements Severe headache (especially in morning when ICP is high) 5 D’s (diplopia, dysarthria, dysphasia, drop attack, dizziness) 3 N’s (numbness, nausea, nystagmus) Vomiting Ataxia Cerebellar signs CV palsies Papilloedema Fever Weakness Horner’s sign

Disequilibrium Cervical spine screen first!Visual, sensory or

vestibular disturbance?Eye exam:

CN III, IV, VI = H test/ visual field tracking

SaccadesVORHead thrust test

Sensory exam:Light touchVibration

Balance exam:EO on firm surfaceEC on firm surfaceEO on variable surfaceEC on variable surface

Benign Paroxysmal Positional Vertigo

B: not life threateningP: sudden, brief spellsP: triggered by head position or movementV: false sense of rotational movementLifetime occurrence: 2.4%Re-occurrence rate: 50% in first 5 years90% of pts. respond in 1-3 treatmentsCanalithiasis: otoconia are in the canals, symptoms resolve <60 secondsCupulolithiasis: otoconia adhere to the cupula and symptoms last for >60 seconds

Anterior canal = rotation around sagittal plane (nodding head)

Posterior canal = rotation around coronal plane (side bending)

Horizontal canal = rotation around a vertical axis (cervical rotation)

Nystagmus The result of a miscommunication between the

vestibular and visual systems that causes rapid uncontrollable eye movements.

BPPV specific:Latency of 5-10 seconds before onset of nystagmusLasts 5-120 secondsPositionalRepeated stimulation causes fatigue or disappearance Rotatory/torsional component present

Geotropic: towards the groundAgeotropic: away from the ground

Visual fixation will suppress intensity

Treatment of BPPV Cupulolithiasis:

Liberatory Maneuver: utilize rapid head movements in the plane of the affected canal to dislodge the crystals first

Canalithiasis: Anterior canal (<5%)

Dix-Hallpike Test (R cervical rotation tests the R inner ear) Semont Maneuver (L cervical rotation treats the R inner ear) : 90.3% success rate

Horizontal canal (10-15%) Roll Test Roll Maneuver

* Posterior canal * Dix-Hallpike Test Epley Maneuver: 90.3% success rate

Brandt-Daroff exercises (HEP) Habituation method which is similar to the Semont Maneuver The pt. rolls onto the unaffected side and the head is rotated towards the

affected side 5-10 reps, 3x a day until pt. is symptom free at least 2 days

Epley Maneuver

Dix Hallpike Test

Semont Maneuver

Roll Maneuver

Case studyA 60 year old woman reports sudden dizziness when she

arises from bed. She feels nauseous and had been vomiting. She recently had a severe cold. Her vomiting has settled, but she is dizzy on turning her head to the

right. She is frightened to leave her house.Rising from bed: postural hypotensionVomiting: peripheral vestibular diseaseCold: vestibular neuritisPositional symptoms: BPPVAnxiety: impedes central adaptation

References http://www.ncbi.nlm.nih.gov/pmc/articles/PMC552814/ http

://www.mayoclinic.org/diseases-conditions/dizziness/basics/tests-diagnosis/con-20023004

https://medlineplus.gov/ency/article/001054.htm http://vestibular.org/autoimmune-inner-ear-disease-aied# http://vestibular.org/understanding-vestibular-disorders/types-ve

stibular-disorders/benign-paroxysmal-positional-vertigo

http://www.neuropt.org/docs/vsig-physician-fact-sheets/beyond-posterior-canal-bppv.pdf?sfvrsn=2

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2791733/