Approach to Dizziness and Vertigo

Approach to Dizziness and Vertigo

• Dizziness is a general term describing various sensations, including vertigo, lightheadedness, faintness, and imbalance.
• Vertigo is the sensation of spinning or other motion, which can be physiological (during or after head rotation) or pathological (vestibular dysfunction).
• Presyncope is the feeling of fainting.
• Syncope is a temporary loss of consciousness due to impaired cerebral blood flow.
• Lightheadedness is a sensation often associated with presyncope, but can also be a sign of disequilibrium or imbalance.
• Disequilibrium is an unsteady feeling in the lower extremities.

Peripheral vs. Central Vertigo

• Peripheral Vertigo:
  • Benign Paroxysmal Positional Vertigo (BPPV)
  • Meniere's Disease
  • Vestibular Neuritis
  • Drugs
• Central Vertigo:
  • Vestibular Migraine
  • Ischemic insult to medulla and cerebellum
  • Vestibular Schwannoma
  • Multiple sclerosis
  • Drugs

Features of Peripheral and Central Vertigo

• Peripheral: Unidirectional nystagmus (fast phase away from the affected ear), inhibited by visual fixation, head impulse test is positive
• Central: Nystagmus may change direction with gaze, not inhibited by visual fixation, head impulse test is negative, unilateral hearing loss suggests peripheral, diplopia, dysarthria, limb ataxia suggest central

Acute Prolonged Vertigo (Vestibular Neuritis)

• Due to asymmetry in inputs from the inner ear or central connections.
• Symptoms: Constant vertigo, nausea, vomiting, visual disturbances (oscillopsia), and imbalance.
• Benign Paroxysmal Positional Vertigo (BPPV): Caused by dislodged otoconia (calcium carbonate crystals) in the semicircular canals, typically posterior. Short episodes (15-20 seconds) triggered by head position changes.

Vestibular Migraine

• Episodic vertigo, sometimes with mild headache.
• Can last minutes to hours, or longer periods of disequilibrium.
• Motion sensitivity (to visual motion, e.g., movies) common.

Meniere's Disease

• Vertigo accompanied by hearing loss, tinnitus, ear fullness, or pressure.
• Asymmetric low-frequency hearing loss on audiometry.
• Caused by excess endolymph fluid in the inner ear.

Vestibular Schwannoma

• Also known as Acoustic Neuroma.
• Unilateral sensorineural hearing loss (SNHL) and vestibular hypofunction.
• Head impulse test will show a deficient response when the head is rotated toward the affected side.
• Nystagmus may not be prominent.
• MRI of the internal auditory canals for diagnosis.

Central Vestibular Disorders

• Involve vestibular pathways in the brainstem and/or cerebellum (e.g., ischemic or hemorrhagic stroke, demyelination, or tumors).
• Acute central vertigo is a medical emergency, possibly life-threatening.
• Brain MRI is indicated, and patients should be referred for neurological evaluation.

Psychosomatic and Functional Dizziness

• Dizziness can be a symptom of psychiatric conditions such as anxiety, depression, or panic disorder.
• Phobic postural vertigo, psychophysiological vertigo, and chronic subjective dizziness are potential conditions.
• Persistent postural-perceptual dizziness (PPPD) is a specific subtype.

Approach to Dizziness

• Obtain a comprehensive history (e.g., duration of symptoms, related symptoms, previous attacks).
• Evaluate if the dizziness is vestibular in origin (e.g., peripheral vs central).
• Rule out neurological red flags (e.g., double vision, loss of strength).
• Assess for acute aural fullness, hearing loss, tinnitus.

Examination

• Neurological examination assessing eye movements, vestibular function, and hearing
• Tests to assess pursuit, saccades, cover test, nystagmus, head impulse test and test of skew (for visual misalignment, may indicate brainstem or cerebellar issue).

Tests of Diagnosis

• Dix-Hallpike Maneuver (to detect BPPV)

• Dynamic Visual Acuity testing (during head movements)

• Neuroimaging (e.g., MRI)

Treatment

• Medications (antihistamines, benzodiazepines, anticholinergics)
• Physical therapy
• Vestibular rehabilitation
• Diuretics and low-sodium diet (in some conditions)
• Antimigrainous medications
• SSRIs (selective serotonin reuptake inhibitors)

Associated Features to Consider

• Hearing loss, tinnitus
• Headache and photophobia
• Nystagmus
• Past medical history, medications
• Family history, personal history (e.g., alcohol use)

References

• Harrison's Principles of Internal Medicine 21st Edition

This quiz explores the various types of dizziness, including vertigo and presyncope. It distinguishes between peripheral and central vertigo, detailing their causes and symptoms. Test your knowledge on the physiological and pathological aspects of these conditions.