A PRACTICAL APPROACH TO DIZZINESS
DIZZINESS is a Common complaintAssessment is often daunting & challengingDiagnosis is usually made on:• history• history• historyDiagnosis is usually confirmed by:• Physical Examination• InvestigationsEg: Benign Paroxysmal Positional Vertigo (BPPV)
!!! KEY: History begins by trying to understand what the patient means by "dizziness" !!! VertigoDysequilibriumLight-headedness Vertigo• Defn: illusion of motion• Subjective vs Objective• Types:• Rotatory (? SCC problem)• Linear (? Otolith organ problem)• Floating Dysequilibrium• Defn: inability to maintain the centre of gravity• "On a boat"• Imbalance, falling, stumbling• Cause:• Vestibular (peripheral or central)• Non-vestibular - Sensory (propriocetn/senstn) - Motor (muscle weakness/arthritisLight-headedness
• Defn: similar symptoms to those preceding syncope bullet Eg: sitting up quicklybullet Cause: bullet • NOT Vestibularbullet • ? Cardiac, Vascular (VBI), vaso-vagal, metabolic, hyperventilation ?? Try to simulate by hyperventilating The History"I understand you have been referred to me because you have dizziness, please tell me what you feel when you have this sensation and let us not use this word"Attack characteristics• Initial attack: date/duration/nature• Last attack : date/duration (secs min hrs) /nature• Frequency: per day/week/month• Precipitating factors: causal event/position/exertion• Relieving factors: position/medn• Associated SymptomsOtologic symptoms* Hearing loss* Tinnitus* Ear Fullness/PressureNon-Otologic symptoms• Visual disorientation (loss of visual cues)• Intolerance of visual motion• Disruption of focusing & depth perception• Oscillopsia: movement of horizon with walking (eg video recorder)• Neurologic: headaches (migranous vertigo)• weakness, numbness, seizures (vascular, tumours, MS)• Psychiatric: anxiety, hyperventilation, halluc’n (not usually vertigo)• Cardiac: palpitations• Autonomic: dysautonomia may => postural hypotension• Degenerative: presbystasis• Metabolic CLUES TO Diagnosis IF VERTIGO (ie Duration of VERTIGO) Seconds (5-90 secs): Benign Paroxysmal Positional Vertigo bullet Minutes (2-20mins): Vascular (usually assoc with other symptoms) (?? Under-reported) Non Vascularbullet Hours (20 mins-24hrs): Meniere’s Disease (usually 4-8 hours) Migraine Acoustic Neuroma (? Infarction of nerve) (Tip: telephone positive sign) Days: Strongly suspect Vestibulo-Neuro-Labyrinthitis (VNL) NB: Perilymphatic fistula: any of above, usually assoc’d with hearing loss) EXAMINATION OF THE DIZZY PATIENTGeneral Examination: PR, BP, TempENT, Head & Neck ExaminationNeurotologic Exam (Balance Testing):Fistula TestEyes: Smooth Pursuit, Nystagmus, Head Shake, Snellen's oscillopsiaGaitRombergUnterbergerHallpikeOther Tests of co-ordination EYES:Smooth Pursuit:- allows clear continuous vision of moving objects- Test: target 1 m from pt- If Ab(N) => ? B/Stem or cerebellarmedn’s: BZ’s, Anticonvul, LiSaccadic Eye Movement:- Test: 2 objects 1m away, 150 apart- If Slowing: INO (B/S , MS)- If Inaccurate: cerebellum- Prob initiating: Parkinson’sNystagmus:Direction = Fast PhasePlaneTypes: Spontaneous: Primary Gaze or <300 from midline(Remember: End Point Nystagmus)Evoked: Head shake, PositioningVestibular = "direction fixed" (vs Central)? Side of Vestibular Lesion:Acute Hypofunction (cut vestib nerve) = FAST PHASE C/LATERALChronic Lesion (usually htpofunction) = FAST PHASE C/LATERALAcute Irritative lesion (VNL) = FAST PHASE IPSILATERALSnellen’s Oscillopsia:• Sensitive test for vestibular lesion• Test: read Snellen's chart with head stationary then read with 60 deg head rotation (1-2 cycles/sec)• (N) = degrade by 1 line• Unilateral loss = degrade by 2-4 lines• Bilateral loss = degrade by 5-6 lines• Good test for monitoring ototoxic medicationsGAITQuestions ??• Is the gait relatively normal ?• Does the patient require assistance to walk stand ? • wide based (? cerebellar disorder)• shuffling (? Parkinson’s) (?exaggerated ???? malingering)• Does the patient veer into wall ? (vestibular / cerebellar)ROMBERG TESTSharpened (or Tandem) RombergTests: dorsal white column & vestibularUNTERBERGER (FUKUDA) TESTMarching, eyes closed, arm extendedPositive if >45 deg turn in 50 stepsGood vestibular testHALLPIKE TESTTest of BPPVPositive if: nystagmus +/- subjective vertigo INVESTIGATIONS Audiogram (pure tone & speech discrimination) Vestibular Function Tests (VFT’s) • Electronystamography (ENG) • Rotational Chair ullet • Posturography • Electrocochleography (ECoG).. If suspect MD ImagingIf suspect a central lesion on Hx & ExamAtypical clinical featuresAsymmetry on above investigationsMRI & MRA (with Gadolinium)…. Soft tissue lesionCT Petrous Temporal Bones…. Bony lesionsBloods (rarely)TRANSCRANIAL DOPPLER emits a signal => reflected off moving RBC’smagnitude of change in frequency = velocity STENOSISincrease in blood flow velocity to allow same volume of blood to pass through DIZZINESS – SUMMARY(VDLMOP)VertigoDysequilibriumLight-headednessMultisensory DizzinessMigraine VariantOcular DizzinessOscillopsiaPsychological DizzinessPhysiologic Dizziness
Copyright © 2001. Dr Zoran Becvarovski. All rights reserved.Revised: 26-02-2003.
• Defn: similar symptoms to those preceding syncope bullet Eg: sitting up quicklybullet Cause: bullet • NOT Vestibularbullet • ? Cardiac, Vascular (VBI), vaso-vagal, metabolic, hyperventilation ?? Try to simulate by hyperventilating The History"I understand you have been referred to me because you have dizziness, please tell me what you feel when you have this sensation and let us not use this word"Attack characteristics• Initial attack: date/duration/nature• Last attack : date/duration (secs min hrs) /nature• Frequency: per day/week/month• Precipitating factors: causal event/position/exertion• Relieving factors: position/medn• Associated SymptomsOtologic symptoms* Hearing loss* Tinnitus* Ear Fullness/PressureNon-Otologic symptoms• Visual disorientation (loss of visual cues)• Intolerance of visual motion• Disruption of focusing & depth perception• Oscillopsia: movement of horizon with walking (eg video recorder)• Neurologic: headaches (migranous vertigo)• weakness, numbness, seizures (vascular, tumours, MS)• Psychiatric: anxiety, hyperventilation, halluc’n (not usually vertigo)• Cardiac: palpitations• Autonomic: dysautonomia may => postural hypotension• Degenerative: presbystasis• Metabolic CLUES TO Diagnosis IF VERTIGO (ie Duration of VERTIGO) Seconds (5-90 secs): Benign Paroxysmal Positional Vertigo bullet Minutes (2-20mins): Vascular (usually assoc with other symptoms) (?? Under-reported) Non Vascularbullet Hours (20 mins-24hrs): Meniere’s Disease (usually 4-8 hours) Migraine Acoustic Neuroma (? Infarction of nerve) (Tip: telephone positive sign) Days: Strongly suspect Vestibulo-Neuro-Labyrinthitis (VNL) NB: Perilymphatic fistula: any of above, usually assoc’d with hearing loss) EXAMINATION OF THE DIZZY PATIENTGeneral Examination: PR, BP, TempENT, Head & Neck ExaminationNeurotologic Exam (Balance Testing):Fistula TestEyes: Smooth Pursuit, Nystagmus, Head Shake, Snellen's oscillopsiaGaitRombergUnterbergerHallpikeOther Tests of co-ordination EYES:Smooth Pursuit:- allows clear continuous vision of moving objects- Test: target 1 m from pt- If Ab(N) => ? B/Stem or cerebellarmedn’s: BZ’s, Anticonvul, LiSaccadic Eye Movement:- Test: 2 objects 1m away, 150 apart- If Slowing: INO (B/S , MS)- If Inaccurate: cerebellum- Prob initiating: Parkinson’sNystagmus:Direction = Fast PhasePlaneTypes: Spontaneous: Primary Gaze or <300 from midline(Remember: End Point Nystagmus)Evoked: Head shake, PositioningVestibular = "direction fixed" (vs Central)? Side of Vestibular Lesion:Acute Hypofunction (cut vestib nerve) = FAST PHASE C/LATERALChronic Lesion (usually htpofunction) = FAST PHASE C/LATERALAcute Irritative lesion (VNL) = FAST PHASE IPSILATERALSnellen’s Oscillopsia:• Sensitive test for vestibular lesion• Test: read Snellen's chart with head stationary then read with 60 deg head rotation (1-2 cycles/sec)• (N) = degrade by 1 line• Unilateral loss = degrade by 2-4 lines• Bilateral loss = degrade by 5-6 lines• Good test for monitoring ototoxic medicationsGAITQuestions ??• Is the gait relatively normal ?• Does the patient require assistance to walk stand ? • wide based (? cerebellar disorder)• shuffling (? Parkinson’s) (?exaggerated ???? malingering)• Does the patient veer into wall ? (vestibular / cerebellar)ROMBERG TESTSharpened (or Tandem) RombergTests: dorsal white column & vestibularUNTERBERGER (FUKUDA) TESTMarching, eyes closed, arm extendedPositive if >45 deg turn in 50 stepsGood vestibular testHALLPIKE TESTTest of BPPVPositive if: nystagmus +/- subjective vertigo INVESTIGATIONS Audiogram (pure tone & speech discrimination) Vestibular Function Tests (VFT’s) • Electronystamography (ENG) • Rotational Chair ullet • Posturography • Electrocochleography (ECoG).. If suspect MD ImagingIf suspect a central lesion on Hx & ExamAtypical clinical featuresAsymmetry on above investigationsMRI & MRA (with Gadolinium)…. Soft tissue lesionCT Petrous Temporal Bones…. Bony lesionsBloods (rarely)TRANSCRANIAL DOPPLER emits a signal => reflected off moving RBC’smagnitude of change in frequency = velocity STENOSISincrease in blood flow velocity to allow same volume of blood to pass through DIZZINESS – SUMMARY(VDLMOP)VertigoDysequilibriumLight-headednessMultisensory DizzinessMigraine VariantOcular DizzinessOscillopsiaPsychological DizzinessPhysiologic Dizziness
Copyright © 2001. Dr Zoran Becvarovski. All rights reserved.Revised: 26-02-2003.
Disclaimer
Please note: The above is intended as a general guideline only for Dr. Becvarovski’s patients.
This material should not be used for purposes of diagnosis or treatment without consulting a physician.
Each patient is an individual and should be treated accordingly.
Please contact our rooms if you are concerned or require any further information.
Please note: The above is intended as a general guideline only for Dr. Becvarovski’s patients.
This material should not be used for purposes of diagnosis or treatment without consulting a physician.
Each patient is an individual and should be treated accordingly.
Please contact our rooms if you are concerned or require any further information.