VERTIGO / DIZZINESS

 

Overview:

  1. When dealing with pt c/o dizziness we have to differentiate by history if pt has vertigo of Vestibule origin i.e. labyrinth, brain stem or cerebellum or not - i.e. cardiac (pre-syncope, arrhythmia), vascular (anemia,  volume), autonomic dysfunction, carotid blockage. In case of Vestibule origin, pt has sense of self spinning, whereas if dizziness is not originated from "equilibrium organs" (not Vestibular) pt c/o lightheadedness, weakness. The latter may have orthostatic changes, anemia, +UPT, heart murmur (AS), neuropathy (DM).
     
  2. Just like when dealing with SOB as a possible sign of angina equivalent or as a sign of PE, when dealing with   vertigo consider VBI (vertbro basilar insufficiency).
     
  3. Once it is established that you are dealing with vertigo, you have to determine if  it is "peripheral" and   benign  or  "central" and more ominous.

 

Classification:

  1. PERIPHERAL: Labyrinth  or Cranial nerve VIII apparatus is involved.

Causes:  

    1. Vestibular neuritis: Viral. Tinnitus. No hearing loss.
       
    2. Labirinthitis: Viral. Hearing loss. Can be also 2ry to trauma to or near ear = "concussion" labirinthitis.
       
    3. Meniere's: Recurrence  of vertigo, deafness, tinnitus. M=F > 50y.o.
       
    4. Drugs : ASA, Quinidine, Phenytoin.
       
    5. Post traumatic : Can be acute and resolve in weeks or appear days after  injury and resolve in a few months.
       
    6. Acustic neuromas and CP angle tumors : Hearing loss, unsteady gait, N/V.
       
    7. Benign Positional Vertigo (BPV): No deafness or tinnitus. Vertigo with change of position that lasts less  than a minute.

S &S :

    1. N/V, Diaphoresis, +/- Tinnitus, +/- Hearing loss, Fatiguable nistagmus. 

DX :

    1. History is important to distinguish among various causes of  peripheral vertigo
       
    2. Nylen-Barany test is helpful in diagnosis of  BPV and consists of nistagmus that occurs with latency of  2-20 s, lasts < 1min and fatigues after repetitive exams. Pt is held in sitting position , then placed supine quickly  and head is rotated 45 first L and then R. While doing this look for nistagmus.
       
    3. CT of head, drug screen and electrolytes are ordered as needed

Treatment:

    1. Antihistaminics such as Dimenhydrinate (Dramamine)
       
    2. Meclizine (Antivert).
       
    3. Diazepam (Valium) if above are not helpful.

B. CENTRAL: Cerebellum and brain stem are involved.

Causes:

    1. CVA (vertibrobasilar infarct)
    2. TIA (vertibrobasilar insufficiency)
    3. Tumor (in cerebellar location)
    4. Infection
    5. MS

S & S :

    1. Vague vertigo, ataxia, and other signs of cerebellar involvement such as dysarthria, dyskinesia,visual changes, etc.
       

DX :

    1. Nistagmus of central origin has no latency, does not fatigue, lasts > 1min, multidirectional.
       
    2. CT, MRI.
       

Treatment:

    1. Depends on diagnostic outcome.

       

C. OTHER CAUSES of VERTIGO

    1. Psychogenic (described as out-of-body experience)
       
    2. Motion sickness
       
    3. Visual-to-Sensory input imbalance as when watching fast moving object or watching from height.
       
    4. Disequilibrium Syndrome that occurs 2ry  to sensory deficit (visual, auditory) that alters pt's  equilibrium
       
    5. Flu and  fatigue
       
    6. Hyperventilation
       
    7. Anxiety
       
    8. Autonomic dysfunction  in  elderly  or diabetic pts.
       
    9. VBI

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