Dizziness & Vertigo

~Sneha S
Final year Mbbs
● Dizziness nonspecific symptom used to describe a
variety of common sensations that include vertigo,
light-headedness, faintness, and imbalance.
● Vertigo refers to a sense of spinning or other
motion.
● Physiological- occurring during or after a sustained
head rotation
● pathological – due to vestibular dysfunction.
 Causes of dizziness

● BPPV ● Basilary artery migraine

● Labyrinthitis ● Cerebellar infarct
● Vestibular neuronitis ● Vertebrobasillar insufficiency
● Ménière’s disease ● AICA /PICA syndrome
● Acoustic neuroma ● Hypoglycemia.
Approach to the patient
History:
● onset : acute /chronic
● Duration:
seconds(BPPV&orthostatic hypotension)
Minutes (TIA of posterior circulation)
Hours&days:(Attacks of vestibular migraine& Ménière’sdisease)
● First attack or prior epidodes
● Provoking factors
● Accompanying symptoms( helps to distinguish central
peripheral causes.)
● U/L hearing loss , aural symptoms (ear pain,pressure,
fullness,tinnitus) points peripheral causes
● Double vision,numbness,limb ataxia are symptoms of brainstem
and cerebellum lesions.
Vertigo-Examination

● Cerumen/FB in EAC ● Auscultate for carotid

(otoscopy) bruit
● Neurological examination ● BP&Pulse in both arms
● Nystagmus ● Dix-Hallpike maneuver
● Fundoscopic Examination ● Head Impulse Test
● Pupillary abnormalities ● Gross hearing
● EOM (eye movements) ● Weber-Rinne test
● Cranial nerves ● Gait &cerebellar function
 Examination
Eye movements
● Range of eye movements
● Peripheral eye movement disorders -
disconjugate (different in the two eyes).
● Pursuit -the ability to follow a smoothly
moving target
● Saccades -the ability to look back and
forth accurately between two targets
● Poor pursuit or inaccurate (dysmetric)
saccades - central pathology involving
cerebellum..
 Cover test
● To check Alignment of the two eyes

● while the patient is looking at a target,

alternately cover the eyes and observe

for corrective saccades.

● vertical misalignment- brainstem or

cerebellar lesion.
 Nystagmus
● Nystagmus - involuntary back-and-forth movement of the
eyes
● Lesions of the cerebellar pathways:
▪vertical nystagmus (downbeat nystagmus)
▪horizontal nystagmus (gaze evoked nystagmus)
● Peripheral lesions - unidirectional horizontal nystagmus.
● Use of Frenzel eyeglasses
● infrared video goggles
● they reduce the patient’s ability to use
visual fixation to suppress nystagmus.
 Head Impulse Test
● The most useful bedside test of
peripheral vestibular function.
● vestibulo-ocular reflex (VOR) is
assessed
● While the patient fixates on a target,
the head is rotated quickly to the left or
right.
● If the VOR is deficient, the rotation is
followed by a catch-up saccade in the
opposite direction (e.g., a leftward
saccade after a rightward rotation).
● Unilateral/Bilateral
 Dix Hallpike maneuver:
● episodic dizziness, especially if
provoked by positional change,
should be tested with the
Dix-Hallpike maneuver
● The patient begins in a sitting
position with the head turned 45
degrees; holding the back of the
head,
● the examiner then lowers the
patient into a supine position with
the head extended backward by
about 20 degrees while watching
the eyes.
● Posterior canal BPPV can be
diagnosed if transient
upbeating-torsional nystagmus is
seen.
● If no nystagmus is observed after
15–20 s, the patient is raised to the
sitting position, and the procedure is
repeated with the head turned to
the other side.
● Frenzel goggles may improve the
sensitivity of the test.
 Dynamic visual acuity
● Functional test - assessing vestibular
function.
● Visual acuity is measured with the head
still and when the head is rotated back
and forth by the examiner (about 1–2
Hz).
● A drop in visual acuity during head
motion of more than one line on a near
card or Snellen chart is abnormal
● indicates vestibular dysfunction.
Features of central and peripheral vertigo
FEATURES PERIPHERAL CENTRAL

Nystagmus Unidirectional (beating Changes direction with

away from ear with lesion) gaze

Type of Nystagmus Transient mixed Pure vertical/pure torsional

vertical-torsional
Nystagmus

Head impulse sign Present Absent

On visual fixation Nystagmus inhibited Nystagmus not suppressed

Associated symptoms U/L Hearing loss Diplopia,Dysarthia,Limb

ataxia
 Ancillary test:
● Audiomtery - vestibular disorder
● Videonystagmography- positional nystagmus
● Caloric testing compares the responses of the two horizontal
semicircular canals
● video head-impulse testing - the integrity of each of the six
semicircular canals.
● Neuroimaging - central vestibular disorder is suspected.
● MRI of the internal auditory canals to rule out a
schwannoma.
Differential Diagnosis and
Treatment
Acute Prolonged Vertigo (vestibular
neuritis)
➢ An acute U/L vestibular lesion causes constant vertigo,
nausea, vomiting, oscillopsia (motion of the visual
scene) &imbalance.
➢ sudden asymmetry of inputs from the two labyrinths or
in their central connection.
➢ central - cerebellar or brainstem infarct or hemorrhage.
➢ peripheral-affects vestibular nerve or labyrinth
(vestibular neuritis).
➢ Vestibular neuritis recover spontaneously.

Treatment:
➢ Antiviral medications - herpes zoster oticus (Ramsay
Hunt syndrome).
➢ Vestibular suppressant medications reduce acute
symptoms but should be avoided after the first several
days because impede central compensation &recovery.
➢ Vestibular rehabilitation therapy.
Benign paroxysmal positional vertigo (BPPV)
● Recurrent vertigo. (Extremely common)
● Episodes are brief (<1 min and typically 15–20 s)
● Provoked by changes in head position relative to gravity
● On lying down, rising from a supine position, and
extending the head to look upward.
● Rolling over in bed is a common trigger (distinguish BPPV
from orthostatic hypotension).
 Pathophysiology
● Calcium carbonate crystals-otoconia
displacement
● Dislodge from utricle to semicircular
canalas
● Posterior semicircular canal (mc) -
upbeating-torsional nystagmus and
vertigo
● Horizontal canal-Horizontal nystagmus
● Anterior (superior) canal -rare
● No hearing loss /tinnitus.
TREATMENT
● BPPV is treated with repositioning maneuvers that use
gravity to remove the otoconia from the semicircular
canal.
● For posterior canal BPPV, the Epley maneuver is the
most commonly used procedure.
Bilateral Vestibular hypofunction:
➢ No vertigo-vestibular function is lost on both sides
simultaneously, and there is no asymmetry of vestibular
input.
➢ Symptoms:
loss of balance, particularly in the dark, where
vestibular input is most critical.
oscillopsia
➢ Idiopathic ,drugs like gentamicin.
On Examination:
● diminished dynamic visual acuity
● abnormal head impulse responses in both
directions
● Romberg sign positive.

Treatment:
● vestibular rehabilitation therapy.
● Vestibular suppressant medications not used-
increase the imbalance.
● Refer to neurologist.
Vestibular Migraine:
★ Episodic vertigo
★ Precedes typical Migraine headache/mild
headache/without headache (often).
★ Other migraine features:
photophobia,phonophobia,visual aura present.
★ Motion & visual motion (movies) sensitivity
★ Treatment: medication for prophylaxis of migraine
. At the time of attack - antiemetics.
 Meniere’s Disease
★ Lowfrequency hearing loss
,vertigo,tinnitus
★ Excess endolymph fluid in the inner ear
Endolymphatic hydrops.
★ refer to an otolaryngologist for further
evaluation.
 Treatment:

★ Diuretics & sodium restriction (initially)

★ If attacks persist, injections of glucocorticoids or
gentamicin into the middle ear may be considered.
★ Nonablative surgical options –decompression and
shunting of the endolymphatic sac.
★ Full ablative procedures (vestibular nerve section,
labyrinthectomy) are seldom required.
Vestibular Schwannoma:
➢ Aka acoustic neuromas and other tumors at the cerebellopontine
angle
➢ slowly progressive U/L sensorineural hearing loss and vestibular
hypofunction.
➢ No vertigo- compensated gradual vestibular deficit
➢ head impulse test - deficient
➢ nystagmus not prominent.
➢ MRI of internal auditory canals .
 Central Vestibular Diorders

Central lesions involving vestibular pathways in the

brainstem and cerebellum.

● Ischemic/hemorrhagic stroke
● Demyelination,tumours (vestibulocerebellum lesion)
Acute central vertigo -emergency condition.
MRI brain , full neurological evalution needed.
Psychosomatic &Functional Dizziness
● Chronic dizziness >3months
● major depression, anxiety or panic
disorder (mc)
● phobic postural vertigo,
psychophysiologic vertigo, or chronic
subjective dizziness,now referred to as
persistent postural-perceptual
dizziness (PPPD).
● Increased sensitivity to self-motion,
visual motion ,complex visual motion
like super markets .
● neuro-otologic examination and vestibular testing are normal
○ indicating that the ongoing subjective dizziness cannot be
explained by a primary vestibular pathology.
● Treatment
○ selective serotonin reuptake inhibitors
 Treatment of vertigo
Antihistamines Benzodiazepines
★ Meclizine 25-50mg TID
★ Dimenhydrinate 50mg OD/BD ★ Diazepam 2.5mg OD/TID
★ Promethazine 25mg BD/TID. ★ clonazepam 0.5mg OD/TID
(rectally or im)
Anticholinergic
★ Scopolamine transdermal patch

Physical therapy Others

★ Repositioning maneuvers ★ Diuretics
★ Vestibular rehabilitation (for ★ Low sodium diet (1000mg/d).
gaze stabilization & balance) ★ SSRI
★ Anti migraine drugs
References:
HARRISON’S PRINCIPLES OF INTERNAL MEDICINE 21st Edition
Thank you