Dizziness

“Coles Notes”

Dr. Rick Balys MD, FRCSC

Sue Ehler, BSC PT ; Steven MacNeil, BSC PT, RCA MPT

Faculty/Presenter Disclosure

Faculty: Dr. Rick Balys, FRCSC Otolaryngology

Relationships with commercial interests:

– Grants/Research Support: None

– Speakers Bureau/Honoraria: None

– Consulting Fees: None

– Other: None

CFPC CoI Templates: Slide 1

Disclosure of Commercial Support

None

Potential for conflict(s) of interest:

– None

CFPC CoI Templates: Slide 2

Objectives

Provide an approach to the dizzy patient

Help differentiate the most common forms

of dizziness and vertigo

Discuss when to refer and resources

Philosophy

Rule out the bad stuff

Treat the treatable stuff

Make patients feel better / compensate

Make sure patients don’t get worse (fall)

Method

1. Get them to describe it

2. Classify it

3. What is the timing and trajectory

4. Associated symptoms / signs

What do you mean…Dizzy?

Lightheaded

Faint

Off-Balance

Clumsy

Unable to concentrate

Weak

Leaning

Trouble focusing

Disorientated

Anxious

Floating

Confused

Shaky

Nauseous

Sweating

Fatigue/exhaustion

Spinning

Pulled to one side

The 4 Flavor’s of Dizzyness

1. Lightheaded / presyncopy

2. Disequilibrium (others notice)

A. Gait

B. Global

3. Vertigo

– The illusion of motion

4. Psychogenic / vague / disconnected /

floating (others don’t notice)

1. Presyncope “nearly blacking out”, “nearly fainting”

When you spin around, you might vomit but you never think you are about to pass out

lasts seconds to minutes – Medications

– Orthostatic hypotension

– Cardiac arrhythmias

– Vasovagal attacks

– Severe Anemia / Hypoglycemia

– Hyperventilation / Anxiety

2A. Gait Disequilibrium

Only when standing / walking

Fine when sitting - able to drive

Imbalance / Unsteady / Fall

Neurology / Neuromuscular Multisensory / Progressive disequilibrium of aging

Joints, spine

Cerebellar / movement disorders

Muscular disorders: PMR / MG / GBS / ALS

Progressive Dysequilibrium of

Aging - *** Fall Risk ***

Multisensory disorder:

1. peripheral neuropathy

2. visual impairment

3. musculoskeletal issues

4. vestibular disorder

5. central problems with integration

6. bunyons and improper footwear

7. general weakness

Medications, especially antidepressants,

benzo’s and anticholinergics

Progressive Dysequilibrium of

Aging - *** Fall Risk ***

Slowly get more rickety

Reach a tipping point:

– New drug

– New joint

– New injury

– New environment

– New illness, usually with weight loss

– BPPV

2B. Global Disequilibrium

Symptoms even when sitting

– Unable to drive

– May be central or peripheral vestibular

– Look for ataxia

3. Vertigo…The Illusion of Motion

Never “all the time”

Worse with head movement

Often associated with N/V, Sweating, Pale

There is usually nystagmus

Rotating, tilt, rock, bounce, floor drops

4. Psychogenic

Spacey / Disconnected / Watching world

on TV

Stress, Anxiety, Sleep issues, Medications

(including caffeine)

Possibly Migraine “a global distortion of

sensory perception”

Chronic Subjective Dizziness

– Persistent activation of the Threat State

– MOST COMMON FORM IN PTS < 40

Method

1. Get them to describe it

2. Classify it

3. What is the timing and trajectory

4. Associated symptoms / signs

Timing (of Vertigo) is Everything

Seconds – Minutes

– BPPV

Minutes to Hours

– Migraine or Meniere’s

– CNS (VBI, TIA brainstem or labyrinth)

Days

– Vestibular Neuronitis

– Cerebellar CVA, Lateral Medullary syndrome, MS

Chronic continuous…Psychogenic, Migraine,

CSD, Post-concussion, Chronic pain

Associated Symptoms “You can get to know a person by looking at

who their friends are”

CNS: PD3, Weak, Numb, Ataxia

Meniere’s: Single sided fullness/pressure, Tinnitus, Fluctuating hearing loss

Migraine: Aura, SS Pounding Headache, Photo/phonophobia – Motion sickness, Family History, Menstruation related H/S

Anxiety: SOB, Palpitations, Hyperventilation

With noise or exertion: PLF, SCDS, Meniere’s, Syphilis

BPPV

Episodes of true, often violent spinning

Brief <1min but often followed by N/V

When you think your dying, a minute is an eternity

No hearing change, no tinnitus, no pressure

Occurs in 10%, responsible for about 50% of

Vertigo in Elderly

BPPV – What is Provocative?

1. Rolling in bed (which side?)

2. Looking up and to one direction (grocery store, lightbulb)

3. Putting your head between your legs

Still feel ‘off’ between events

Can last for days to years

but you can take it away instantly!

BPPV Pathophysiology

Otoconia (CaCO3) from the Utricle gets

loose and gets trapped in the posterior

canal (usually)

Where is the posterior

Canal???

BPPV – the Dix Hallpike

The Provocative Position: Head slightly extended

and turned 45o

1. Usually a brief delay

2. Rotatory geotropic nystagmus with a vertical

component (in the plane of the PSSC)

3. Lasts 10 sec to 1 min

4. Vertigo returns but nystagmus less

pronounced on return to upright

5. Fatigable

BPPV – the Dix Hallpike

(Also the first position of Epley)

Meniere’s Disease

One Sided Ear Symptoms!

1. CONTINUOUS Vertigo lasting minutes to hours (can have a few days of fatigue)

2. Fluctuating Unilateral SNHL

3. Unilateral Tinnitus

– Usually low pitch

– Can intensify before an attack

4. Unilateral pressure / fullness

Meniere’s / Endolymphatic Hydrops

Meniere’s Treatment

Low salt diet (<1500mg/d)

Avoid caffeine, cola, nicotine, alcohol, chocolate

HCTZ

Serc (8-24mg TID)

Tympanostomy tube

Intratympanic steroids

Intratympanic gent

Migraine & Vertigo

15x more common than Meniere’s(Rauch)

Problem with brain chemistry – dysfunction of sensory signal processing

Migrainous vertigo: – 2 episodes of vertigo concurrent with migraine

features (H/A, PP, PP, Aura)

Migraine-associated vertigo: – Episodic vertigo in a pt with migraine disorder (HIS

criteria)

Mimics Meniere’s but no hearing loss

Motion Sensitivity

Migraine Associated Vertigo

Treatment

Avoid triggers

– Stress change, caffeine change, weather change, hormone change.

– Dietary triggers

TCA, B-Blocker, CCB, Topiramate,SSRI’s

Manage flare ups

Vestibular Neuronitis

Constant Vertigo x Days

– Usually with nausea, vomiting, and nystagmus

– Often a URTI within 2 wks before event

No other neurological or audiological symptoms

Horizontal and slight torsional nystagmus

COWS (fixed direction) and Alexander’s Law

Fixation suppression, worse with head

movement

Vestibular Neuronitis

Ensure hearing is not involved

Vertigo stops in days

– Use Vestibular suppressants for 5 days tops

Imbalance persists for weeks

Expect full recovery

Can be followed by BPPV

Rarely recurrent (recurrent vestibulopathy)

Central Nystagmus

Can be purely vertical, purely horizontal

Can change in direction with gaze change

(bidirectional)

No fixation suppression

No significant change with head motion

Doesn’t stop (BPPV)

Not fatigable

Other neurological findings

Red Flags - Image

Neck injuries / Head injuries

Hx of Significant Ear disease / surgery / trauma

Unexplained Neurolgical Findings

Exam findings – Vertical nystagmus, direction changing, not following the rules

– Horners

CVA RF – Advanced age

– Previous TIA / CVA / CAD

– Hypertension

– DM

– Hypercholesterolemia

– Smoking

– Atrial fibrillation

Exam

Otoscopy

Gait – Ataxic, Staggering, Wide based gait

Nystagmus

CN testing, Horner’s

Cerebellar testing – Finger nose

– RAM

– Toe tapping and Heel shin

Romberg testing – With distraction

Stepping Test – With distraction

Dix Hallpike

Cheat Sheet Describe it

Classify it:

1. Lightheaded

2. Vertigo

3. Gait vs Global dysequilibrium

4. ‘Spacey’

Timing

– Min: BPPV

– Hours: Migraine, Meniere’s (ss ear sx), VBI

– Days: Vestibular neuronitis, MS, VBI/CVA

– Weeks: ?anxiety

Associated symptoms

– Focal neurological

– Single side tinnitus, pressure and hearing loss

– Motion sickness, photophobia, phonophobia, headache

– SOB, palpitations, anxiety

When To Refer

Red Flags

Suspected Central Cause

Not responding / Symptoms progressing

Associated hearing loss

Deteriorating quality of life

Who to refer to?

Audiology (hearing assessment)

Radiology (head and temporal bones)

Physiotherapy “specialists”

– Atlantic Balance and Dizziness Centre

– Vest Rehab Adv Comp (Emmory)

ENT

Neurology

If all else fails….

Meniere’s Natural History

Exacerbations and remissions

Within 10 years most patients are in

remission

– Often with a 50dB hearing loss

10-50% can get bilateral disease