DizzinessDizziness

A Patient Complaint That Can A Patient Complaint That Can Make the Doctor’s Head Spin.Make the Doctor’s Head Spin.

What Is DizzinessWhat Is Dizziness ??

• A non-specific term used to describe A non-specific term used to describe a number of signs and symptomsa number of signs and symptoms– UnsteadinessUnsteadiness– GiddinessGiddiness– Light-headedLight-headed– DisequilibriumDisequilibrium– VertigoVertigo

Dizziness, Hearing Loss, and TinnituDizziness, Hearing Loss, and Tinnitus/ Baloh,R.W 1998,F.A.Davis Cos/ Baloh,R.W 1998,F.A.Davis Co

Focus of Diagnostic WorkupFocus of Diagnostic Workup

• Vertigo – auditory and Vestibular systemVertigo – auditory and Vestibular system• Near-faint dizziness– cardiovascular Near-faint dizziness– cardiovascular

systemsystem• Psychophysiological dizziness - Psychophysiological dizziness -

psychiatricpsychiatric• Hypoglycemic dizziness- metabolic Hypoglycemic dizziness- metabolic

assessmentassessment• Disequilibrium – peripheral nerves, Disequilibrium – peripheral nerves,

spinal cord, inner ear, vision, CNSspinal cord, inner ear, vision, CNS

VertigoVertigo

• An illusion of movement in spaceAn illusion of movement in space– Rotation (most common)Rotation (most common)– LinearLinear– TiltTilt

History of the Dizzy PatientHistory of the Dizzy Patient

• Detailed description of dizzinessDetailed description of dizziness

• Differentiate vertigo from non-vertigoDifferentiate vertigo from non-vertigo

• Determine onset, length, and if recurrentDetermine onset, length, and if recurrent

• Associated neurological or systemic Associated neurological or systemic signssigns

• Any hearing loss?Any hearing loss?

• Current medicationsCurrent medications

• Differentiate Peripheral vs. Central causeDifferentiate Peripheral vs. Central cause

Differential Diagnosis and ManagemDifferential Diagnosis and Management for the Chiropractor, Aspen Publient for the Chiropractor, Aspen Publishers, Inc 2001shers, Inc 2001

Peripheral or Central Cause?Peripheral or Central Cause?

PeripheralPeripheral• Labyrinth or Labyrinth or

vestibular nerve vestibular nerve dysfunctiondysfunction

• RecurrentRecurrent• Nystagmus-Nystagmus-

horizontalhorizontal• Position changePosition change• Moderate to severe Moderate to severe

vertigovertigo

CentralCentral

• Cerebellum or Cerebellum or brain stem brain stem dysfunctiondysfunction

• ContinuousContinuous

• Nystagmus-verticalNystagmus-vertical

• Mild vertigoMild vertigo

• Non-positionalNon-positional

Assessment of the dizzy patient, AustAssessment of the dizzy patient, Australian Family Physician Vol. 31, No. ralian Family Physician Vol. 31, No. 8, August 20028, August 2002

Peripheral Vestibular Peripheral Vestibular DisordersDisorders

• BPPVBPPV

• LabrynthitisLabrynthitis

• Meniere’s diseaseMeniere’s disease

• Acoustic NeuromaAcoustic Neuroma

• Motion sicknessMotion sickness

• CervicogenicCervicogenic

• Perilymphatic Perilymphatic fistulafistula

• Vestibular Vestibular neuronitisneuronitis

• Semicircular canal Semicircular canal infectioninfection

• Semicircular canal Semicircular canal water penetrationwater penetration

Assessment of the dizzy patient, AustAssessment of the dizzy patient, Australian Family Physician Vol. 31, No. ralian Family Physician Vol. 31, No. 8, August 20028, August 2002

Central Vestibular DisordersCentral Vestibular Disorders

• Brain stem lesionBrain stem lesion

• Basilar artery Basilar artery migrainemigraine

• TIATIA

• StrokeStroke

• MSMS

• Cerebellar lesionsCerebellar lesions

• Metastatic TumorMetastatic Tumor

• MeningiomaMeningioma

Anatomic and Physiologic Anatomic and Physiologic Components of BalanceComponents of Balance

• Vestibular – labyrinth, vestibular Vestibular – labyrinth, vestibular nucleinuclei

• Visual – CN III, IV, VI Visual – CN III, IV, VI

• Proprioceptive – upper cervical ms Proprioceptive – upper cervical ms and jointsand joints

Types of VertigoTypes of Vertigo

• Subjective vertigoSubjective vertigo– The patient feels The patient feels

that they are that they are spinningspinning

• Objective vertigoObjective vertigo– The patient feels The patient feels

still but objects still but objects appear to be appear to be moving around moving around themthem

Causes of VertigoCauses of Vertigo

• Ear diseaseEar disease

• Toxic conditions (alcohol, food Toxic conditions (alcohol, food poisonings)poisonings)

• Postural hypotensionPostural hypotension

• Infectious diseaseInfectious disease

• CervicogenicCervicogenic

• Disease of the eye or brainDisease of the eye or brain

• PsychologicalPsychological

Schimp D. A diagnostic algorithm forSchimp D. A diagnostic algorithm for the dizzy patient Chiropractic Techn the dizzy patient Chiropractic Technique, vol 6(4) Nov 1994ique, vol 6(4) Nov 1994

Vertigo

Episodicpositional

EpisodicNon-positional

Non-episodicNon-positional

Episodic positional

Benign positional

CervicogenicVertebobasilar

ischemia

gradualsudden sudden

Fades 30-60 seconds

persists progression

Benign Paroxysmal Benign Paroxysmal Positional Vertigo (BPPV) Positional Vertigo (BPPV)

20%20%• Brief episodes – recurrentBrief episodes – recurrent

• Moderate to severeModerate to severe

• Associated with head positionAssociated with head position

• Gradually diminishes over a month or twoGradually diminishes over a month or two

• No hearing lossNo hearing loss

• Latency or delayed onset of S/S Latency or delayed onset of S/S

• Positive Nylen-Barany maneuverPositive Nylen-Barany maneuver

• Caused by otoconia (debris) floating in PSCCaused by otoconia (debris) floating in PSC

Nylen-Barany AKA Dix-Nylen-Barany AKA Dix-HallpikeHallpike

• Patient seated, head turned 45 degreesPatient seated, head turned 45 degrees• Patient quickly lays supinePatient quickly lays supine• Latency period, then horizontal or Latency period, then horizontal or

rotational nystagmusrotational nystagmus• Nystagmus decreases after 10-20 Nystagmus decreases after 10-20

secondsseconds• Affected ear is the side head is turned Affected ear is the side head is turned

toward when nystagmus and vertigo toward when nystagmus and vertigo occursoccurs

Dizziness, Hearing Loss, and TinnituDizziness, Hearing Loss, and Tinnitus R.W. Baloh, F.A. Davis Company 1s R.W. Baloh, F.A. Davis Company 1998998

Nylen-Barany ManeuverNylen-Barany Maneuver

Treatment Options for BPPVTreatment Options for BPPV

• Epley’sEpley’s

• Sermont’sSermont’s

• Habituation exercises (Brandt-Daroff)Habituation exercises (Brandt-Daroff)

• Cervical adjustingCervical adjusting

Modified Epley’s ManeuverModified Epley’s Maneuver

• Patient placed supine with head turned Patient placed supine with head turned 45 degrees toward the affected ear (30 45 degrees toward the affected ear (30 sec.)sec.)

• Dr. turns head 90 degrees so affected ear Dr. turns head 90 degrees so affected ear is up. (30 sec.)is up. (30 sec.)

• Patient rolls on to side, head looking Patient rolls on to side, head looking toward the floor (30 sec.)toward the floor (30 sec.)

• Patient is lifted into sitting positionPatient is lifted into sitting position• Procedure is repeated until no nystagmusProcedure is repeated until no nystagmus

Dizziness,Hearing Loss, and Tinnitis Dizziness,Hearing Loss, and Tinnitis R.W. Baloh, F.A. Davis Company 19R.W. Baloh, F.A. Davis Company 199898

Modified Epley ManeuverModified Epley Maneuver

Sermont’s ManeuverSermont’s Maneuver

• Patient can be instructed to do this at Patient can be instructed to do this at home.home.

• Patient turns head 45 degrees away Patient turns head 45 degrees away from the affected sidefrom the affected side

• Quickly lays down maintaining head Quickly lays down maintaining head position (4 minutes)position (4 minutes)

• Brought up and placed on other side Brought up and placed on other side with same head position. (4 min) Sit with same head position. (4 min) Sit up normalup normal

Archives Otolaryngol Head Neck SurArchives Otolaryngol Head Neck Surgery, Vol 119, p452, 1993gery, Vol 119, p452, 1993

Sermont’s ManeuverSermont’s Maneuver

Post Maneuver InstructionsPost Maneuver Instructions

• Patient waits 10 min. before leaving Patient waits 10 min. before leaving office.office.

• Other person drives them home.Other person drives them home.

• Sleep half-reclined 2-3 days.Sleep half-reclined 2-3 days.

• Avoid laying on bad side.Avoid laying on bad side.

• Avoid extreme head extension for 2-Avoid extreme head extension for 2-3 days3 days

Cervicogenic VertigoCervicogenic Vertigo

• Hx of neck trauma, muscle spasmHx of neck trauma, muscle spasm• Limited cervical ROMLimited cervical ROM• Positive chair rotation test (Fitz-Ritson)Positive chair rotation test (Fitz-Ritson)• Patients may complain of Patients may complain of

dysequilibrium (tilt) more than dysequilibrium (tilt) more than rotational vertigorotational vertigo

• Overstimulation of upper cervical Overstimulation of upper cervical proprioceptorsproprioceptors

• May overlap BPPV or Meniere’s diseaseMay overlap BPPV or Meniere’s disease

Vertebrobasilar Insufficiency Vertebrobasilar Insufficiency TIA’sTIA’s

• Vertigo with associated Neurological signsVertigo with associated Neurological signs

• DiplopiaDiplopia

• AtaxiaAtaxia

• Drop attacksDrop attacks

• DysarthriaDysarthria

• Paralysis/weakness/NumbnessParalysis/weakness/Numbness

• HeadacheHeadache

• Risk factors (HTN, Diabetes, Coronary Risk factors (HTN, Diabetes, Coronary Disease)Disease)

Episodic non-positional

Meniere’s Perilymph fistula

Meniere’s DiseaseMeniere’s Disease

• Sudden and recurrent (paroxysmal) Sudden and recurrent (paroxysmal) attack of severe vertigo (4attack of severe vertigo (4thth leading leading cause)cause)

• Low-tone hearing lossLow-tone hearing loss• Low-tone tinnitisLow-tone tinnitis• Sense of fullness in the earSense of fullness in the ear• Vertigo lasts for hours to a day then Vertigo lasts for hours to a day then

burn outburn out• Hearing loss may progressHearing loss may progress

Cause of Meniere’sCause of Meniere’s

• Overproduction or retention of Overproduction or retention of endolymphendolymph

• Possible autoimmune etiologyPossible autoimmune etiology

• Head traumaHead trauma

• Previous infectionPrevious infection

• Pregnant females are more pronePregnant females are more prone

Management of Meniere’sManagement of Meniere’s

• Salt-restriction dietSalt-restriction diet

• Diuretic therapyDiuretic therapy

• Cervical adjusting (overlaps with Cervical adjusting (overlaps with cervicogenic vertigocervicogenic vertigo

Perilymphatic FistulaPerilymphatic Fistula

• Hx of barometric pressure changes Hx of barometric pressure changes (airplane or weight lifting)(airplane or weight lifting)

• Opening develops between middle Opening develops between middle and inner ear (oval window rupture)and inner ear (oval window rupture)

• Rare cause of vertigoRare cause of vertigo

• Bearing down reproduces s/sBearing down reproduces s/s

• Tx - surgicalTx - surgical

Non-episodicNon-positional vertigo

Labyrinthitis Acoustic neuroma Cerebral hemorrhage

LabyrinthitisLabyrinthitis

• Sudden severe vertigo that last days Sudden severe vertigo that last days to weeksto weeks

• Maybe nausea and vomiting Maybe nausea and vomiting

• Viral infection - no hearing lossViral infection - no hearing loss

• Bacterial infection hearing lossBacterial infection hearing loss

Acoustic NeuromaAcoustic Neuroma

• Mild but constant hearing lossMild but constant hearing loss

• Dizziness with possible tinnitisDizziness with possible tinnitis

• Gradual onsetGradual onset

• Benign schwannoma of 8Benign schwannoma of 8thth CN CN

• Other CN findings as tumor growsOther CN findings as tumor grows

• Surgical excisionSurgical excision

Cerebral HemorrhageCerebral Hemorrhage

• Sudden vertigo and nauseaSudden vertigo and nausea

• Vomiting associated with a headacheVomiting associated with a headache

• Inability to standInability to stand

• Nystagmus, nuchal rigidity, facial Nystagmus, nuchal rigidity, facial paralysis, ataxia, dysrythmia, small paralysis, ataxia, dysrythmia, small reactive pupilsreactive pupils

• Hx of HTN in 2/3 of patientsHx of HTN in 2/3 of patients

Australian Family Physician Vol. 31, Australian Family Physician Vol. 31, No 8, August 2002No 8, August 2002

When to refer to a specialistWhen to refer to a specialist

• Serious vertigo that is disablingSerious vertigo that is disabling

• Ataxia out of proportion to vertigoAtaxia out of proportion to vertigo

• Vertigo longer than 4 weeksVertigo longer than 4 weeks

• Changes in hearingChanges in hearing

• Vertical nystagmusVertical nystagmus

• Focal neurological signsFocal neurological signs

• Systemic disease or psychological originSystemic disease or psychological origin