Dizziness

Dizziness: Excerpt from Field Guide to Bedside Diagnosis

Differential Overview

Vertigo

❑ Benign paroxysmal positional vertigo

❑ Vestibular neuronitis

❑ Toxic labyrinthitis

❑ Vertebrobasilar insufficiency

❑ Ménière disease

❑ Migraine

❑ Multiple sclerosis

❑ Acoustic neuroma

❑ Herpes zoster oticus (Ramsey–Hunt)

Disequilibrium

❑ Multifactorial disequilibrium

❑ Stroke

❑ Cerebellar disease

❑ Frontal lobe apraxia

Lightheadedness

❑ Orthostatic hypotension

❑ Common fainting (presyncope)

❑ Hyperventilation

❑ Panic attack

Diagnostic Approach

Differentiate between vertigo, disequilibrium, and lightheadedness. Each has its own non-overlapping differential:

• Vertigo is the illusory sensation of rotatory motion, either of the patient or the environment.

• Disequilibrium is a sensation of imbalance when standing and walking.

• Lightheadedness is a sensation of impending loss of consciousness.

Provide the patient with experiential examples to refine the history (e.g., vertigo after spinning around as a child).

Attempt to provoke dizziness with maneuvers to confirm a provisional diagnosis, such as observation of gait, ambulation, and turning; orthostatic vital signs; Dix–Hallpike maneuver; Romberg; and/or 3-minute hyperventilation. The Dix–Hallpike maneuver provokes vertigo and nystagmus by stimulation of the posterior semicircular canal with the head tilted toward the affected side at 30 degrees below the horizontal. Have the patient look straight ahead to observe nystagmus. The nystagmus will fatigue. These findings indicate posterior canalithiasis causing benign paroxysmal positional vertigo (BPPV). The Romberg maneuver is performed by observing the patient standing. Swaying with eyes closed suggests disordered proprioception and/or vestibular function. Swaying with eyes open or closed is cerebellar in origin.

Vertigo usually implies a vestibular lesion (rarely brainstem). Suspect a central lesion if symptoms are preceded by a headache and vomiting without tinnitus. Central dizziness is very sensitive to movement of the head and is usually constant. Other cranial nerve findings or long track signs are usually present. Tinnitus, pressure, or decreased hearing localizes the problem to the inner ear and indicates the involved side. Nystagmus may persist after vertigo clears. Spontaneous vertical nystagmus suggests a lesion at the vestibular nucleus or cerebellum. Nystagmus that reverses direction when the patient looks in the direction of the slow phase suggests a central lesion. Exertional lightheadedness occurs in severe anemia, aortic stenosis, pulmonary hypertension, pericardial disease, and hypertrophic cardiomyopathy.

Clinical Findings

Benign paroxysmal positional vertigo  BPPV presents as episodic vertigo of short duration, precipitated by position of the head, especially when recumbent and turned toward the affected side. The Dix–Hallpike maneuver will be positive. There is no hearing deficit. A prior (remote) history of head trauma is common.

Vestibular neuronitis  Acute labrynthitis is associated with a more prolonged episode of vertigo, and often with other viral symptoms.

Toxic labyrinthitis  Prototypical causes include alcohol and aminoglycosides, the latter associated with hearing loss. Salicylate intoxication produces vertigo, hyperventilation, and deafness. The history of salicylate use may be obscured by mental confusion.

Vertebrobasilar insufficiency  Occurs with the full spectrum of episodic vertigo, blurred or double vision, tingling in the face, weak legs, or dysarthria in an elderly patient. When these symptoms occur with arm usage, and a subclavian bruit combined with asymmetric blood pressure is present, subclavian steal should be suspected.

Ménière disease  Appears as episodic (1 to 3 hours), recurrent vertigo with tinnitus, unilateral decrement in hearing, distortion of sounds (diplacusis), or hypersensitivity to loud sounds. The episode is more violent than with other causes, leaving the patient prostrated, with pallor, sweating, and spontaneous nystagmus. Fluctuation and recruitment favor Ménière over acoustic neuroma.

Migraine  Vertigo is accompanied by other migraine phenomena, such as unilateral headache, nausea, light or sound sensitivity, or scintillating scotoma.

Multiple sclerosis  Optic neuritis (new or old) and an afferent pupillary defect may be present. Internuclear ophthalmoplegia (when conjugate gaze is attempted, one eye will not adduct medially, and the abducting eye on lateral gaze will have nystagmus) indicates involvement of the medial longitudinal fasciculus. Transient facial numbness or diplopia is also common.

Acoustic neuroma  Usually presenting with slowly progressive tinnitus and hearing loss, it may also present with vertigo. Central nystagmus, diminished corneal reflexes, and facial dysesthesias may be present.

Herpes zoster oticus (Ramsey–Hunt)  Vertigo is associated with vesicles in the external auditory canal, hearing loss or tinnitus, and facial palsy.

Multifactorial disequilibrium  Ambulation requires visual, vestibular, and proprioceptive input and may be impaired when any of these are affected or with a critical mass of multiple minor impairments. Romberg and tandem gait are usually abnormal.

Stroke  Vertigo may arise when there is thrombosis of posterior inferior cerebellar artery or pontine branches. Consider this in older patients, as well as when vascular disease or atrial fibrillation is present.

Cerebellar disease  The Romberg will be positive with the eyes closed or open, and finger-to-nose pursuit will be abnormal.

Frontal lobe apraxia  The patient will appear to be walking on ice. There is difficulty initiating the gait, and turns are accomplished by pivoting around on one foot.

Orthostatic hypotension  Symptoms are only present when changing to the upright position. An orthostatic increase in pulse of 30 per minute, or enough lightheadedness to cause fainting, or needing to lie down is associated with a volume loss greater than 1 liter.

Common fainting (presyncope)  There is often a prodromal sensation of “graying out,” nausea, clamminess, blurred vision, and pallor.

Hyperventilation  A key clue is perioral and acral tingling. Anxiety is present.

Panic attack  Dizziness is associated with severe apprehension, chest pressure, palpitations, and fear of losing control. The differential diagnosis for this includes paroxysmal tachycardia, autonomic phenomena with pheochromocytoma, hypoglycemia, and complex partial seizures.

Pictures

Book Source Details

• Book Title: Field Guide to Bedside Diagnosis
• Author(s): David S. Smith
• Year of Publication: 2007
• Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Field Guide to Bedside Diagnosis Authors: David S. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-78178-165-5

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