13: VERTIGO and DIZZINESS

INTRODUCTION Vertigo = illusion or sensation that the environment or body is moving Dizziness = anything from weakness, to lightheaded Syncope = transient loss of consciousness Disequilibrium = feeling of imbalance or unsteadiness while walking PERIPHERAL (CN8 and Vestibular apparatus) Sudden onset Severe intensity; more N/V Duration of seconds, minutes, or intermittent Aggravated or precipitated by head positional change Tinitis, hearing loss No BS or CN findings ddx:

(1) (2) (3) (4) (5) (6) (7) (8) (9) (10)

BPV Menieres FB in ear canal Cerumen or hair against TM Acute OM Labyrinthitis (serous, toxic, suppurative, chronic) Vestibular Neuronitis Post-traumatic vertigo (labyrinth concussion) Perilymphatic fistula CN8 lesion (aucoustic neuroma) or Cerebellopontine angle tumor

CENTRAL (BS and CB +/- CN8) Gradual onset (except stroke) Mild intensity; less prominent N/V Duration of weeks to months, usually continuous Not related to head position No hearing loss, tinnitus rare Associated BS or CB s/s (diplopia, ataxia, dysphagia, facial numbness or weakness, hemiparesis) ddx: (1) Brainstem ischemia, infarct, bleed, tumor, MS plaque (2) Cerebellar ischemia, infarct, bleed, tumor, MS plaque (3) Vertebrobasilar migraine (4) Vertebrobasilar insufficiency (5) Post concussion syndrome (6) Infection (meningitis, encephalitis, brain abcess) (7) Cervical soft tissue injury (8) Subclavian steal syndrome (9) Temporal lobe epilepsy

SYSTEMIC Diabetes Mellitus Hypothyroidism Hypoglycemia

MISCELLANEOUS Anemia Presyncope/Syncope Anxiety Hyperventilation Disequilibrium syndrome Viral syndromes

PATHOPHYSIOLOGY Equilibrium depends on three systems (i) visual (ii) proprioception from muscles/joints (iii) vestibular apparatus (labyrinth). Involvement of any system can produce vertigo All pathways connect through the vestibular nuclei to enter the cerebellum Vestibular apparatus Inner ear; also called labyrinth Located in petrous portion of temporal bone Vulnerable to trauma, blood-borne toxins, infections 3 semicircular canals with cristae and 2 otoliths (utricle and saccule) Semicircular canals provide information about movement and angular momentum. Otoliths provide information about body position w.r.t. gravity Semicircular canal response is equal bilaterally, thus any unilateral disease, stimulation, or resting movement produces vertigo Neuroanatomy Vestibular apparatus > CN VII > Brainstem vestibular nuclei > Cerebellum > Medial Longitudinal Fasiculus and Vestibulospinal tracts MLF connects to eye muscles to maintain visual axis with head mvmt Vestibulospinal tracts connect to muscles to adjust body position to maintain balance Nystagmus Occurs when synchronized vestibular information becomes unbalanced usually due to unilateral disease. This causes slow movement toward the stimulus by contraction of medial rectus and lateral rectus. The cortex tries to correct by bringing eyes back in a fast movement and the cycle is repeated. Direction of nystagmus is defined by the direction of the fast movement It is normal to have a few beats of nystagmus on extreme lateral gaze Hallpike Maneuver Drop patient back from sitting position whith head turned first the good side and then to the affected side so that head hangs over bed; watch nystagmus Avoid if suspecting VertebroBasilar Insufficiency

CENTRAL DIRECTION Any

PERIPHERAL Horizontal or horizontorotatory (never vertical) Bilateral Suppressed

LATERALITY VISUAL FIXATION HALLPIKE -latency -duration -intensity -fatigability

uni or bilateral NOT suppressed (may be enhanced) short (<10 sec b/f nystagmus) sustained (> 1min) mild nonfatigable

long (>10sec) transient (< 1min) mild to severe fatigable with repeat testing

APPROACH TO THE PATIENT

GENERAL ABCs Chemstrip, ECG History/Physical Dizziness versus true vertigo Peripheral versus Central Management based on suspected diagnosis CLINICAL FEATURES History Must determine what the patient means by light headed or dizzy (anemia, presyncope, drug side-effect, infections depression, etc) Relationship of symptoms to mvmts, head position, postures Onset, time of day, duration Associated symptoms: N/V, diplopia, dysphagia, numbness, weakness, tinnitus, hearing loss, ataxia, tinitis, hearing loss, recent viral illness, ear pain Medications important (? any vestibulotoxins: aminoglycosides, anticonvulsants, alcohols, quinidine, quinine, minocycline) Pmhx: DM, drugs Recent head or neck trauma Physical Nystagmus: direction, laterality, fatiguability, visual fixation, Hallpike CN testing very important. Dont forget corneal reflex, gag reflex and assessment of hearing. Mild depression of corneal reflex is sensitive, early sign. Remember internuclear opthalmoplegia with MS plaque of BS Brainstem and Cerebellar testing very important: Cerebellar gait is wide

base, unsteady, irregular steps, tremor of trunk, lurching from side to side. Dysdiadokinesis is rapid alternating movments. General exam key points: postural vitals, cardiac exam for arrythmias etc Ear: cerumen, FB, AOM, perforated or scarred TM may indicate perilymphatic fistula Hearing loss (aucoustic neuroma), Rinnes test Drachmans Dizziness Stimulation Battery

(1) (2) (3) (4) (5) (6)

Postural vitals Valsalva maneuver Sudden turn when walking 3 min hyperventilation Hallpike Head turn - standing w/ eyes open

Investigations Glucose: DM causes decreases nerve function ECG and/or cardiac monitoring if presyncope hx CT head if central MRI needed to look for acoustic neuroma and MS MRA needed for suspected vertebrobasilar insufficiency Audiology testing for hearing Electronystagmography tests vestibular function

PERIPHERAL VERTIGO
BENIGN PERIPHERALVERTIGO Repeat attacks precipitated by posture, head position (typically turning over in bed) NO hearing loss or tinitis Last seconds, intermittent, and usu subside w/i a few weeks Due to calcium carbonate crystals which have detached from otoconia of the utricle and fallen against the cupula of the semicircular canal Single position can often precipitate vertigo and horizontorotatory nystagmus at bedside Hallpike is diagnositic and therapeutic MENIERES SYNDROME Classic Triad of (i) vertigo (ii) tinnitis (iii) hearing loss (fluctuating) Typical History: patient over 50yo w/ slowly progressive tinnitus and deafness in one or both ears over months to years who suddenly develops severe vertigo w/ and intense sensation of rotation, N/V, diaphoresis, diarrhea. Attacks last hours and occur at regular intervals separated by weeks to years (long remission). Consider acoustic neuroma on ddx. Positional nystagmus not present on examination Pathophysiology largely unkown but gross dilation of endolymphatic system of the internal ear is present Mx: low salt diet, diuretics, ammonium chloride, glycerol all unproven. May require surgical destruction of labyrinth or endolymphatic shunt LABYRINTHITIS

Inflammation of vestibular apparratus Serous Mild to severe positional symptoms. Usually coexisting or antecedent infection of ear, nose, throat, or meninges Mild to severe hearing loss can occur Nontoxic exam with minimal if any fever Acute Suppurative Coexisting acute exudative infection of the inner ear. Severe symptoms. Usually severe hearing loss, nausea, vomiting Febrile, toxic patient with AOM Rare, associated with long-standing OM with fistula, meningitis, mastoiditis, dermoid tumor, or postsurgical infection Toxic Gradually progressive symptoms due to medication toxicity to inner ear Hearing loss may become rapid, severe N/V Hearing loss, ataxia common in chronic phase Drugs/chemicals affecting the inner ear Antibiotics: aminoglycosides, erythromycin, minocycline Diruetics: lasix, ethacrinic acid NSAIDs: salicylates, ibuprofen, naproxen, indomethacin Anticonvulsants: phenytoin, tegretol, barbituates Cytotoxins: viinblasitne, cisplatin Others: quinine, methanol, ethanol, propylene glycol, mercury, choroquine Chronic Perilymphatic leak from a fistula at the round or oval window can cause vertigo May occur as a result of trauma Intermittent or positional vertigo exacerbated by straining, sneezing, coughing which may also cause a fistula Subjective vertigo induced by pneumatic otoscopy is diagnostic

POST TRAUMATIC VERTIGO Trauma easily produces unilateral contussion or concussion of labyrinthene membranes Acute posttraumatic vertigo begins immediately and results in continuous vertigo, N/V, and symptoms gradually improve over days and resolve over weeks Posttraumatic positional vertigo may develop days to weeks after injury; symptoms ppt by head movement, lasts months to years. VESTIBULAR NEURONITIS Sudden onset of severe vertigo, increasing in intensity for hours then gradually subsiding over several days. Vertigo worsened by head movement. Mild positional vertigo often lasts for weeks to months. Sometimes hx of infection or toxic exposure that precedes initial attack. Highest incidence in third and fifth decades. May complain of ear fullness or tinitis. Associated N/V but hearing loss/tinitis do NOT occur Spontaneous nystagmus toward the involved ear may be present Peripheral vertigo without hearing loss (labyrinthitis has hearing loss). Thought to be a viral encephalitis affecting the brainstem or vestibular nerve but exact lesion unknown.

ACOUSTIC NEUROMA Gradual onset and progression of symptoms hearing loss, tinnitis, vertigo. Neurologic signs in later stages. Most common in women b/w 30 - 60. Typically complain more of unsteadiness rather than true vertigo Associated hearing loss, tinnitus. True ataxia and BS signs as tumor enlarges Physical exam shows unilateral decreased hearing. Ataxia (truncal) as tumor enlarges. May have diminution or absence or corneal reflex. Other cerebellopontine angle tumors: meningiomas, dermoid tumors

CENTRAL VERTIGO
VASCULAR DISORDERS Vertebrobasilar Insufficiency Should be considered in any patient of advanced age with isolated new onset vertigo without an obvious cause. More likely with atherosclerosis. Initial episode usually secodns to minutes. Often associated with headache and neurologic sympotms including dysarthria, ataxia, weakness, numbness, diplopia. Tinnitus and deafness uncommon. Neurologic deficits usually present but exam can be normal Cerebellar hemorrhage Sudden onset of severe symptoms Associated with headache, vomiting, ataxia Ataxia on exam. May have false localizing sixth nerve palsy. Posterior Inferior Cerebellar artery occlusion (Wallenberg syndrome) Sudden onset vertigo with associated neurologic complaints Ipsilateral paralysis of the palate/pharynx/larynx, dysphagia, dysphonia, ipsilateral facial numbness w/ loss of corneal reflex, ipsilateral horners, CN 6,7,8 lesions w/ vertigo, n/v, nystagmus and hiccups, contralateral loss of pain and temp on limbs and trunk Subclavian steal syndrome Classic picture is syncopal attacks during exercise but most cases present with more subtle symptoms Associated arm fatique, cramps, mild lightheadedness may be only other symptoms than vertigo Diminished radial pulse, BP difference b/w arms Vertebrobasilar Migraine Vertigo preceeding headache, previous hx, migraine hx Associated dysarthria, ataxia, visual disturbance, parathesias before headache No residual physical signs NON-VASCULAR CENTRAL CAUSES Neck Trauma Usually onset 7-10 days after whiplash injury; episodes while turning head, can last months

Neck pain Neck tenderness, may induce symptoms and nystagmus when turning head Multiple Sclerosis Vertigo is presenting symptom in 7-10%; involved in 1/3; onset maybe severe and present like labyrinthitis; hx of similar attacks with various signs or symptoms Associated with N/V Nystagmus in any direction that may persist after symptoms subsided. Internuclear opthalmoplegia and ataxic eye movements suggest MS Temporal Lobe Epilepsy Can be initial or prominent symptom Associated with memory impairment, hallucinations, trancelike states, seizures May have aphasia or convulsions Hypoglycemia Suspect in diabetics Associated with tremors, diaphoresis, anxiety Tachycardia, mental status change may be present

MISCELLANEOUS CAUSES OF VERTIGO Physiologic: motion sickness which results from mismatched sensory input Psychogenic: longstanding vertiginous feeling unaffected by motion and position without associated N/V Ramsay Hunt Syndrome: herpetic lesion on auditory canal + Bells palsy; can have vertigo Hyperventilation syndrome: primary hyperventilation can lead to dizziness Anxiety: anxiety alone can produce dizziness Pre-syncope: common cause for dizziness Dysequilibrium Syndrome: ill-defined dizziness as a result of multiple sensory abnormalities where there is chronic mismatch of input from the body systems providing spatial orientation. Usually elderly patient with diminished vision, hearing, CB, peripheral nerve, and proprioceptive function. Disequilibrium exaggerated by diminished light, unfamiliar environment, sedatives. MANAGEMENT Antihistamines act peripherally in the labyrinthine apparatus and centrally at the brain stem. Anticholinergics act peripherally at the efferents of the vestibular cells and centrally in the brainstem. Diazepam acts centrally on the lateral vestibular nucleus and is effective in peripheral vertigo. Prochloroperazine and metaclopramide less effective. Meclizine (Antivert) 25 mg q8hr, diphenhydramine (Benadryl) 25 - 50 mg q6hr, Scopolamine patch (ineffective), promethazine (Phenergan) 25 mg po q6hr or 12.5 - 25 mg iv Diazepam, lorazepam Droperidol Metaclopramide Avoid caffeine, nicotine, pseudoephedrine Disposition Generally: peripheral home, central admit; ENT consult for peripheral causes, neurology consult for central causes (if required)

May need admission for peripheral if toxic, severe symptoms, or unable to walk after symptomatic treatment Acute bacterial labyrinthitis requires admission for iv antibiotics +/- surgery F/U with GP or ENT for suspected acoustic neuroma, perilymphatic fistula