Dizziness and Vertigo (Case 57)

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Dizziness and Vertigo (Case 57)

Lana Zhovtis Ryerson MD and Stephen Krieger MD

Case: A 34-year-old woman presents to the ED with dizziness. She states that 2 days ago she began to feel a “spinning sensation” and was walking around “as though she were drunk.” These symptoms worsened the day before admission, when she developed nausea and vomiting and had increasing difficulty walking. She has no significant past medical history. On exam she has beating nystagmus in all directions of gaze, worse when looking to the right. She has a slightly flattened right nasolabial fold. She has full strength and an intact sensory exam, but on coordination testing she has significant postural instability, as well as dysmetria in the right arm. She is unable to tandem walk, falling to the side.

Differential Diagnosis

Vertigo	Dizziness/presyncope/light-headedness
Benign paroxysmal positional vertigo (BPPV)	Orthostatic hypotension
Acute labyrinthitis/vestibular neuritis	Cardiac arrhythmia
Meniere disease	Vasovagal disorder
Cerebellar infarction or hemorrhage	Intoxication/medication side effects
Perilymphatic fistula	Anxiety

Speaking Intelligently

“Dizziness” refers to a variety of abnormal sensations relating to perception of the body’s relationship to space. What can be difficult for both a patient and the physician is the subjectivity of the term dizziness; people use it to describe an array of abnormal sensations. Furthermore, patients may use different terms to describe the same kind of abnormal sensation, and one must clarify what patients are experiencing when beginning to characterize their symptoms.

Although prevalence studies vary in their definition of the symptom, dizziness is common in all age groups, and its prevalence increases modestly with age. While peripheral vestibular etiologies are among the most common causes, as many as 25% of patients with risk factors for stroke who present to the emergency medical setting with the combination of vertigo, nystagmus, and postural instability may have a stroke affecting the cerebellum.

For most patients the symptom of dizziness resolves spontaneously, but an important minority of patients can develop chronic, disabling symptoms. Patients with chronic dizziness may benefit from an approach aimed at identifying and managing treatable conditions, whether etiologic or contributory. This approach may include correcting visual impairment, improving muscle strength, adjusting medication regimens, identifying and treating psychological comorbidities such as anxiety and depression, and instructing patients on vestibular exercises.

PATIENT CARE

Clinical Thinking

• The first step in evaluating a patient with dizziness is to take a detailed history focusing on the meaning of the term “dizziness” to the patient and to classify his or her symptoms into vertigo as opposed to presyncopal light-headedness.

• Vertigo is an illusory sensation of motion of either oneself or one’s surroundings.

• Presyncope is described as a light-headed, faint feeling, as though one were about to pass out, that is usually due to transient reduction of cerebral blood flow.

• If the symptoms are suggestive of vertigo, the next question that arises is whether the history and findings on examination are consistent with a central disorder such as hemorrhage/infarction of the cerebellum or a peripheral vestibular etiology such as benign positional vertigo or vestibular neuritis.

• It is vital that physicians are able to differentiate the two pathologic localizations, since central causes of acute vertigo, such as cerebellar hemorrhage and infarction, can be life-threatening and may require immediate intervention.

History

When evaluating a complaint of dizziness to establish if there is frank vertigo or presyncope, questions to consider include the following:

• Is there a true sensation of movement or spinning?

• Is there a feeling of faintness and light-headedness?

• Are there vague, persistent feelings of imbalance?

• What are the associated characteristics?

• Nausea/vomiting may accompany vertigo.

• The sensation of warmth, diaphoresis, and visual blurring may indicate presyncope.

• Palpitations, dyspnea, or chest discomfort can indicate a cardiac cause.

• What is the duration of the episodes, and what are any exacerbating factors (e.g., head movement)?

• Has syncope ever occurred during an episode?

• Do episodes occur only when the patient is upright, or do they occur in other positions?

Physical Examination

• If presyncope is suspected, the physical exam should include evaluation of heart rate and blood pressure in the supine, sitting, and standing positions to evaluate for orthostatic hypotension. Assessment of the pulse and direct cardiac auscultation may assist in determining if the episode is associated with arrhythmia.

• When vertigo is suspected, the clinical exam, with particular attention to nystagmus, helps to distinguish between peripheral and central vestibular etiologies.

Feature of Nystagmus	Peripheral (Labyrinth or Nerve)	Central (Brainstem or Cerebellum)
Latency of nystagmus	3–40 sec	None: immediate vertigo and nystagmus
Fatigability of nystagmus	Yes	No
Direction of nystagmus	Unidirectional, often rotatory	Can be bidirectional, unidirectional, or vertical
Visual fixation	Inhibits nystagmus and vertigo	No inhibition
Intensity of vertigo	Severe	Mild
Tinnitus and/or hearing loss	Often present	Usually absent
Associated CNS abnormalities	None	Extremely common (e.g., diplopia, hiccups, cranial neuropathies, dysarthria)
Common causes	BPPV, vestibular neuritis, labyrinthitis, Meniere disease	Infarction, hemorrhage, multiple sclerosis, neoplasm

Figure 65-1 The Dix-Hallpike maneuver. With the patient sitting on the exam table (facing forward and eyes open), the physician turns the patient’s head 45 degrees to the right (A). The physician then supports the patient’s head as the patient lies back quickly from a sitting to a supine position, ending with the head hanging 30 degrees off the end of the examination table. The patient remains in this position for 30 seconds (B). Next the maneuver is repeated with the patient’s head initially turned to the left. A positive test is indicated if any of these maneuvers produce vertigo with or without nystagmus.

Tests for Consideration

• If stroke or hemorrhage is suspected, laboratory studies including CBC and prothrombin time/partial thromboplastin time (PT/PTT) should be performed. Other tests that may be helpful when evaluating peripheral vertigo in the outpatient setting include electronystagmography (ENG) and audiography.

$11, $15, $185, $85

IMAGING CONSIDERATIONS

→ Brain MRI (with attention to the cerebellum and posterior fossa) is recommended when the examination of a patient with an acute vestibular syndrome yields findings suggestive of a central localization. Urgent imaging is also recommended when the onset of symptoms is sudden in a patient with prominent risk factors for stroke or when a new-onset headache accompanies the acute vertigo.	$534
→ If prompt brain MRI is not available, head CT should be performed, with fine cuts through the cerebellum.	$334

Clinical Entities

Medical Knowledge

Benign Paroxysmal Positional Vertigo
Pφ	Otoliths, or calcium carbonate crystals, become dislodged from the utricle, one of the gravity-sensitive structures in the inner ear, and then migrate to the posterior semicircular canal, which is the most gravity-dependent structure in the vestibular labyrinths.
TP	Classically, patients describe a brief spinning sensation brought on when turning in bed or tilting the head backward to look up or down. Each episode of vertigo lasts only 10–20 seconds. The initial onset of vertigo is often associated with nausea, with or without vomiting. The dizziness may be quite severe, so as to halt all activity during its duration.
Dx	The diagnosis is generally made by eliciting the history of the episode, characterized by brief episodes of vertigo provoked by certain changes in head position such as rolling over in bed, bending over, and looking upward. The diagnosis can be confirmed with the Dix-Hallpike maneuver, for which the diagnostic criteria consist of typically rotatory nystagmus with the upper pole of the eye beating toward the dependent ear. The nystagmus typically begins after a latency of several seconds and is associated with a sensation of rotational vertigo. After the patient returns to the seated position, nystagmus is again observed, but the direction of nystagmus is reversed.
Tx	The treatment currently recommended is the bedside canalith repositioning procedure (CRP), also known as the Epley maneuver. The purpose of the maneuver is to relocate free-floating debris from the posterior semicircular canal into the vestibule of the vestibular labyrinth, where it presumably adheres. The debris can be moved within the labyrinth noninvasively through a sequence of head orientations with respect to gravity.

Vestibular Neuritis
Pφ	Although the pathophysiology is unclear, the condition is thought to result from a selective inflammation of the vestibular nerve and is presumably of viral origin.
TP	Vestibular neuritis presents as rapid onset of severe, persistent vertigo, nausea, vomiting, and gait instability. Physical exam findings are consistent with an acute peripheral vestibular imbalance: spontaneous vestibular nystagmus and gait instability without a loss of the ability to ambulate. In pure vestibular neuritis, auditory function is preserved; when this syndrome is combined with unilateral hearing loss, it is called labyrinthitis.
Dx	The diagnosis is based on the ability to clinically differentiate between peripheral and central causes of acute prolonged vertigo. ENG, if available, can document the unilateral vestibular loss.
Tx	There is no established treatment for vestibular neuritis. Symptomatic therapy is typically used, with the main classes of drugs including antihistamines (meclizine, dimenhydrinate, promethazine), anticholinergic agents, antidopaminergic agents, and GABAergic agents (diazepam, clonazepam). These drugs do not eliminate but rather reduce the severity of vertiginous symptoms.

Meniere Disease
Pφ	The disease is thought to be related to an increase in the volume of endolymph in the labyrinths (endolymphatic hydrops). The hydrops causes hearing loss by a direct effect on the sensory outer hair cells of the cochlea, but the sudden spells of vertigo are less well understood. Some cases appear to be related to mutations in the cochlin gene on chromosome 14q12–q13, with the disease showing genetic anticipation (i.e., becomes apparent at on earlier age as it is passed on to the next generation).
TP	Patients present with recurring episodes of spontaneous episodic vertigo lasting for minutes to hours and usually associated with unilateral tinnitus, hearing loss, and a sensation of ear fullness. Acute attacks are characterized by severe vertigo, nausea, vomiting, and disabling imbalance. The attacks recur at intervals ranging from weeks to years.
Dx	The diagnosis is made by obtaining the history of episodic vertigo associated with hearing loss and tinnitus, with family history helping to confirm the diagnosis. A low-frequency sensorineural hearing loss on audiometry and a unilateral reduced vestibular response on ENG help confirm the diagnosis.
Tx	Diuretics and salt restriction are directed to reducing possible hydrops. Symptomatic relief may be obtained during acute attacks with drugs similar to those used for vestibular neuritis. In persistent, disabling, drug-resistant cases, surgical procedures such as endolymphatic shunting, labyrinthectomy, and vestibular nerve section can be helpful.

Cerebellar/Brainstem Infarct or Hemorrhage
Pφ	The blood supply to the peripheral vestibular labyrinth and vestibular nerve, as well as the brainstem vestibular area and cerebellum, comes from the vertebrobasilar arterial system. Occlusion of one or more of the posterior circulation arteries due to embolism or atherosclerotic stenosis can produce cerebellar or brainstem vascular events.
TP	Abrupt onset, history of TIAs, vascular disease, or significant other risk factors for stroke, usually associated with other neurologic symptoms, are diagnostic.
Dx	On exam, spontaneous central-type nystagmus is seen with other associated signs of the lateral brainstem including Horner syndrome, facial numbness and weakness, hemiataxia, and dysarthria. MRI of brain shows infarction or hemorrhage in the medulla, pons, or cerebellum. Audiography may show ipsilateral hearing loss if the anterior cerebellar artery is involved.
Tx	Patients with acute ischemic strokes may be offered IV tPA, intra-arterial tPA, or other clot-retrieving procedures depending on the institution and the time of onset of symptoms (for more details, see Chapter 66, Weakness). Within 72 hours after a cerebellar infarction, cerebellar swelling may develop that can compress the brainstem and produce obstructive hydrocephalus. Therefore, patients with cerebellar infarctions should be examined frequently in an ICU setting, and brain imaging should be repeated. If deterioration occurs, neurosurgical intervention may be warranted.

Perilymphatic Fistula
Pφ	A perilymphatic fistula is an abnormal connection between the inner and middle ears that allows escape of perilymph fluid into the middle ear compartment. The episodic vertigo and/or hearing loss provoked by loud sounds occur because sound-induced pressure waves are abnormally distributed through the inner ear.
TP	Signs suggesting this diagnosis include abrupt onset associated with a history of head trauma or sudden strain during heavy lifting, coughing, or sneezing, and possible association with chronic otitis or cholesteatoma.
Dx	On physical exam, spontaneous, peripheral nystagmus associated with gait imbalance and unilateral hearing loss is noted. Possible perforation of the tympanic membrane may be noted. The most sensitive test for perilymph fistula is the vertigo and nystagmus induced by pressure in the external ear canal. ENG may show unilateral hypoexcitability; audiography may confirm the sensorineural hearing loss, and CT of the temporal bone may reveal associated skull fracture.
Tx	The first step in treatment involves bed rest, head elevation, and avoidance of straining. Failure to resolve after several weeks of conservative therapy is an indication to consider a surgical patch.

a. Basilar artery migraine is a rare form of migraine with aura, in which the auras consist of a combination of vertigo, dysarthria, tinnitus, diplopia, bilateral visual symptoms, bilateral paresthesias, and decreased level of consciousness. A migraine headache during or following the aura is required by current diagnostic criteria. MRI is often necessary to rule out other etiologies, with some patients having transient MRI abnormalities in the occipital cortex due to vasogenic edema.

b. Acoustic neuromas (or acoustic schwannomas) are Schwann cell–derived tumors commonly arising from the vestibular portion of the eighth cranial nerve and account for 80% to 90% of tumors involving the cerebellopontine angle. Symptoms associated with acoustic neuroma are due to cranial nerve involvement and cerebellar compression. Because the tumor grows slowly, the subtle imbalances in vestibular input are compensated by the CNS, and patients often do not experience disabling vertigo. Imbalance or a vague feeling of swaying may be the only manifestation of vestibular injury.

Practice-Based Learning and Improvement: Evidence-Based Medicine

Title
Short-term efficacy of Epley’s manoeuvre: a double-blind randomized trial

Authors
von Brevern M, Seelig T, Radtke A, et al.

Institution
Neurologische Klinik, Charité, Campus Virchow-Klinikum, Berlin, Germany

Reference
J Neurol Neurosurg Psychiatr 2006;77:980–982

Problem
What maneuvers effectively treat posterior canal BPPV?

Intervention
Sixty-six patients with a diagnosis of BPPV based on a positive Dix-Hallpike maneuver compared a CRP with a sham procedure.

Quality of evidence
Level I

Outcome/effect
After 24 hours, 80% of treated patients were asymptomatic and had no nystagmus with the Dix-Hallpike maneuver, compared with 10% of sham patients. At this point, all patients in both the treatment and control groups with a persistently positive Dix-Hallpike maneuver underwent an Epley maneuver. Ninety-three percent of patients with BPPV from the original control group reported resolution of symptoms 24 hours after undergoing the procedure. By 1 week, 94% of patients in the original treatment group and 82% of patients in the original control group (all of whom underwent the maneuver at 24 hours) were asymptomatic.

Historical significance/comments
The Epley maneuver, or CRP, is used to clear the affected semicircular canal from mobile particles by a set of five successive head positions that are hand-guided by a therapist. At this time, two level I and three level II studies have demonstrated a short-term resolution of symptoms in patients treated in this way. As a result of the above-mentioned and other studies, the American Academy of Neurology released Level A recommendations for the CRP to be established as an effective and safe therapy that should be offered to patients of all ages with posterior semicircular canal BPPV.

Interpersonal and Communication Skills

Base Reassurance on Appropriate Medical Explanations

Although the symptoms of BPPV are extremely uncomfortable and will probably be frightening to the patient and his or her family, the disease does not usually portend serious neurologic impairment. Nonetheless, persons presenting with these symptoms will worry about having a very serious and debilitating illness. Simple reassurance must be accompanied by medical explanations based on an understanding of the patient’s feelings, expectations, and ideas about causality. Reassurance that is perceived to have no real basis may be counterproductive. Failure to explore patients’ ideas, expectations, and beliefs that underlie their concerns, and failure to validate those concerns using empathetic communication, can compromise the patient–physician relationship.

Professionalism

Uphold the Welfare of Patients Who Do Not Speak English

Dizziness and vertigo are complaints that are often evaluated in both the ED and outpatient settings, and their evaluation requires thorough clinical histories. Particularly in these high-volume environments, language barriers can be detrimental to optimal patient care. Studies find that individuals with limited English-speaking ability experience the following:

images A greater likelihood of hospital admission,

images Frequent misdiagnosis or inappropriate treatment,

images More diagnostic tests and longer lengths of stay, and

images Lack of follow-up care.

The Americans with Disabilities Act guarantees that patients will have language accommodations in the health-care setting. Family members, friends, or bilingual staff members who are not trained as interpreters should not be used as interpreters, as they may not be unbiased when issues of decision making and informed consent are involved. Conflict of interest and confidentiality issues are among the concerns brought to the forefront when qualified interpreters are not used. Given the importance of the clinical history when evaluating complaints of dizziness and vertigo, health-care providers should offer the services of a qualified interpreter to patients who do not have English proficiency.

Systems-Based Practice

Patient Satisfaction Is Part of Value-Based Purchasing

Patients with dizziness may require hospital admission for evaluation and management, necessitating interactions with numerous healthcare personnel, including their primary physician, consultants, nurses, and other support staff. Creating an environment for proper communication and patient satisfaction is important to their perception of receiving quality care. HCAPS (Hospital Consumer Assessment of Healthcare Providers and Systems) is a survey that was developed by the Centers for Medicare and Medicaid Services (CMS) and that applies to any acute-care hospital receiving Medicare funding. The survey measures patients’ perceptions of parameters such as pain control, communication with health-care providers, hospital cleanliness, and noise. Results of this survey are part of the value-based purchasing program, in which CMS will make value-based incentive payments to acute-care hospitals based on how well the hospital performs. Because the Affordable Care Act mandated that the hospital value-based purchasing program be budget neutral, it will be funded by Medicare inpatient payment reductions for hospitals not performing at certain levels, beginning with a 1% payment reduction in federal fiscal year 2013.