!1.11 Vertigo ("Dizzy, lightheaded")
Presentation
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This may be a nonspecific complaint which must be refined further into either
an altered somatic sensation (giddiness, wooziness); orthostatic blood
pressure changes (lightheadedness, sensation of fainting); or the sensation of
the environment (or patient) spinning (true vertigo). In inner ear disease,
vertigo is virtually always accompanied by nystagmus, which is the ocular
compensation for the unreal sensation of spinning; but the nystagmus may be
extinguished when the eyes are open and fixed on some point (by the same
token, vertigo is usually worse with the eyes closed). Nausea and vomiting are
common accompanying symptoms, but less common (depending on the underlying
cause) are hearing changes, tinnitus, cerebellar or adjacent cranial nerve
impairment.
What to do:
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* Have the patient tell you in his own words what it feels like (without
using the word "dizzy"). Ask about any sensation of spinning, factors which
make it better or worse, and associated symptoms. Ask about drugs or toxins
which could be responsible.
* Determine whether the patient is describing vertigo (a feeling of movement
of one's body or surroundings) or a sensation of an impending faint or a
vague unsteady feeling.
* If the problem is near syncope or orthostatic lightneadedness, then
consider potentially serious etiologies such as heart disease, cardiac dys-
rhythmias or blood loss.
* With a sensation of dysequilibrium or an elderly patient's feeling that he
is going to fall, look for peripheral neuropathy, cervical spondylosis,
stiff legs and vasodilator medication. These patients should be referred to
their primary care physicians for management of their underlying medical
problems and adjustment of their medications.
* If there is light-headedness that is unrelated to changes in position and
posture and there is no evidence of disease found on physical examination
and laboratory evaluation, then instruct the patient to hyperventilate by
breathing deeply in and out fifteen times. If this reproduces the symptoms,
assess the patient's emotional state as a possible cause of his symptoms.
* If the patient is having true vertigo, examine for nystagmus, which can be
horizontal, vertical or rotatory (pupils describe arcs). Have the patient
follow your finger with his eyes as it moves a few degrees to the left and
right (not to extremes of gaze) and watch whether there are more than the
normal 2 to 3 beats of nystagmus before the eyes are still. You may detect
nystagmus when the eyes are closed by watching the bulge of the cornea
moving under the lid.
* If nystagmus is not clearly evident and the patient can tolerate it,
attempt a provocative maneuver for positional nystagmus by having the
patient sit up and then lie back, quickly hang his head over the stretcher
side and turn his head and eyes to one side. Repeat to the other side. When
this maneuver produces positional nystagmus, it indicates a benign inner
ear dysfunction. A negative test is not helpful.
* Examine ears for cerumen, foreign bodies, otitis media, and hearing loss.
* Examine the cranial nerves. Test cerebellar function (rapid alternating
movement, finger-nose, gait). Check the corneal blink reflexes: if absent
on one side in a patient who does not wear contact lenses, consider
acoustic neuroma.
* Decide, on the basis of the above, whether the etiology is central
(brainstem, cerebellopontine angle tumor, multiple sclerosis) or peripheral
(vestibular organs, eighth nerve). Central lesions may require further
workup, otolaryngologic or neurologic consultation, or hospital admission,
while peripheral lesions, although more symptomatic, are more likely self-
limiting.
* In the emergency department, treat moderate to severe symptoms of vertigo
with intravenous diazepam (Valium) 10 mg or diphenhydramine (Benadryl)
50mg. Add promethazine (Phenergan) 25mg iv for nausea. If there are no
contraindications (e.g. glaucoma) then a patch of transdermal scopolamine
can be worn for three days. Some authors recommend hydroxyzine (Vistaril,
Atarax) while others suggest corticosteroids (Solu-Medrol, Prednisone).
Nifedipine (Procardia) had been used to alleviate notion sickness but is no
better than scopolamine patches, and should not be used for patients with
postural hypotension or who take beta blockers. If the patient does not
respond, he may require hospitalization for further parenteral treatment.
* Treat vertigo symptoms in outpatients with diazepam (Valium) 5-10mg qid,
meclizine (Antivert) 12.5-25mg qid, diphenhydramine (Dramamine, Benadryl)
25-50mg qid, promethazine (Phenergan) 25mg qid,or hydroxyzine (Vistaril)
25mg qid, and bedrest as needed until symptoms improve.
* Arrange for followup if there is no clear improvement in 2 days or if
there is any suggestion of a central etiology.
What not to do:
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* Do not attempt provocative maneuvers if the patient is symptomatic with
nystagmus.
* Do not give anti-vertigo drugs to elderly patients with dysequilibrium.
These medications have sedative properties which can make them worse.
* Do not make the diagnosis of Meniere's disease (endolymphatic hydrops)
without the triad of paroxysmal vertigo, sensorineural deafness, and
tinnitus, along with a feeling of pressure or fullness in the affected ear.
Discussion
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In general, the more violent and spinning the sensation of vertigo, the more
likely the lesion if peripheral. Central lesions tend to cause less intense
vertigo and more vague symptoms. Peripheral etiologies of vertigo or nystagmus
include irritation of the ear (utricle, saccule, semi- circular canals) or the
vestibular division of the eighth cranial (acoustic) nerve by toxins otitis,
viral infection, or cerumen or a foreign body against the tympanic membrane.
The term "labyrinthitis" should be reserved for vertigo with hearing changes,
and "vestibular neuronitis" for the common short-lived vertigo without hearing
changes usually associated with viral upper respiratory infections. Paroxysmal
positional vertigo may be related to dislocated otoconia in the utricle and
saccule. If it occurs following trauma, suspect a basal skull fracture with
leakage of endolymph or perilymph, and consider otolaryngologic referral for
further evaluation and positional Central etiologies include multiple
sclerosis, temporal lobe epilepsy, basilar migraine and hemorrhage in the
posterior fossa. A slow-growing acoustic neuroma in the cerebellopontine angle
usually does not present with acute vertigo but rather a progressive
unilateral hearing loss with or without tinnitus. The earliest sign is usually
a gradual loss of auditory discrimination.
Vertebrobasilar arterial insufficiency can cause vertigo, usually with
associated nausea, vomiting and cranial nerve or cerebellar signs. It is
commonly diagnosed in dizzy pateints who are older than 50, but more often
than not the diagnosis is incorrect. The brainstem is a tightly-packed
structure in which the vestibular nuclei are crowded in with the oculomotor
nuclei, the medial longitudinal fasiculus, cerebellar, sensory and motor
pathways. It would be unusual for ischmia to produce only vertigo without
accompanying diplopia, ataxia, sensory or motor disturbance. Although vertigo
may be the major symptom of an ischemic attack, careful questioning of the
patient commonly uncovers symptoms implicating involvement of other brainstem
structures. Objective neurologic signs should be present in frank infarction
of the brainstem.
Either central or peripheral nystagmus can be due to toxins, most commonly
alcohol, tobacco, aminoglycosides, minocycline, disopyramide, phencyclidine,
phenytoin, benzodiazepines, quinine, quinidine, aspirin, salicylates, non-
steroidal anti-inflammatories and carbon monoxide. Nystagmus occuring in
central nervous system disease may be vertical and disconjugate, whereas inner
ear nystagmus never is. Central nystagmus is gaze-directed (beats in the
direction of gaze) whereas inner ear nystagmus is direction-fixed (beats in
one direction regardless of the direction of gaze). Central nystagmus is
brought out by visual fixation, which supressed inner ear nystagmus.
References:
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* Herr RD, Zun L, Matthews JJ: A directed approach to the dizzy patient. Ann
Emerg Med 1989;18:664-672.
* Froehling DA, Silverstein MD, Mohr DN et al: Does this patient have a
serious form of vertigo? J Am Med Assoc 1994;271;385-388.
* Epley JM: Positional vertigo related to semicircular canalithiasis.
Otolaryngol Head Neck Surg 1995;112:154-161.
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