Dizziness A Diagnostic Approach

Dizziness A Diagnostic Approach. Rosul Al Zayer.

Introductions. Diagnosing the cause of dizziness can be difficult because symptoms are often non specific and the differential diagnosis is broad. A few simple questions and physical examination tests can help narrow the possible diagnoses. It is estimated that primary care physicians care for more than one half of all patients who present with dizziness. Dizziness is the chief presenting symptom in about 3 percent of primary care visits for patients 25 years and older. Dizziness can be classified into four main types: vertigo, disequilibrium, presyncope, or lightheadedness. Although appropriate history and physical examination usually leads to a diagnosis. However, the final cause of dizziness is not identified in up to one in five patient..

Patient History. The history should first focus on what type of sensation the patient is feeling, include descriptors for the main categories of dizziness. It is important to note that some causes of dizziness can be associated with more than one set of descriptors. A medication history should be obtained because dizziness especially from orthostatic hypotension is a well-known adverse effect of many drugs . Patients should also be asked about caffeine, nicotine, and alcohol intake. Head trauma and whiplash injuries can cause a variety of dizziness symptoms, from vertigo to lightheadedness..

Patient History. Table 2. Medications Commonly Associated with Dizziness from Orthostatic Hypotension Cardiac medications Alpha blockers (e.g., doxazosin [Cardura], terazosin) Alpha/beta blockers (e.g., carvedilol (Coreg], labetalol) Angiotensin-corwerting enzyme inhibitors Beta blockers Clonidine (Catapres) Dipyridamole (Persantine) Diuretics (e.g., furosemide [Lasix]) Hydralazine Methyldopa Nitrates (e.g., nitroglycerin paste, sublingual nitroglycerin) Reser pine Central nervous system medications Antipsychotics (e.g., chlorpromazine, clozapine [Clozaril), thioridazine) Opioids Parkinsonian drugs (e.g., bromocriptine [ParlodeIJ, levodopa/ carbidopa [Sinemet]) Skeletal muscle relaxants (e.g., baclofen ILioresall, cyclobenzaprine (Flexeril], methocarbamol [Robaxin], tizan idine [Zanaflex)) Tricyclic antidepressants (e.g., amitriptyline, doxepin, trazodone) Urologic medications Phosphodiesterase type S inhibitors (e.g., sildenafil (Viagra]) IJrinary anticholinergics (e.g., oxybutynin (Ditropan]) Jnfarmabon from refererxes TO and JJ..

Titrate the Evaluation. TiTrATE is a novel diagnostic approach to determining the probable etiology of diz­ziness or vertigo. The approach uses the Ti ming of the symptom, the Tr iggers that provoke the symptom, A nd a T argeted E xamination. The responses place the diz­ziness into one of three clinical scenarios: Episodic triggered, spontaneous episodic, or continuous vestibular..

Physical Examination. Blood pressure should be measured while the patient is standing and in the supine position. Orthostatic hypotension is present when the systolic blood pres­sure decreases 20 mm Hg, the diastolic blood pressure decreases 10 mm Hg, or the pulse increases 30 beats per minute. A full neurologic examination should be performed in patients with orthostatic dizziness but no hypotension or BPPV. The patient’s gait should be observed and a Romberg test performed. Patients with an unsteady gait should be assessed for peripheral neuropathy. The use of the HINTS (head­ impulse, nystagmus, test of skew) examination can help distinguish a possible stroke (central cause) from acute vestibular syndrome (peripheral cause)..

Differential Diagnosis. Table 1. Differential Diagnosis of Dizziness and Vertigo: Common Causes Cause (rmst to least frequent) Peripheral causes Benagn paroxysmal positional Vestibular neuritis Meniere disease Otoqlerosis Central cauws Vestibular mtgrane disease angle fossa mening•cmas Other causes Medication induced metatx)lic Orthostatic Clinical descrip bon Transient episodes of vertigo caused by dtslcxiged canallths •n the canals Spontaneous episodes of vertigo caused by inflammation of the vestibular nerve or labyrinthine organs. usudly from a viral infection Spontaneous of vertigo asscxiat«i with unilateral hearing loss caused by excess endolymphatic fluid pressure in the inner ear Spontaneous episodes Of vertigo by abnormal bone growth in the middle ear associat«i With conductive hearing loss Spontaneous episodes of vertigo asscxiat«i with migraine Continuous of vertigo caused by arterial occlusion or insufficiency. esp«jally affecting the vertebrcA)asdar system Continuous episcxies of déziness caused by vestibular schwannome (I.e., acoustic neurorna). infratentorial branstem or neurofibrornatOSIS Initially epecxiic. then often continuous episc&s of deaness without another cause and associat«i With psychiatrjc condition (e.g. anxiety. depression, bipolar dtso&r) Continuous eptsodes of dizziness without another cause and assocøted wth a possible medication adverse effect Acute episodic symptoms that are not asscxiated with any Acute eptßdic symptoms associat«i with a in from supine or Sitting to standing Information frcvn and 3..

Continue. BPPV is diagnosed with the Dix­Hallpike maneuver:.

Additional Testing. CBC (if you suspect anemia, polycythemia). Fasting and random plasma sugar (if you suspect hyper/ hypoglycemia). ECG (to rule out arrhythmia). Audiometry (to rule in or rule out Menier’s disease). Caloric test (to confirm Benign positional vertigo). CT scan or MRI (if you suspect stroke and brain tumors). EEG (if epilepsy is suspected)..

Algorithm. Approach to the Patient with Dizziness Patient presents with dizziness Ask about medication regimen: caffeine. nicotine, and alcohol intake; and history of head trauma or whiplash What sensation does the patient describe? False sense Of or spinning sensation Vertigo Ask about migraine symptoms Migrainous vertigo is diagnosed with history of episodic vertigo with a current migraine or history Of migraine and one Of the following symptoms during at least two episodes of vertigo: migraine head,Khe, photophobia, phonophobia, aura Off-balance or wobbly Dysequilibrium Consider possible underlying conditions, such as peripheral neuropathy and Parkinson disease medication regimen, especially in older patients Examine gait and vision, perform Romberg test. screen for neuropathy Feeling of losing consciousness or blacking out Presyncope Ask about history of arrhythmias and myocardial hfarction Recheck medication regimen, especially in older patients Measure orthostatic blood pressures Consider cardiac testing in patients with relevant history Vague symptoms, possibly feeling disconnected with the environment Lightheadedness Ask history of anxiety or depression Perform hyperventilation provocation test Hearing loss? Yes Episodic vertigo? No Episodic vertigo? Yes Meniere disease NO Labyrinthitis Yes Benign paroxysmal positional vertigo NO Vestibular neuritis Perform Dix-Hallpike maneuver (Figure 1).

Treatment. Cause Treatment Vertigo Benign paroxysmal positional vertigo Meclizine (Antivert), 25 to 50 mg orally every four to six hours, vestibular rehabilitation. Meniere disease Salt restriction (less than 1 to 2 g of sodium per day) and/or diuretics (most commonly, hydrochlorothiazide/ triamterene [ Dyazide ]) Intratympanic dexamethasone or gentamicin. Vestibular neuritis Methylprednisolone (Depo-Medrol), initially 100 mg orally daily then tapered to 10 mg orally daily over three weeks. Migrainous vertigo Migraine prophylaxis with serotonin 5-HT1 receptor agonists (triptans). Presyncope Orthostatic hypotension Review medication regimen. Disequilibrium Treatment of underlying cause (e.g., peripheral neuropathy, Parkinson disease). Lightheadedness Hyperventilation syndrome/ Anxiety Breathing control exercises, rebreathing into a small paper bag, beta blockers, antianxiety agents (e.g., selective serotonin reuptake inhibitors) or short- term use of benzodiazepines..

Summary. Assessment of Dizziness Episodic Is it triggered or spontaneous? Patient presents with dizziness or vertigo IS the timing episodic or continuous? Cont inuous Is it associated with trauma or toxins. or spontaneous? Triggered • Dix.Hallpike maneuver Spontaneous Migraine headache Vestibular migraine Trauma or toxin Spontaneous HINTS examination Hearing loss Meniere disease Psychiatric symptoms Panic attack. psychiatric condition Barotrauma Positive Benign paroxysmal positional vertigo Negative Assess for Orthostatic hypotension Medications Saccade present, unidirectional horizontal nystagmus, normal test of skew Peripheral etiology Vestibular neuritis No saccade, nystagmus dominantly vertical, torsional Or gaze- evoked bidirectional, abnormal test of skew Central etiologyt Stroke or transient ischemk attack of Symptoms with movement does not aid in determining whether the etiology is peripheral vs. central. t—Central catses can also occur with patterns triggered by movement..

References. BMJ Best Practice; Assessment of Dizziness. AAFP; Dizziness: Approach to Evaluation and Management. AAFP; Dizziness: A Diagnostic Approach. UpToDate ; Approach to the patient with dizziness..