Dizziness/Vertigo

Approach to patient with Dizziness

Subjective

• “Does it feel like either the room is spinning or that you are spinning?” and/or “Is it triggered or worsened by turning your head or rolling over in bed?”

  • Yes = vertigo

    • BENIGN PAROXYSMAL POSITIONAL VERTIGO (most common)

      • brief, recurrent episodes (seconds to minutes), +/- nausea and vomiting

    • Vestibular Neuritis

      • rapid onset, severe, persistent (days), N/V, imbalance

    • Ménière’s Disease

      • recurrent episodes (minutes to hours), fluctuating hearing loss, tinnitus, and sensation of aural fullness

    • Vestibular Toxicity

      • aminoglycosides (eg. gentamycin), loop diuretics, ASA, NSAIDs, amiodarone, quinine, cisplatin

  • No = other forms of dizziness

    • Presyncopal Dizziness – “feels like nearly fainting or blacking out”

      • ECG

      • Triggered by exertion? Chest pain/palpitations? Known structural heart dz? FmHx of sudden death? Abnormal ECG? (if pt stable, fax ECG for urgent advice)

        • If yes to any, suspect cardiac etiology. Refer to Emergency

        • If no, orthostatic hypotension?

          • Yes = investigate underlying cause. meds/alcohol? Consider CBC/lytes

          • No = likely vasovagal/situational etiology. If recurrent episodes or pt is at risk of injury, consider referral for tilt test (+/- carotid sinus massage if >40 yo)

    • Disequilibrium Dizziness – “unsteadiness while walking”

      • Often multifactorial, common in elderly, risk of falls. Complete neuro and MSK exams to rule out peripheral neuropathy, Parkinsonism, MSK d/o, CVA, etc

    • Nonspecific Dizziness – “woozy”, “giddy”, “light-headed”

      • DDx: hypoglycemic (glucose), thyroid disease (TSH), pregnancy (β-HCG), meds, psychiatric disorders, alcohol/drugs, menstruation, previous head trauma

• Ask about: onset, duration, nausea, vomiting, hearing loss, tinnitus, headache, imbalance, aural fullness, ear pain, rash, facial paralysis, medications

Objective

Assessment

• viral labyrinthitis

• benign positional vertigo

• Eustachian tube dysfunction (often with serous otitis media)

• Meniere's disease

• Vertebrobasilar insufficiency (in the elderly with vasculopathy)
  

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Plan