Approach to Dizziness & Vertigo

Approach to Dizziness & Vertigo 2018-01-30T16:37:04+08:00

Differential diagnosis

  • Cardiac
    • Arrhythmia
    • Aortic stenosis
    • Hypertrophic obstructive cardiomyopathy
  • Neurological
    • Vertebra-basilar insufficiency
    • Multiple system atrophy
    • Chiari malformation
    • Cerebellar stroke
    • Multiple sclerosis
    • Brain tumour
    • Wernicke’s encephalopathy
    • Lateral medullary syndrome
    • Vertebral artery dissection
  • Peripheral
    • Vestibular neuronitis
    • Benign paroxysmal positional vertigo
    • Otitis media
    • Meniere’s disease
  • Endocrine
    • Hyperglycaemia
    • Hypoglycaemia
    • Addison’s
    • Hyperthyroidism
  • Haematological
    • Anaemia
  • Dehydration
  • Vasovagal
  • Drugs
    • Acute alcohol intoxication
    • Phenytoin
    • Anti-hypertensives
    • Ototoxicity from aminoglycosides / vancomycin
    • Illicit drugs such as LSD
  • Psychological
    • Hyperventilation
    • Anxiety

History

  • Characterise the dizziness
    • Is the room spinning around you?
    • What were you doing when you noticed it?
    • Is the dizziness continuous, or does it come and go?
    • How long does each episode last?
    • Does anything bring it on? For example turning your head?
  • Peripheral vertigo
    • Are there any associated symptoms?
    • Do you hear a ringing sound in your ears?
    • Do you ears feel blocked?
    • Have you noticed any discharge from your ear?
    • Have you had a sore throat or runny nose recently?
    • Has your hearing gotten worse recently?
  • Central vertigo
    • Did the dizziness come on suddenly?
    • Do you feel nauseous?
    • Have you had any problems with your vision?
    • Do you find you are bumping into things?
    • Do you have a headache?
    • Do you find it difficult to look at light?
    • Is the giddiness worse when you look up?
    • Have you noticed that colours are not as vibrant as before?
    • Have you noticed any numbness in your hands and feet?
  • Endocrine:
    • Do you have, or have you ever had diabetes?
    • Are you on any medication for this?
    • Have you noticed that you are excessively thirsty?
    • Do you get up in the middle of the night to pass urine?
    • Have you noticed any change in the colour of your skin?
    • Do you feel unusually tired lately?
  • Drugs:
    • Do you take any long-term medication?
      • Specifically, are you on a water tablet?
      • Have you been given any antibiotics recently?
    • Do you use any recreational drugs?
    • Do you drink alcohol?
    • When was your last drink?

Examination

  • Pulse: rate and rhythm
  • Optic nerve
    • Pupils equal and reactive to light?
    • Look for relative afferent pupillary defect (demyelination)
    • Visual fields (posterior circulation stroke)
  • Extra-ocular movements
    • Multi-directional nystagmus indicates central vertigo
    • Unilateral nystagmus implies either
      • Ipsilateral cerebellar disease
      • Contralateral peripheral vestibular disease
    • Internuclear ophthalmoplegia (demyelination of medial longitudinal fasciculus)
  • Check for facial sensory loss and lower motor neurone facial weakness (cerebello-pontine angle lesion)
  • Hearing
    • Screen hearing for sensorineural hearing loss
    • Rinne’s test (compare hearing through air versus bone – mastoid process)
      • Normal: air conduction better than bone conduction
      • Conductive hearing loss: bone conduction better than air conduction
    • Weber’s test
      • Normal: sound is equal in both ears
      • Conductive hearing loss: sound is louder in affected ear
      • Sensorineural hearing loss: sound is louder in the normal ear
  • Cerebellar dysfunction
    • Intention tremor
    • Dysmetria
    • Dysdiadochokinesis
  • Auscultation
    • Carotid bruits
    • Ejection systolic murmur (aortic stenosis or HOCM)
  • Ask for:
    • Vitals
    • Postural blood pressure

Investigations

  • Blood tests
    • Full blood count (symptomatic anaemia, polycythaemia can pre-dispose to stroke)
    • Blood glucose
    • Renal panel (raised urea in dehydration or anaemia from gastrointestinal blood loss)
  • Electrocardiogram to look for anaemia
    • Holter or REKA if index of suspicion of cardiac arrhythmia is high
  • Echocardiogram if clinical examination picks up cardiac abnormality
    • To assess severity of aortic stenosis / left ventricular outflow tract obstruction
  • Computed tomography scan of the brain if central vertigo is suspected
  • Magnetic resonance imaging of the brain
    • Cerebellopontine angle tumours
    • Demyelination
  • Audiometry to delineate hearing loss

Management

  • Patient education
  • Stroke
    • Thrombolysis if within the thrombolysis window (4.5 hours)
    • Load aspirin and control of cardiovascular risk factors otherwise
    • Decompression if haemorrhagic stroke
  • Peripheral vertigo
    • Vestibular suppressants such as antihistamines
    • Epley manoeuvre

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This Sliding Bar can be switched on or off in theme options, and can take any widget you throw at it or even fill it with your custom HTML Code. Its perfect for grabbing the attention of your viewers. Choose between 1, 2, 3 or 4 columns, set the background color, widget divider color, activate transparency, a top border or fully disable it on desktop and mobile.