AssessmentsDizziness and vertigo: Clinical practice
USMLE® Step 1 style questions USMLE
USMLE® Step 2 style questions USMLE
A 65-year-old male presents to the office with the complaint of gait disturbance. History reveals he has never experienced this before, and it has become progressively worse over the past month. He has difficulty initiating movements and frequently falls. His wife states that he has been more forgetful recently. He has forgotten to take his medication and cannot recall the names of his grandchildren. History reveals that he also has trouble controlling his urine, having multiple episodes of incontinence a week. MRI of the brain shows expansion of the third ventricle. Which of the following is the most appropriate next step in management?
Content Reviewers:Rishi Desai, MD, MPH
The term “dizziness” can be used to refer to a number of related symptoms like presyncope, disequilibrium, what’s called “non-specific dizziness”, and vertigo.
Asking individuals specific questions about how they experience dizziness can help clarify the symptom. Let’s go through each of these.
Pre-syncope is the prodromal phase that occurs before syncope.
Individuals often complain of seconds to minutes of “nearly blacking out” or “nearly fainting”, and “feeling lightheaded when standing,” along with palpitations, sweating, a feeling of warmth, nausea or even blurry vision. Sometimes there’s a history of cardiac disease, such as congestive heart failure or coronary artery disease may be present.
Disequilibrium refers to a sense of imbalance specifically while walking, and usually is due to neurologic disorders like Parkinson’s disease, cerebellar disorders, peripheral neuropathy, or cervical spine disease.
This is often described as “feeling the ground moving” or “feeling like you’re on a boat”.
Non-specific dizziness is a more vague term that has a variety of causes ranging from anxiety or panic attacks, to hypoglycemia, or side effects of medications like anticholinergics.
Finally, there’s vertigo which can be thought of as having an illusion of self-motion, or movement of the surrounding environment.
Vertigo arises when there’s a mismatch between other sensory systems and the vestibular system.
The vestibular system is made of the vestibular apparatus; including the three semicircular canals, the utricle and saccule, the vestibular nerve, and the vestibular structures in the brainstem and cerebellum.
Vertigo can be broken down into peripheral vertigo, which is due to damage to the vestibular apparatus, or damage to the vestibular nerve, and central vertigo, which is due to damage to the vestibular structures in the brainstem or cerebellum.
Major causes of peripheral vertigo include benign paroxysmal positional vertigo, or BPPV, vestibular neuritis, Ménière’s disease, and an acoustic neuroma.
Other associated symptoms also provide a clue. For example, the 4 Ds: diplopia, dysphagia, dysarthria, or dysmetria, often suggest central vertigo, whereas auditory symptoms like hearing loss or tinnitus suggest peripheral vertigo.
See, we normally have calcium carbonate crystals in the utricle and saccule, but the problem arises when they sneak into the semicircular canals, most commonly, the posterior canal. The crystals obstruct the normal flow of endolymph in the canals when the head moves in a specific direction. Like stones causing turbulence in a smooth river. Without normal endolymphatic flow, the semicircular canal can’t properly detect angular acceleration, causing vertigo.
BPPV causes recurrent episodes of vertigo that are provoked by a specific and predictable changes in head position, such as rolling out of bed.
Episodes last less than one minute, and are usually accompanied by nausea or vomiting. Hearing loss and tinnitus are usually absent in BPPV.
To perform the Dix-Hallpike maneuver, you have to extend the neck and turn it to one side while the individual is sitting. Then, you have to rapidly place them in a supine position so that their head hangs over the edge of the bed. After 30 seconds there might be nystagmus or vertigo symptoms.
The treatment of BPPV is the Epley maneuver, which aims at guiding the lost crystals back into the utricle where they belong.
So let’s say an individual has right-sided BPPV based on the Dix-Hallpike maneuver. With the individual upright, grasp their head on both sides, and rapidly position them to the supine position with the right ear pointing downwards. Then immediately rotate the head to the left side so that the right ear points upwards. Hold this position for 30 seconds.
Next, ask the individual to turn their body to the left side, and then rotate their head until their nose is pointing towards the floor. Hold this position for 30 seconds, then rapidly lift the individual back to the upright position. Works like magic.
Because BPPV can recur, individuals are taught a modified version of the Epley maneuver that they can do themselves. First, in the sitting position, the individual should turn their head about 45 degrees to the affected side, let’s say the right side. Then, lie down supine, and wait for 30 seconds. Next, without raising the head, turn it 90 degrees to the left, and wait again for 30 seconds. Next, turn the body 90 degrees to the left, and wait another 30 seconds. Finally, sit up on the left side. The modified Epley maneuver should be performed 3 times a day until the individual has no symptoms for at least 24 hours.
Vestibular neuritis or labyrinthitis is inflammation of the vestibular portion of the 8th cranial nerve.
In comparison with BPPV, vestibular neuritis causes acute, severe, constant, peripheral vertigo lasting several days. Head movement can worsen the symptoms, but the symptoms can occur at rest and don’t rely on a specific position. Also, unlike BPPV, there may be hearing loss. Individuals with vestibular neuritis sometimes have a prior viral upper respiratory tract infection.
The diagnosis is based on the symptoms, and although there’s conflicting evidence, corticosteroids can be given to help the inflammation.
Alright, now Ménière’s disease is also called endolymphatic hydrops, and it’s due to having excess endolymphatic fluid in the semicircular canals.
Ménière’s disease tends to occur in people over the age of 65, who develop a classic triad of symptoms: recurrent episodic vertigo, hearing loss, and tinnitus. Additional symptoms include a sense of ear fullness - called aural fullness- , as well as nausea or vomiting. The onset of symptoms is usually abrupt, and episodes usually last from 20 minutes up to 24 hours.
Typically, there are long periods of remission in between clusters of vertigo attacks, and triggers include high salt intake, caffeine, alcohol, and nicotine.
The diagnosis is based on a person having the classic symptoms.
Audiometry is done to measure the hearing loss.
Initial treatment is to limit salt, caffeine, alcohol, and nicotine, which improves health in a number of ways.