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DIZZINESS: APPROACH LEARNING OBJECTIVES

TO EVALUATION AND • To discuss a novel approach to evaluate dizziness


MANAGEMENT • To differentiate between peripheral versus central
etiologies of dizziness
KEIDREN LEWI, MD PGY-1
CREIGHTON UNIVERSITY DEPARTMENT OF FAMILY MEDICINE
• Management of different etiologies of dizziness

DIZZINESS TRADITIONALLY

• More than one half of patients present with complaints • Vertigo, pre-syncope, disequilibrium, light-headedness
of dizziness • Fallen out of use – vague terms
• Try to get a patient to describe their symptoms – difficult,
• Very common yet imprecise symptom
and often contradictory
• Broad differential diagnoses (common etiologies don’ t • Symptom quality does not reliably predict cause of
account for more than 10% of cases) dizziness
• Benign vs serious causes

TITRATE THE EVALUATION


TITRATE THE EVALUATION (2)

• Novel diagnostic approach to determining possible etiology of • Based on the responses above - three scenarios:
dizziness or vertigo
• 1 ) Episodic triggered
• Two components: paying attention to the timing of dizziness,
and the triggers of dizziness
• 2 ) Spontaneous Episodic

• TITRATE – Timing of symptom • 3 ) Continuous Vestibular


• Triggers that provoke the symptom
• And Targeted Examination

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EPISODIC TRIGGERED SPONTANEOUS EPISODIC

• Timing: lasting seconds to hours • Timing: lasts seconds to days


• Trigger: head motion on change of body position • No trigger
• Consistent with BPPV (Benign paroxysmal positional • Need patient history to establish diagnosis
vertigo) • Meniere disease, vestibular migraine, psychiatric
diagnoses such as anxiety disorder, lying down -
vestibular

CONTINUOUS VESTIBULAR

• Timing: lasting days to weeks


• Triggers: none
• Traumatic vs toxic exposure
• Commonly: nausea, vomiting, nystagmus, gait instability
• Diagnoses – consistent with vestibular neuritis/central
etiologies

HISTORY MEDICATIONS

• Vertigo • Implicated in 23% of cases of dizziness in older adults in


primary care setting
• Hearing loss
• Use of five or more medications is associated with
• Triggered by position or change in position
increased risk of dizziness
• Medications
• Medication adverse effects because of age-related
pharmacokinetic and pharmacodynamic changes

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PHYSICAL EXAM

• Cardiac and neurologic assessment usually normal in


patients presenting with dizziness

PHYSICAL EXAM (2) PHYSICAL EXAM (3)

• Blood pressure – measure standing and supine • Gait observation – assess for peripheral neuropathy
• Orthostatic hypotension – systolic BP decreases 20 • Romberg test
mm Hg, diastolic BP decreases 10 mm Hg, OR pulse • Positive Romberg suggests abnormality with
increases 30 beats per minute going from supine to proprioception receptors or their pathways
standing for one minute

HINTS EXAMINATION HEAD IMPULSE

• Can help distinguish stroke (central causes) vs acute • Have patient sit, thrust head 10 degrees to right and
vestibular syndrome (peripheral cause) then to the left while patient’s eyes remain fixed on the
examiner’s nose
• Three components:
• Head-impulse • If saccade (rapid eye movement) occurs , etiology is
• Nystagmus likely peripheral. No eye movement suggests central
• Test of Skew etiology

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NYSTAGMUS TEST OF SKEW

• Have patient follow examiner’s finger moving slowly from • Ask patient to look straight ahead, cover and uncover
left to right each eye
• Spontaneous unidirectional horizontal nystagmus that
• Vertical deviation of covered eye after uncovering is
worsens when gazing in direction of nystagmus – suggests
peripheral cause
abnormal result – suggests brainstem involvement

• Vertical or torsional, or changes direction with gaze


suggests central etiology

DIX-HALLPIKE MANEUVER LABORATORY TESTING AND IMAGING

• Not necessary for complaint of dizziness


• If patient has diabetes or hypertension, may want to
check electrolyte & glucose
• H/x of cardiac disease – may consider
echocardiography, Holter monitoring, carotid Doppler
• Imaging – CT/MRI if considering cerebrovascular
disease

PERIPHERAL ETIOLOGIES CENTRAL ETIOLOGIES

• Abnormalities in peripheral vestibular system – • Includes vestibular nuclei, cerebellum, brianstem, spinal
semicircular canals, saccule, utricle, vestibular nerve cord, vestibular cortex
• BPPV • Vestibular migraine
• Vestibular neuritis • Vertebrobasilar ischemia
• Meniere disease

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REFERENCES
SUMMARY

• Muncie HL, Sirmans SM, James E. Dizziness: Approach to Evaluation


• TiTrATE is a novel diagnostic approach to determine and Management. American Family Physician. 2017; 95(3):154-162
probable etiology of dizziness of vertigo. Timing, trigger
• Post RE, Dickerson LM. Dizziness: a diagnostic approach. Am Fam
and targeted exam – 3 classifications: episodic triggered, Physician. 2010;82(4): 361-368, 369.
spontaneous episodic, continuous vestibular.
• Newman-Toker DE, Edlow JA. TiTrATE: a novel, evidence based
• Medications implicated in 23% of cases of dizziness. approach to diagnosing acute dizziness and vertigo. Neurol Clin.
• HINTS (head-impulse, nystagemus, test of skew) can 2015;33(3):577-599, viii.
differentiate peripheral cause vs central cause of vestibular • Shoair OA, Nyandege AN, Slattum PW. Medication-related dizziness in
neuritis. the older adult. Otolaryngol Clin North Am. 2011;44(2):455-471, x.

THANK YOU!