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DIZZINESS AND VERTIGO

LEARNING OBJECTIVES:

At the end of this tutorial, you should be able to:

1. Define dizziness
2. Outline the differential diagnosis for dizziness
3. Take a history from a patient with dizziness, focussing on the clinical
features which aid in narrowing the differential
4. Examine a patient with dizziness, focussing on eliciting clinical features
which assist in determining the aetiology.
5. Outline with justification the investigations indicated in a patient with
tremor.

DEFINITION: Dizziness is a non-specific term often used by patients to describe

symptoms. The most common disorders lumped under this term include
vertigo, non-specific dizziness, dis-equilibrium and pre-syncope. The first and
most important step in the evaluation is to fit the patient into one of these more
specific categories.

DIFFERENTIAL DIAGNOSIS:

Cardiovascular Disorders

A. Postural (Orthostatic) Hypotension: Orthostatic hypotension is defined as

drop of > 20 mm Hg systolic blood pressure and > 10 mm Hg diastolic
blood pressure in the upright posture.
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This occurs in patients who have a chronic defect in, or variable instability of
vasomotor reflexes.

1. Drug Induced: Especially anti-hypertensives or vasodilator drugs

2. Peripheral Neuropathy:

(a)Diabetic
(b) Alcoholic
(c)Nutritional
(d) Amyloid

3. Idiopathic postural hypotension: Patients with idiopathic postural

hypotension may be identified by a characteristic response on the upright
tilt on a table.
4. Multisystem Atrophies: These are CNS disorders in which orthostatic
hypotension is associated with:

(a)Parkinsonism (Shy-Drager Syndrome)

(b) Progressive cerebellar degeneration
(c)A more variable parkinsonian and cerebellar syndrome (striatonigral
degeneration)

5. Physical De-conditioning: Such as after prolonged illness with

recumbency, especially individuals with reduced muscle tone or
prolonged weightlessness as in space flight
6. Sympathectomy: This abolishes vasopressor reflexes
7. Acute Dysautomania: Guillain Barre syndrome variant
8. Decreased Blood Volume

(a)Adrenal insufficiency
(b) Acute blood loss

Cardiac arrhythmias

1. Bradyarrhythmias: Syncope due to bradyarrhythmias may occur

abruptly, without presyncopal symptoms and recur several times daily.

(a)Sinus Bradycardia:
(b) Sino-atrial Block:
(c)Sinus Arrest:
(d) Sick Sinus Syndrome:
(e)AV Block:

2. Tachyarrhythmias: Syncope due to tachyarrhythmia is usually preceded

by palpitation or light-headedness but may occur abruptly with no
warning symptoms.

(a)SVT with Structural Heart Disease: SVT are unlikely to cause syncope
in individuals with structurally normal hearts but may if they occur in
patients with:

i. Heart disease that also compromises cardiac output

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ii. Cerebrovascular disease

iii. A disorder of vascular tone or blood volume
iv. Rapid ventricular rate.

(b) AF with WPW Syndrome: Patients with WPW may experience

syncope when a very rapid ventricular rate occurs due to re-entry across
an accessory AV connection.
(c)Atrial Flutter with 1:1 AV Conduction
(d) Ventricular Tachycardia: VT is a common cause of syncope,
particularly in patients with a prior MI. Patients with aortic valvular
stenosis and HOCM are also at risk of VT.
(e)Torsade de Point: Individuals with abnormalities of ventricular
repolarisation (long QT interval) are at risk of developing polymorphic VT
(Torsade). Those with an inherited form of this syndrome usually have a
family history of sudden death in young individuals.

Other cardiopulmonary aetiologies:

1. Pulmonary embolism
2. Pulmonary hypertension
3. Atrial myxoma
4. Myocardial disease (massive MI)
5. LV myocardial restriction or constriction
6. Pericardial constriction or tamponade
7. Aortic outflow tract obstruction
8. Aortic valvular stenosis
9. HOCM

C. Carotid Sinus Hypersensitivity: Syncope due to carotid hypersensitivity is

precipitated by pressure on the carotid sinus baroreceptors, which are
located just cephalad of the bifurcating common carotid artery. This
typically occurs in the setting of shaving, a tight collar or turning the head to
one side. Carotid sinus hypersensitivity usually occurs in men 50 years of
age. Activation of the carotid baroreceptors gives rise to impulses carried
via the nerve of Hering, a branch of the glossopharyneal nerve, to the
medullar oblongata. These afferent impulses activate efferent sympathetic
nerve fibres to the heart and blood vessels, cardiac vagal efferent nerve
fibres or both. In patients with CSH, these responses may produce:

1. Cardio-inhibitory Response: Sinus arrest or AV block

2. Vasodepressor Response: Vasodilation
3. Mixed: Both

Neurocardiogenic Syncope: The term neurocardiogenic syncope is used to

encompass both vasovagal and vasodepressor syncope.

1. Vasovagal Syncope: This is associated with both sympathetic

withdrawal (vasodilation) and increased parasympathetic activity
(bradycardia)
2. Vasodepressor Syncope: This is associated with sympathetic
withdrawal alone.
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The syncope often occurs in the setting of peripheral sympathetic activity

and venous pooling. Under these conditions, vigorous myocardial
contraction of the relatively empty ventricle activates myocardial
mechanoreceptors and vagal afferent nerve fibres that inhibit
sympathetic activity and increase parasympathetic activity. The resultant
vasodilation and bradycardia induce hypotension and syncope.

D. Situational: A variety of activities, including cough, deglutition, micturition

and defectation are associated with syncope in susceptible individuals.

1. Cough: Cough syncope typically occurs in men with chronic bronchitis or

chronic obstructive lung disease during or after prolonged coughing fits.
2. Micturition: Micturition syncope occurs predominantly in middle aged
and older men, particularly in those with prostatic hypertrophy and
obstruction of the bladder neck. LOC usually occurs at night during or
immediately after voiding.
3. Deglutition: Deglutition syncope may be associated with oesophageal
spasm. In some individuals, particular foods and carbonated or cold
beverages initiate episodes by activating esophageal sensory receptors
that trigger reflex sinus bradycardia or AV block.
4. Defaecation: This is probably secondary to a Valsalva manoeuvre in
older individuals with constipation.

Non-Vestibular Neurological Disorders

1. Multiple sensory deficits

2. Parkinson's disease
3. Normal pressure hydrocephalus
4. Cerebellar disease (degeneration, tumour, infarction)
5. Peripheral neuropathy (diabetes)
6. Dorsal column loss (B12 deficiency/syphilis)
7. Drugs (alcohol, benzodiazepines, anti-convulsants).

Vestibular Disorders

Periphe 1. Benign positional Central 1. Cerebrovascular disease

ral vertigo (BPV) 2. Cerebellar degeneration
2. Labyrinthitis 3. Migraine
3. Meniere's disease 4. Multiple sclerosis
4. Uncommonly head 5. Alcohol intoxication
trauma, herpes zoster 6. Phenytoin toxicity
7. Tumours of the
brainstem/cerebellem

Psychiatric

1. Major depression
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2. Anxiety/Panic disorder
3. Somatisation disorder

HISTORY:

The first principle to observe in evaluating the dizzy patient is not to put words
in the patient's mouth. When the patient says to you 'I feel dizzy', ask the
patient 'What do you mean by dizzy?'. There are typical responses the patient
might give as outlined below:

Cardiovascular Typical 'I might faint'; 'I'm giddy'; 'I'm light-

Disorders Response headed'
Precipitants 1. Standing
2. Shaving (carotid sinus
hypersensitivity)
3. Coughing
4. Micturition
5. Swallowing
6. Defaecation

History 1. Coronary artery disease

2. Heart failure
3. History of syncope
4. Palpitations
5. Medications (Anti-hypertensives
and/or vasodilators)
6. Melaena or rectal bleeding (acute
blood loss)

Non Vestibular Typical 'I might fall'.

Neurological Response
Disorders Precipitants Walking
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History 1. Diabetes
2. Neuropathy
3. Visual problems
4. Imbalance
5. Medications (e.g., phenytoin)

Vestibular Typical 'I'm tilting or rocking'; 'The room is

Disorders Response spinning'.
Precipitants Turning over in bed or looking up to
ceiling.
History 1. Attack Duration: BPV typically
lasts seconds to minutes.
Meniere's disease typically lasts
minutes to hours. Vestibular
neuronitis can last days.
2. CNS (Central Symptoms):
Dysarthria, ataxia, headache,
neck pain.
3. Peripheral Symptoms: Hearing
loss and tinnitus (Meniere's
disease)

Psychiatric Typical 'I'm just dizzy'.

Disorders Response
Precipitants Stress
History Patients usually have multiple medical
complaints and feel down and hopeless.
Anhedonia.

EXAMINATION:

Cardiovascular 1. Lying and standing blood pressures

Disorders 2. Cardiovascular examination

Non Vesibular 1. Gait

Neurological 2. Sensation
Disorders 3. Vibration/Proprioception
4. Cranial nerve exam
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5. Co-ordination.

Vestibular 1. Gait
Disorders 2. Cranial nerve exam (CN VIII, nystagmus)
3. Co-ordination
4. Dix-Hallpike manoeuvre

Psychiatric Thorough history

Disorders

INVESTIGATIONS:

Cardiovascular 1. Holter monitor: Arrhythmias (brady and tachy)

Disorders 2. Tilt table test: Used in the diagnosis of syncope
and dysautomania.
3. Echocardiogram: Aortic stenosis, mitral stenosis

Non Vestibular 1. CT Brain: Stroke, cerebellar haemorrhage,

Neurological evaluation of severe head injuries.
Disorders 2. MRI: Acoustic neuroma and other cerebellopontine
angle tumours, demyelination with MS.

Vestibular 1. Audiometry: To allow assessment of any

Disorders accompanying hearing loss.
2. ENT Referral

Psychiatric Psychiatric review

Disorders