ENT GPSI Dr Rakesh Chopra's advice on sorting out the vestibular, cardiovascular and neurological causes of dizziness.
1 Categorise the symptom.
The history will help point you in the right direction:
• ‘spinning' dizziness often has a vestibular cause
• faintness or a sensation of blackout (presyncope) points to a cardiovascular cause
• a sensation of imbalance, drunkenness or instability points towards a neurological cause.
These are not rigid compartments but a very useful initial compass, so try to fit the symptoms into one of these three categories.
2 The duration of dizziness is a great clue.
Dizziness that is short-lasting – a few seconds up to a minute or two – is often seen in benign paroxysmal positional vertigo. The vertigo of Ménière's disease lasts at least 20 minutes but not more than 24 hours. Acute dizziness that can take days to subside points toward acute labyrinthitis or vestibular neuronitis. However, veritiginous migraine can straddle all these timelines.
3 Think migraine.
Up to 20% of migraine patients have dizziness. We all see and diagnose migraine, but rarely associate dizziness with migraine. The important point is that migrainous vertigo – or vertiginous migraine – can mimic almost any kind of dizziness.
The Neuhauser criteria for diagnosing this condition are:
1 Recurrent episodic vestibular symptoms (attacks).
2 Migraine headaches meeting International Headache Society (1988) criteria.
3 At least one of the following migrainous symptoms during at least two of these attacks:
• migraine-type headache
• photophobia
• phonophobia
• visual or other auras.
4 Other causes ruled out by appropriate investigations.1
4 Consider vertebro-basilar insufficiency (VBI).
Cerebrovascular disease is widely prevalent, strokes and TIA are common, and when presented with stroke symptoms we often focus on the internal carotid circulation and symptoms related to the internal capsule, such as hemiplegia. Vascular events and episodes occur in the basilar circulation (the vertebral artery in up to 25% of cases). These are easily overlooked, and are associated with symptoms such as:
• bouts of dysarthria
• weakness of the legs
• vertigo
• facial numbness.
Symptoms of dizziness can present after a stroke or during a TIA. They may also be precipitated by turning of the head (Bow Hunter's syndrome). So in patients with hyperlipidaemia, known carotid stenosis or atherosclerosis and known CVD or arteriopaths, VBI is an important possibility.
5 Do not label ‘labyrinthitis' casually.
Acute labyrinthitis or vestibular neuronitis are severe vertiginous disorders. The patients will have severe acute vertigo of sudden onset and there is often significant vomiting. Patients are often bedridden, and will need a home visit and an injection of prochlorperazine. If a patient is well enough to walk into your surgery, they do not have acute labyrinthitis. It slowly settles over a period of days, and over weeks there are periods of decompensation.
6 Remember age affects all organs.
The vestibular apparatus, the proprioceptive sense, the organs of vision and our neurological interconnections are no exceptions. Remember a condition called ‘benign disequilibrium of ageing'.
It is important to recognise that vestibulopathy may simply be age-related and not all dizzy patients will have a specific diagnosis.
Multiple sensory deficit dizziness is similar, especially in patients who have impaired sensation in their feet, poor vision or over-rely on an ageing vestibular apparatus – such as an elderly diabetes patient with neuropathy, arthritis and cataract.
7 Benign paroxysmal positional vertigo is the most common cause of dizziness.
Key features are:
• age – usually over 60 years
• postural – turning in bed, bending down and straightening
• brief – less than a minute
• rotatory
• there are no other associated symptoms
• can be self-limiting
• diagnosed easily by Dix-Hallpike test
• fixed in most patients by the Epley manoeuvre.
8 Always consider the possibility that the problem might be related to medication.
When a patient presents with dizziness we often do not first think of an iatrogenic cause – but we should. They are so many drugs in everyday use that can be incriminated: antihypertensives, BPH drugs, anti-epileptics, antidepressants and sedatives to name a few.
9 Consider Ménière's disease.
Ménière's disease is defined as recurrent, spontaneous episodic vertigo, hearing loss, aural fullness and tinnitus.
The American Academy of Otolaryngology's head and neck surgery diagnostic criteria are widely used. For a definite diagnosis of Ménière's disease, the following must be satisfied:
• two or more definitive, spontaneous episodes of vertigo lasting 20 minutes or longer
• audiometrically documented hearing loss on at least one occasion
• tinnitus or aural fullness in the treated ear
• other cases excluded.
10 Beware cervical dizziness.
Cervicogenic dizziness remains controversial, as most patients with neck pain, bulging cervical disks and whiplash do not suffer dizziness. No significant double-blind studies have been undertaken regarding cervicogenic dizziness, so a diagnosis of cervical disease as a cause of dizziness must be made with caution.
Dr Rakesh Chopra is a GPSI in ENT in St Helen's, Merseyside
Dr Chopra is running the NB Medical ENT in Primary Care Course on Thursday 24th June 2010 at the Brunei Gallery in London.
You can find out more about the course by clicking the link above or calling 0191 3853030.
Consider vertebro-basilar insufficiency in patients with a known carotid artery stenosis Carotid artery stenosis
