This document provides a summary of approaches to assessing dizzy patients. It describes classifying dizziness by "flavor" such as vertigo or disequilibrium. It outlines assessing the trajectory of symptoms over time and considering medication side effects. For acute vertigo, a diagnostic matrix is provided to classify it as BPPV, Meniere's disease, vestibular neuritis or labyrinthitis based on persistence and hearing loss. Conditions not fitting the matrix include migraine-associated dizziness, progressive disequilibrium of aging, and cervical vertigo.

1. a practical approach to
assessment of the dizzy
patient

2. practical assessment
• easy – mainly based on the
history
• effective – diagnostic groups for
investigation & treatment

3. ‘flavours’ of dizziness
• near syncope
• disequilibrium – ‘gait only’ or ‘global’
• true vertigo
• psychogenic

4. trajectory of dizziness over time
SYMPTOM SEVERITY
TIME

5. dizziness associated with commonly used
drugs
Drug Type of dizziness Mechanism
Aminoglycosides Vertigo & dyseqm. VHC damage
Antiepileptics Dysequilibrium Cerebellar toxicity
Tranquilizers Intoxication CNS depression
Antihypertensives Near-syncope CBF, Postural
& diuretics hypotension
Amiodarone Dysequilibrium ?
Alcohol Intoxic. & Position. CNS depression &
cupula specific gravity
Methotrexate Dysequilibrium Cerebellar toxicity
Anticoagulants Vertigo Inner ear bleed

6. diagnostic matrix for acute vertigo
VERTIGO
EPISODIC PERSISTENT
HEARING LOSS
+
Kentala & Rauch, 2003

7. diagnostic matrix for acute vertigo
VERTIGO
EPISODIC PERSISTENT
HEARING LOSS
+
BPPV

8. benign paroxysmal positional vertigo
• most common type of vertigo seen
• causes:
• closed head injury
• vestibular neuritis – 20% will develop BPPV
• ear surgery
• prolonged bed rest

9. history : key features
• vertigo
• sudden attacks triggered by movement
• last less than 30 seconds
• occur in spells
• time of day, sleeping habits
• avoidance behaviour
• disequilibrium
• poor balance, light-headedness, nausea
• abnormal postural stability (Herdman, 1995)

12. how do otoconia get into posterior SCC?

13. mechanisms
cupulolithiasis
• ‘heavy cupula’ theory
• basophilic particles
adherent to cupula
canalithiasis
• free floating particles in
SCC

14. Dix-Hallpike test

15. Epley canalith repositioning procedure
• first patient 1978
• presented 1980
• published 1992
• induced migration of
canaliths by gravitation
• otoconia dissolve in
endolymph (Zucca, 1978)

16. CRP for left PSCC BPPV

19. Brandt-Daroff exercises (1980)

20. diagnostic matrix for acute vertigo
VERTIGO
EPISODIC PERSISTENT
HEARING LOSS
Meniere’s
+ disease
BPPV

21. Meniere’s disease
• repeated attacks of spontaneous vertigo
(hours) with nausea & vomiting
• unilateral hearing loss, tinnitus & aural
fullness
• occurs in clusters
• otolithic crises of Tumarkin

22. Meniere’s disease : natural history
• variable
• single bout for a few months
• relentless course
• permanent loss of auditory & vestibular
function as disease progresses
• burnt-out Meniere’s disease
• becomes bilateral in about 40-50%

23. Meniere’s disease : medical treatment
• buccastem • salt restriction
• stemetil <2000mg/day
suppositories • life style changes
• diuretics
• betahistine
• urea

24. Meniere’s disease : surgical treatment
• aimed at destroying inner ear balance
function
• intra-tympanic gentamicin injections
• labyrinthectomy
• vestibular nerve section
• ‘conservative’ surgery
• endolymphatic sac surgery

25. diagnostic matrix for acute vertigo
VERTIGO
EPISODIC PERSISTENT
HEARING LOSS
Meniere’s
+ disease
labyrinthitis
BPPV vestibular
neuritis

26. vestibular neuritis
• sudden onset of intense vertigo, lasting
several days with vomiting
• spontaneous nystagmus away from affected
ear
• usually able to stand without support
• disequilibrium may last for months
• “labyrinthitis” – labyrinthine infarction with
severe or total acute unilateral hearing loss

27. vestibular neuritis : natural history
• only 50% recover peripheral vestibular
function
• 20% experience persistent subjective
imbalance
• 20% develop BPPV
• bilateral sequential vestibular neuritis
• Meniere’s disease

28. vestibular neuritis : treatment
• no effective treatment
• stop vestibular suppressants early
• early mobilization
• vestibular rehabilitation : Cawthorne-Cooksey
exercises

29. conditions that do not fit ‘the matrix’
• migraine-associated dizziness
• progressive disequilibrium of
aging
• cervical vertigo

30. migraine-associated dizziness
patterns of vestibular dysfunction
• vertigo aura with hemi-cranial headache
• migraine equivalent vertigo
• basilar artery migraine
• disturbed baseline vestibular function
• more likely to develop BPPV

31. progressive disequilibrium of ageing
• aged patient brought in by adult children
• multi-system decline:
• ear – vestibular presbyastasis
• proprioception – arthritis in major joints
• eyes – poor vision & cataracts
• CNS – loss of Purkinje’s cells in cerebellum
• gradual downward trajectory: gait instability
& falls

32. progressive disequilibrium of ageing
treatment
• stop vestibular suppressants & sedatives
• correct vision & hearing
• occupational therapist
• hard sole-high top shoe
• hand rails, lighting, loose carpets
• physiotherapist
• exercise gait training
• stick or frame

33. cervical vertigo : risk factors
• whiplash injury
• cervical disc disease
• degenerative arthritis
• ergonomic/repetitive stress
injury

34. cervical vertigo : clinical features
• provoked by head-on-body movement
• combination of floating dysequilibrium &
brief episodes of vertigo
• cervical trigger points may produce vertigo
and/or nystagmus: fibromyalgia

35. summary
• what is the ‘flavour’ of dizziness?
• what is the ‘trajectory’?
• exclude patient’s medication as a factor
• if acute vertigo, does it fit ‘the matrix’?
• if not, is it PDA, MAD or CV
• if none of the above, consider
neurological referral