1. dizziness
dizziness
Heba Al-thuwaini – Bayan Alsultan
Group : 1

2. Learning objectives
• What is vertigo and dizziness ?
• What are the causes of dizziness?
• What is the approach to reach the diagnosis?
• Mention steps and findings in examination of dizziness case ?
• Mention the investigation for a dizziness case?
• What is the treatment in the above case?

3. Case summary
A 45 years old female
presents with the primary
complaint of being “ dizzy ”

4. Dizziness
• Dizziness is the feeling of being lightheaded,
woozy, or unbalanced.

5. Types Of Dizziness
Vertigo
54% Disequilibrium Pre-syncope
syncope

6. Types Of Dizziness
• Vertigo: sensation of movement either of the patient
or of the surroundings.
• Disequilibrium: sensation of imbalance.
• Pre-syncope : Sense of impending fainting .
• Syncope: sudden transient loss of consciousness with
concurrent loss of postural tone .

7. Causes of dizziness
Vertigo Disequilibriu
m
Pre-syncope syncope

8. Systems That Maintain
Balance
vision
Vestibular labyrinth
proprioceptors

9. Causes of vertigo

10. Peripheral Causes of
vertigo
• Benign paroxysmal positional vertigo (BPPV) :
20%
• vestibular neuronitis (labyrinthitis):15%
• Meniere’s disease:10%
• Drugs (aminoglycosides)

12. Benign paroxysmal
positional vertigo (BPPV)
• BPPV is caused by particles in the semicircular canals which
alter endolymph flow
• It may be due to minor head injury or because of repetitive
head movement
• symptoms sometimes occur at night during movement whihe
asleep
• vertigo = Less than one minute
• BPPV is common in women than men.

14. Vestibular neuritis :
• This is inflammation of the vestibular nerve, possibly due
to viral infection.
• This inflammation disrupts the transmission of sensory
information from the ear to the brain.
• Vertigo Associated with severe nausea and vomiting
• vertigo = Longer than one day.

15. Meniere’s disease :
• It caused by increased volume of endolymph in the
semicircular canals.
• psychological factors such as stress can act as a
trigger mechanism for an attacks.
• Vertigo = less than one day and more than one minute.
• Associated symptoms :
• Tinnitus
• fluctuating hearing loss ( unilateral )
• Nausea & vomiting

17. Central causes of vertigo
• Vascular disease ( vertebrobasilar
insufficiency): 50% of central causes
• Demyelinating (Multiple sclerosis)
• Drugs (anticonvulsants, alcohol, hypnotics)

18. Vertebrobasilar Insufficiency
• Is a condition where there is an
insufficient delivery of blood flow
via the vertebral and/or basilar
arteries to the brain.
• The vertebrobasilar system supports
the occipital lobes, which are
responsible for vision, and
the cerebellum, which is responsible
for balance and coordination.

19. Multiple Sclerosis (MS):
• Is an immune system disease that affects the central
nervous system.
• A lesion or lesions in the brain stem or cerebellum, the area of the
brain that controls balance & coordinate visual, spatial and other input
to the brain needed to produce and maintain equilibrium, May cause
vertigo.

20. Causes of Disequilibrium
• Common in the elderly people.
• caused by Multisensory disorder due to any combination
of:
·peripheral neuropathy
·visual impairment
·musculoskeletal disorder interfering with gait
·vestibular disorder

21. Causes of Pre-syncope
• Caused by psychiatric disorders:
·Major depression 25%
·Generalized anxiety or panic disorder 25%
·Somatization disorder
·Alcohol dependence
·Personality disorder
·Hyperventilation

22. Causes of Syncope
• Drop in blood pressure (orthostatic hypotension).
• Inadequate output of blood from the heart.
• Dehydration
• Low blood sugar

23. The approach to reach the diagnosis

24. 1- Taking History
• History alone reveals the diagnosis in roughly three out
of four patients complaining of dizziness

25. What to ask!
1- ask patient what he mean by “ I’m dizzy” ?

26. What to ask!
2- Or ask the patient questions to identify the type of
dizziness.

27. What to ask!
3- When did the dizziness occur and the duration of it?
( Help to differentiate between the types of vertigo ).
4- Was is it associated with other symptoms?
(Tinnitus, hearing loss , nausea and vomiting.)
5- Are there certain body position that cause the dizziness?
6- Did it occur after performing certain activates ?

28. Medical history
1. Determine if the patient has a condition such as:
• Vascular disease
• Multiple sclerosis
• Cardic disease
• Hypertntion
• Or recent viral upper repiratory infection.
2- Ask the patient about the drug history.
3- Determine if the patient had an ear surgery.
• Family history .

29. Physical examination
• Review of vital signs :
BP (supine and standing), HR, presence of
fever, irregular pulse.
• Ear examination :
Examine the tympanic membrane for vesicles
or cholesteatoma.

30. Weber’s test
Hearing tests:
Rinne test

31. Rinne Test

32. Weber’s test

33. Romberg test Gait test Dix-Hallpike
maneuver
:Examining Vestibular system

34. Fukuda test Finger-nose test Tandem walking

35. Examining eye function
•Electronystagmography (ENG) -
tests vestibular function by using
electrodes to detect nystagmus.
•Frenzel goggles

36. Investigation
• Patients with sudden ongoing attacks, should
have:
pulse oximetry Glucose test Pregnancy test

37. Further investigations include
ECG MRI Audiological
evaluation

38. • Laboratory tests tests such as
electrolytes, glucose, blood counts, and
thyroid function tests are rarely helpful.
• Except for patients with chronic vertigo
and bilateral hearing loss.

39. Treatment and Management
• Treatment is directed at the cause, including
stopping, reducing, or switching any
causative drugs.
• If a vestibular disorder is present and thought to
be secondary to active Meniere disease or
vestibular neuronitis or labyrinthitis, the most
effective vestibular nerve suppressants are
(diazepam). Antibiotics are rarely needed.

40. • Meniere disese  diuretics & low salt diet.
• vestibular rehabilitation therapy – for recurrent
vertigo secondary to unilateral vestibular
weakness
• Vertigo associated with (BPPV) is treated with
the Epley maneuver (otolith repositioning).

42. Complication
• Patients with frailty are at significant risk of falling with
consequent fractures;
• their fear of moving and falling often significantly
decreases their ability to do daily activities.

43. Prevention
Dizziness is neither predictable nor
preventable. However, we have some
guidelines:
• Avoid reading while traveling if it makes
you feel sick.
• Relaxation techniques can help ward
tension and anxiety that can cause
dizziness.
• Changes to the diet can also cut down
on episodes of dizziness.
• People with menier’s disease may avoid
episodes of vertigo by cutting salt,
alcohol and caffeine out of their diets.

44. Simple self-care tips that can lower you dizziness:
•Dizziness is always a symptom of danger and it is
better to consult the doctor immediately.
•Drink plenty of fluids.
•Have regular meals.
•Get plenty of rest.
•Practice relaxation by yoga or meditation.

45. Summary

46. Reference
www.merckmanuals.com
www.ncbi.nlm.nih.gov
www.aan.com
www.dizziness-and-balance.com

47. Any QUISTIONS !!