Vertigo & Dizziness

Dizziness &
Vertigo
Frederick Mars Untalan MD
www.entmdclinic.webs.com

Vertigo
Latin word “vertere” means to turn
suffix “igo” is a condition of turning about

O Dizziness one of the most common
complaints in the primary care setting
O 3rd most common complaint after chest pain
and fatigue
O 20%, general population, aged 18-
65yrs, reported dizziness within previous
month*
O Incidence increases with age**
*Yardley I,Owen N, Nazareth I, Luxon L. Br J Gen Prac. 1998;.
**Kroenke K, Mangelsdorf D. Am J Med. 1989
Epidemiology

Epidemiology
O Over one year 18% of 65+ complained to
a physician or had loss of usual activities
due to dizziness
O 30% prevalence in community survey
O Most common complaint over age 75
O Risk factor for functional decline

The number of patients presenting with dizziness
to primary care professionals increases with age
0.2
0.7
1.8
1.8
2.4
2
3.4
4
6.7
0 1 2 3 4 5 6 7
0–14
15–24
25–34
35–44
45–54
55–64
65–74
75–84
85+
Ageofpatients
% primary care visits with dizziness as a presenting complaint
Sloane PD. J Fam Pract 1989;29:33–8.
US survey of 2879 physicians

Sloane PD.. J Fam Pract 1989
Proportion Seen by Different Disciplines
GP / FM
44%
General
Internist
23%
Other Internal Med
Specialist
6%
Otolaryngologists
6%
Cardiologists
6%
Other
4%
General Surgeons
4%
Neurologists
4%
Surgical Sub-Specialists
(OB/GYN)
3%
Physicians/Specialists

Sloane PD, dallara J, Roach C, Bailey KE, Mitchell M, McNUtt R.. J Am Board Fam Pract. 1994
*Desmond AL.,2004
3 of 140( 2%) patients referred for otologic diagnosis*
Treatment Strategies done by MDs
Treatment Strategy
0%
Office Lab Test
14%
Advanced Testing
(CT, MRI)
5%
Referral to Specialist
4%
Medication
25%
Observation
29%
Reassurance
17%
Behavioural
Recommendations
6%
Treatment Strategy

Vestibular System

Dizziness vs Vertigo

DIZZINESS VERTIGO
O Lightheadedness
O Heart/vascular
problem
O stroke
O Inner ear disorder
O Viral infx
O Changes in head
position

Types of Dizziness

Vertigo
O Due to an imbalance in vestibular
system, arising from inner or middle
ear, brainstem or cerebellum
O Common causes include benign
paroxysmal positional
vertigo, cerebrovascular dx, and acute
labyrinthitis and vestibular neuronitis

Presyncopal lightheadedness
O Due to diffuse cerebral ischemia
typically arising from vascular or cardiac
causes
O Common causes include vasovagal
episodes, postural hypotension, cardiac
dx (such as arrhythmia, CHF, low
output), and carotid sinus sensitivity

Dysequilibrium
O Perceived as body rather than head
sensation arising from motor control
system
(vision, vestibulospinal, proprioceptive, se
nsory, cerebellar or motor function)
O Common causes include stroke, sensory
deficits, severe vestibular loss, peripheral
neuropathy, and cerebellar disease

Other causes of dizziness
O These are vaguely described and may be
associated with anxiety and other
psychological disorders
O Less common cause of dizziness in older
than younger persons

Multiple Causes
O Subtyping may be useful in only about half
the cases
O Older persons often describe several
subtypes
O Most have dysequilibrium along with some
other type of dizziness - vertigo or
presyncope

Temporal Pattern of
Symptoms
O Continuous -
psychological, medications, permanent
structural damage (e.g. stroke, cerebellar
atrophy, vestibular damage, peripheral
neuropathy, deconditioning)
O Episodic - BPPV, recurrent
vestibulopathy, TIAs, Meniere’s
dx, migraine

Common Problems in Aging
O Greater sway during platform studies with
known loss of hair in semicircular
canals, utricle, and saccule of vestibular
system
O Progressive decline in baroreflex
sensitivity
O Resting cerebral blood flow close to
threshold for cerebral ischemia

Key Dizziness Syndromes
O Postural dizziness
O Positional vertigo
O Labyrinthitis
O Vestibular neuronitis
O Meniere’s disease
O Vertebrobasilar TIAs
O Stroke
O Cervical dizziness
O Physical deconditioning
O Drug induced
O Multiple sensory
impairments
O Psychological

Approach to vertigo

VESTIBULOOCULAR REFLEX
(VOR)
O Enables the preservation of visual acuity
and stable visual environment during
locomotion
O Nystagmus can be the result of any
disorder causing a malfunction in the VOR

Vertigo Made Easy 2011
Spontaneous
NYSTAGMUS

Frenzel glasses to evaluate nystagmus

Examination
Vestibular test : for BPPV
Positional Test : Dix Hallpike test

Test for Coordination:
CEREBELLAR TESTS
Cerebellar Cortical Disease Evaluation

Posture and Gait Test:
A test of somatosensation and
propioception.
Not a test of vestibular input.

Tandem Romberg
test
Standing on
Foam, FT
Pass
Fail
• AbN Vest
• AbN
Somatosensory(SS)
• AbN visual
• All 3 N
20
sec
Eyes
Open
Eyes
Closed
Pas
s
• Vest N
• SS N
Fail
• One of two AbN
30
sec
Standing on foam, FTFallAbN
Vest

Other Vestibular Tests to
Confirm Diagnosis after History
and
Office Exam:
1. ENG/VNG
2. Posturography
3. CT scan
4. MRI

MRI with gadolinium
1 cm, Vestibular
Schwannoma, R
3 x 3 cm CPA tumor, R
Meningioma

HRCT ( HIGH RESOLUTION CT SCAN)
Superior
Canal
Dehiscence
Normal

Dizzy Matrix

Peripheral Symptoms in Inner Ear Disorder:
Disorder Duration of
Vertigo
Hearing
Loss
Tinnitus Aural
Fullness
Meniere’s D Minutes to
hours
Fluctuating
HL
+ +
BPPV seconds +/- +/- +/-
Vestibular
Neuritis
Days to
weeks
- - -
Acoustic
neuroma
“imbalance” +
Progressive
Poor SDS
+ -
Patient feels fine in between spells.

Treatment

TREATMENT OF DIZZINESS
SPECIFIC MANAGEMENT DEPENDS
ON THE DIAGNOSIS THAT IS
CAUSING THE VERTIGO.
GENERAL MANAGEMENT OF
DIZZINESS INCLUDES
PHARMACOTHERAPY.

1 Antihistamines
- Anticholinergic effects
- (dry mouth, blurring of
vision)
1 Diphenhydramine
2 Dimenhydrinate
3 Meclizine
4 Cinnarizine
5 Flunarizine
6 Prometazine
II. Antiemetics
O- Centrally acting, major
tranquilizer, extrapyramindal
symptoms
1 Metoclopramide
2 Prochlorperazine
Vestibular sedatives

Vasodilators
O Disturbed labyrinthine vascularity
O Re-establishes blood flow in ischemic
areas of inner ear
a. Nicotinic acid
b. Histamine
c. Betahistine

Acute versus Chronic Vertigo
• Acute: With well-defined isolated spells of vertigo;
with distinct onset and offset; resolves in two
weeks*
• Chronic: persistent or chronic sensation;
recurrent
Goebel JA. Management options for acute versus chronic vertigo 2000
*Kroenke K, Lucas CA, Rosenberg ML, Scherokman B, Herbers JE, Wehrle
PA, Boggi JO. Ann Intern Med 1992

Treatment for Acute Dizziness
• Use centrally-acting vestibular suppressants to
reduce vertigo and nausea
• Suppress activity of both vestibular nucleus and
reticular activating system(RAS)
• Examples
1. Meclizine 25 mg TID +/- Promethazine 25-
50mg TID
2. Diazepam 2-5mg TID; if severe, 5-10mg IM
3. Droperidol 2.5mg IM
4. Prochlorperazine 25 mg per rectum
• Must be discontinued as soon as possible when the
acute event subsides

START BETAHISTINE AS SOON AS POSSIBLE
TO FACILITATE CENTRAL COMPENSATION
Treatment for Acute Dizziness

Principle of Treatment of Chronic
Dizziness
Vestibular
rehabilitation
Pharmacotherapy

What is Central
Compensation?
Loss or reduction in function of one
organ/ system
Other sensory organ
substitutes for loss of
function
(sensory substitution)
Tonic rebalancing of
sensory inputs
Habituation
(motor learning)
Through cerebellar/ brainstem neural
circuits- adaptive
plasticity/reprogramming
Sensory conflictDizziness

Medical Treatment of Chronic
(persistent) Dizziness
• Enhance central compensation : Betahistine- used
for Meniere’s disease
• Clinical use of most drugs began long before the
development of neuroscience; clinical efficacy and
their dosages have been established empirically*
• Animal studies showed its role in facilitating central
compensation
Bhansali SA. 2001

Mechanisms of Action:
Betahistine hydrochloride
Increase in cochlear blood flow (H3
pre-synaptic heteroreceptor
antagonism)
Decrease resting discharge in
labyrinthine hair cells
(H3 antagonist and H1 agonist
action)
Inhibition of firing activity of
vestibular nuclei (H3 receptor
antagonist)
Vestibular
compensation

Pharmacologic Effects of
Betahistine:
Peripheral endorgan
• Increase cochlear blood
flow
• Decrease in resting
electrical discharge
through presynaptic H3
receptor antagonism
Central organs
• HA release in VN results
in excitation of neuronal
activity
• Effect adaptive
reprogramming of VOR to
stabilize gaze, and VSR to
control posture

Recent Placebo and Active Control
Trials of Betahistine
Reference Method Diagnosis Treatment
and
duration
Result
Albers et. al
2003
N=52
Double-blind,
randomized,
multi-center
Recurrent
Vestibular
vertigo
Betahistine
Flunnarizine
8wks
Betahistine significantly better in
DHI, physical and functional
scores
Mira e.al.
2003
N=144
Double-blind,
multicenter,ran
domized,
parallel
Meniere’s
disease or
paroxysmal
positional
vertigo of
possible
vascular origin
Betahistine
16 tid
Placebo
3 mos
Betahistine significantly reduced
frequency, intensity and duration
of vertigo
Della Pepa
C.et.al.
Meta-analysis
(7 RCT,-
n=367)
Vertiginous
syndromee-
BPPV,vascular
Betahisitne
Placebo
3-8wks
Betahistine relieved vertigo 3x
versus placebo

Adverse Effects
O Generally rare
O Headache
O Skin reactions
O Heart burn/ nausea
Lacour M, Van de Heyning PH, Novotny M,Tighilet b. Betahistine in the treatment of Meniere’s
disease. Neuropsychiatry disease and treatment. 2007;3(4):429-440
Mira E, Guidetti G, Fattori GB,Malaninno M, MaialinoL,MoraR, Ottobonis S, et.al.Betahistine
hydrochloride in the treatment of peripheral vestibula vertigo. Euro Arch
Otorhinolaryngol2003;260;73-77

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