Dizziness/Lightheadedness and Vertigo

11 Dizziness/Lightheadedness and Vertigo


Dizziness is the most common reason why patients older than 75 years visit their doctors. However, most patients who complain of dizziness do not have an ear problem. A careful history is particularly important for these patients. The physician must first determine whether the patient has true vertigo or dizziness/lightheadedness.


True vertigo is a hallucination of movement. Objective vertigo is the illusion that one’s surroundings are moving. Subjective vertigo is the feeling that, with eyes closed, one’s body or head is moving or turning in space.


In contrast, lightheadedness, dizziness, and giddiness represent a sensation of being about to faint (near-syncope); this is not accompanied by true syncope or a feeling of rotation or movement. Some patients describe lightheadedness as a lack of strength or a generalized weakness and may feel that they will pass out if they do not lie down; this symptom usually improves rapidly with recumbency. Lightheadedness, dizziness, and near-syncope must be differentiated from true syncope (not discussed in this chapter), which has more serious implications, especially in elderly patients.



True Vertigo



Nature of Patient


Most vertiginous episodes in children are benign and self-limiting, except those associated with a seizure disorder. Vertigo is seldom the initial symptom of a seizure; when it is, it may be followed by transitory unconsciousness or amnesia of the event. Although true vertigo is uncommon in children, they may complain of vertigo after an upper respiratory tract infection or an acute viral infection in which hearing was also disturbed. The most common causes of vertigo in children are migraine or benign paroxysmal positional vertigo, often referred to as benign positional vertigo (BPV). Vertigo may be secondary to acute viral labyrinthitis. Children with serous otitis media do not usually complain of dizziness or vertigo but may have nondescript balance disturbances. Vertigo or headaches may develop in children several weeks after a head injury. When paroxysmal vertigo occurs in children with a family history of migraine, it may represent a vestibular migraine.


In adults, true vertigo is frequently caused by BPV, Ménière’s syndrome (or disease), and labyrinthitis. Ototoxic and salt-retaining drugs, acoustic neuroma, and brainstem dysfunction are less common causes.


To facilitate diagnosis, vertigo can be separated into central and peripheral causes. Central vertigo is caused by brainstem or cerebellar lesions and is associated with diplopia, dysarthria, dysphagia, paresthesias, headache, and ataxia. Peripheral vertigo is caused by problems of the inner ear or vestibular nerve and can often be diagnosed from the duration of symptoms.



Nature of Symptoms


Although the clinical differential diagnosis of vertigo is best made on the basis of associated symptoms, physical findings, and diagnostic studies, vertigo has some distinguishing features.


Peripheral vertigo is usually severe, has a sudden onset, lasts seconds to minutes, is related to position, is fatigable, and has associated auditory symptoms and horizontal nystagmus.


Central vertigo is mild, has a gradual onset, lasts weeks to months, is not related to position, is not fatigable, and has associated neurologic and visual symptoms and vertical nystagmus.


Recurrent attacks are often associated with BPV and Ménière’s syndrome. Labyrinthitis is usually not recurrent. The vertigo associated with otitis media has a gradual onset and may persist after the otitis subsides. If the vertigo has been continuous and progressive for several weeks or months, a mass lesion should be suspected.


BPV, Ménière’s syndrome, and labyrinthitis have varying durations of symptoms. In positional vertigo, symptoms last from seconds to minutes; in vertebrobasilar insufficiency, minutes; in Ménière’s syndrome, from minutes to hours; and in toxic labyrinthitis, vestibular neuronitis, or brainstem lesion, from days to weeks.


Prior episodes of vertigo may have been correctly diagnosed. However, if the previous physician did not obtain a precise history and perform an appropriate physical examination, prior episodes of vertigo may have been misdiagnosed as “nerves,” “tension,” or “low blood pressure.” Lack of physician awareness of benign paroxysmal positional vertigo is a common cause of the misdiagnosis of dizziness in elderly people.



Associated Symptoms


Tinnitus, ear fullness, and other hearing disturbances are usually present with Ménière’s syndrome, rare in labyrinthitis, and absent in BPV. Nausea and vomiting may be present in all. If vertigo is associated with an acute onset of unilateral weakness, problems with coordination, diplopia, or numbness, the vertigo is caused by brainstem disease, such as vertebrobasilar insufficiency. Patients with such diseases usually have normal hearing but may have other signs of brainstem dysfunction (e.g., vertical, lateral, or rotatory nystagmus).


Nystagmus is also observed in Ménière’s syndrome and BPV. If the patient has a chronic, progressive, unilateral hearing deficit with tinnitus, facial numbness, or weakness, an acoustic neuroma should be suspected. Café-au-lait spots or neurofibromatosis may also be observed in patients with acoustic neuromas. Vertigo may be part of a migraine aura or may be a migraine equivalent, which is more common in adolescents.



Precipitating and Aggravating Factors


By definition, positional changes such as head turning, rolling over in bed, bending over and then standing erect, and looking up by extending the neck may precipitate or aggravate BPV. This is usually not the case in Ménière’s syndrome, which is thought to have its onset around menstruation and during times of emotional stress. Ototoxic drugs (e.g., streptomycin and aminoglycosides, especially gentamicin and rarely furosemide) may also cause vertigo. Recurrent vertigo may be present when salt-retaining drugs (e.g., steroids or nonsteroidal anti-inflammatory drugs) are ingested.


An acute onset of isolated vertigo suggests a viral infection or middle or inner ear lesion. Repeated vertigo episodes (sometimes associated with nausea and vomiting) over many years suggest Ménière’s syndrome or BPV.

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Mar 21, 2018 | Posted by in BIOCHEMISTRY | Comments Off on Dizziness/Lightheadedness and Vertigo

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