Mark F. Walker Robert B. Daroff
Dizziness is a common, vexing symptom, and epidemiologic data indicate that more than 20% of adults experience dizziness within a given year. The diagnosis is frequently challenging, in part because patients use the term to refer to a variety of different sensations, including feelings of faintness, spinning, and other illusions of motion, imbalance, and anxiety. Other descriptive words, such as light-headedness, are equally ambiguous, referring in some cases to a presyncopal sensation due to hypoperfusion of the brain and in others to disequilibrium and imbalance. Patients often have difficulty distinguishing among these various symptoms, and the words they choose do not describe the underlying etiology reliably.
Vascular disorders cause presyncopal dizziness as a result of cardiac dysrhythmia, orthostatic hypotension, medication effects, or another cause. Such presyncopal sensations vary in duration; they may increase in severity until loss of consciousness occurs, or they may resolve before loss of consciousness if the cerebral ischemia is corrected. Faintness and syncope, which are discussed in detail in Chap. 10, should always be considered when one is evaluating patients with brief episodes of dizziness or dizziness that occurs with upright posture.
Vestibular causes of dizziness may be due to peripheral lesions that affect the labyrinths or vestibular nerves or to involvement of the central vestibular pathways. They may be paroxysmal or due to a fixed unilateral or bilateral vestibular deficit. Acute unilateral lesions cause vertigo due to a sudden imbalance in vestibular inputs from the two labyrinths. Bilateral lesions cause imbalance and instability of vision when the head moves (oscillopsia). Other causes of dizziness include nonvestibular imbalance and gait disorders (e.g., loss of proprioception from sensory neuropathy, parkinsonism) and anxiety.
In evaluating patients with dizziness, questions to consider include the following: (1) is it dangerous (e.g., arrhythmia, transient ischemic attack/stroke)? (2) is it vestibular? and (3) if vestibular, is it peripheral or central? A careful history and examination often provide enough information to answer these questions and determine whether additional studies or referral to a specialist is necessary.
APPROACH TO THE
HISTORY When a patient presents with dizziness, the first step is to delineate more precisely the nature of the symptom. In the case of vestibular disorders, the physical symptoms depend on whether the lesion is unilateral or bilateral and whether it is acute or chronic and progressive. Vertigo, an illusion of self or environmental motion, implies asymmetry of vestibular inputs from the two labyrinths or in their central pathways and is usually acute. Symmetric bilateral vestibular hypo-function causes imbalance but no vertigo. Because of the ambiguity in patients’ descriptions of their symptoms, diagnosis based simply on symptom character is typically unreliable. The history should focus closely on other features, including whether dizziness is paroxysmal or has occurred only once, the duration of each episode, any provoking factors, and the symptoms that accompany the dizziness.
Causes of dizziness can be divided into episodes that last for seconds, minutes, hours, or days. Common causes of brief dizziness (seconds) include benign paroxysmal positional vertigo (BPPV) and orthostatic hypotension, both of which typically are provoked by changes in position. Attacks of migrainous vertigo and Ménière’s disease often last hours. When episodes are of intermediate duration (minutes), transient ischemic attacks of the posterior circulation should be considered, although these episodes also could be due to migraine or a number of other causes.
Symptoms that accompany vertigo may be helpful in distinguishing peripheral vestibular lesions from central causes. Unilateral hearing loss and other aural symptoms (ear pain, pressure, fullness) typically point to a peripheral cause. Because the auditory pathways quickly become bilateral upon entering the brainstem, central lesions are unlikely to cause unilateral hearing loss (unless the lesion lies near the root entry zone of the auditory nerve). Symptoms such as double vision, numbness, and limb ataxia suggest a brainstem or cerebellar lesion.
EXAMINATION Because dizziness and imbalance can be a manifestation of a variety of neurologic disorders, the neurologic examination is important in the evaluation of these patients. Particular focus should be given to assessment of eye movements, vestibular function, and hearing. The range of eye movements and whether they are equal in each eye should be observed. Peripheral eye movement disorders (e.g., cranial neuropathies, eye muscle weakness) are usually disconjugate (different in the two eyes). One should check pursuit (the ability to follow a smoothly moving target) and saccades (the ability to look back and forth accurately between two targets). Poor pursuit or inaccurate (dysmetric) saccades usually indicates central pathology, often involving the cerebellum. Finally, one should look for spontaneous nystagmus, an involuntary back-and-forth movement of the eyes. Most often nystagmus is of the jerk type, in which a slow drift (slow phase) in one direction alternates with a rapid saccadic movement (quick phase or fast phase) in the opposite direction that resets the position of the eyes in the orbits. Table 11-1 lists features that help distinguish peripheral vestibular nystagmus from central nystagmus. Except in the case of acute vestibulopathy (e.g., vestibular neuritis), if primary position nystagmus is easily seen in the light, it is probably due to a central cause. Two forms of nystagmus that are characteristic of lesions of the cerebellar pathways are vertical nystagmus with downward fast phases (downbeat nystagmus) and horizontal nystagmus that changes direction with gaze (gaze-evoked nystagmus).
FEATURES OF PERIPHERAL AND CENTRAL VERTIGO
Specialists find that the most useful bedside test of peripheral vestibular function is the head impulse test, in which the vestibuloocular reflex (VOR) is assessed with small-amplitude (approximately 20 degrees) rapid head rotations; beginning in the primary position, the head is rotated to the left or right while the patient is instructed to fixate on the examiner’s face. If the VOR is deficient, a catch-up saccade is seen at the end of the rotation. This test can identify both unilateral (deficient VOR when the head is rotated toward the weak side) and bilateral vestibular hypofunction.
All patients with episodic dizziness, especially if it is provoked by positional change, should be tested with the Dix-Hallpike maneuver. The patient begins in a sitting position with the head turned 45 degrees; holding the back of the head, the examiner then gently lowers the patient into a supine position with the head extended backward by about 20 degrees, and observes for nystagmus; after 30 s the patient is raised to the sitting position and after a 1-min rest the procedure is repeated with the head turned to the other side. Use of Frenzel eyeglasses (self-illuminated goggles with convex lenses that blur the patient’s vision but allow the examiner to see the eyes greatly magnified) can improve the sensitivity of the test. If transient upbeating and torsional nystagmus are elicited in the supine position, posterior canal BPPV can be diagnosed confidently and treated with a repositioning maneuver, and additional testing can be avoided.
Dynamic visual acuity is a functional test that can be useful in assessing vestibular function. Visual acuity is measured with the head still and when the head is rotated back and forth by the examiner (about 1–2 Hz). A drop in visual acuity during head motion of more than one line on a near card or Snellen chart is abnormal.
The choice of ancillary tests should be guided by the history and examination findings. Audiometry should be performed whenever a vestibular disorder is suspected. Unilateral sensorineural hearing loss supports a peripheral disorder (e.g., vestibular schwannoma). Predominantly low-frequency hearing loss is characteristic of Ménière’s disease. Electro- or videonystagmography includes recordings of spontaneous nystagmus (if present), pursuit, and saccades; caloric testing to assess the responses of the two horizontal semicircular canals; and measurement of positional nystagmus. Patients with unexplained unilateral hearing loss or vestibular hypo-function should undergo magnetic resonance imaging of the internal auditory canals, including administration of gadolinium, to rule out a schwannoma.
Treatment of vestibular symptoms should be driven by the underlying diagnosis. Simply treating dizziness with vestibular suppressant medications is often not helpful and may make the symptoms worse. The diagnostic and specific treatment approaches for the most commonly encountered vestibular disorders are discussed next.
Acute prolonged vertigo
An acute unilateral vestibular lesion causes constant vertigo, nausea, vomiting, oscillopsia (motion of the visual scene), and imbalance. These symptoms are due to a sudden asymmetry of inputs from the two labyrinths or in their central connections, simulating a continuous rotation of the head. Unlike BPPV, the vertigo persists even when the head is not moving.
When a patient presents with an acute vestibular syndrome, the most important question is whether the lesion is central (e.g., a cerebellar or brainstem infarct or hemorrhage), which may be life-threatening, or peripheral, affecting the vestibular nerve or labyrinth. Attention should be given to any symptoms or signs that point to central dysfunction (diplopia, weakness or numbness, dysarthria). The pattern of spontaneous nystagmus, if present, may be helpful (Table 11-1). If the head impulse test is normal, an acute peripheral vestibular lesion is unlikely. However, a central lesion cannot always be excluded with certainly on the basis of symptoms and examination alone; thus, older patients with vascular risk factors who present with an acute vestibular syndrome generally should be evaluated for the possibility of stroke even when there are no specific findings that indicate a central lesion.
Most patients with vestibular neuritis recover spontaneously, but glucocorticoids can improve outcome if administered within 3 days of symptom onset. Antiviral medications are of no proven benefit unless there is evidence to suggest herpes zoster oticus (Ramsay Hunt syndrome). Vestibular suppressant medications may reduce acute symptoms but should be avoided after the first several days as they may impede central compensation and recovery. Patients should be encouraged to resume a normal level of activity as soon as possible, and directed vestibular rehabilitation therapy may accelerate improvement.
Benign paroxysmal positional vertigo
BPPV is a common cause of recurrent vertigo. Episodes are brief (<1 min and typically 15–20 s) and are always provoked by changes in head position relative to gravity, such as lying down, rolling over in bed, rising from a supine position, and extending the head to look upward. The attacks are caused by free-floating otoconia (calcium carbonate crystals) that have been dislodged from the utricular macula and have moved into one of the semicircular canals, usually the posterior canal. When head position changes, gravity causes the otoconia to move within the canal, producing vertigo and nystagmus. With posterior canal BPPV, the nystagmus beats upward and torsionally (the upper poles of the eyes beat toward the affected ear). Less commonly, the otoconia enter the horizontal canal, resulting in a horizontal nystagmus when the patient is lying with either ear down. Superior (also called anterior) canal involvement is rare. BPPV is treated with repositioning maneuvers that utilize gravity to remove the otoconia from the semicircular canal. For posterior canal BPPV, the Epley maneuver is the most commonly used procedure. For more refractory cases of BPPV, patients can be taught a variant of this maneuver that they can perform alone at home.
Vestibular symptoms occur frequently in migraine, sometimes as a headache aura but often independent of headache. The duration of vertigo may be from minutes to hours, and some patients also experience more prolonged periods of disequilibrium (lasting days to weeks). Motion sensitivity and sensitivity to visual motion (e.g., movies) are common in patients with vestibular migraine. Although data from controlled studies are generally lacking, vestibular migraine typically is treated with medications that are used for prophylaxis of migraine headaches. Antiemetics may be helpful to relieve symptoms at the time of an attack.
Attacks of Ménière’s disease consist of vertigo, hearing loss, and pain, pressure, or fullness in the affected ear. The hearing loss and aural symptoms are key features that distinguish Ménière’s disease from other peripheral vestibulopathies. Audiometry at the time of an attack shows a characteristic asymmetric low-frequency hearing loss; hearing commonly improves between attacks, although permanent hearing loss may occur eventually. Ménière’s disease is thought to be due to excess fluid (endolymph) in the inner ear, hence the term endolymphatic hydrops. Patients suspected of having Ménière’s disease should be referred to an otolaryngologist for further evaluation. Diuretics and sodium restriction are the initial treatments. If attacks persist, injections of gentamicin into the middle ear are typically the next line of therapy. Full ablative procedures (vestibular nerve section, labyrinthectomy) seldom are required.
Vestibular schwannomas (sometimes less correctly termed acoustic neuromas) and other tumors at the cerebellopontine angle cause slowly progressive unilateral sensori-neural hearing loss and vestibular hypofunction. These patients typically do not have vertigo, because the gradual vestibular deficit is compensated centrally as it develops. The diagnosis often is not made until there is sufficient hearing loss to be noticed. The examination will show a deficient Halmagyi-Curthoys head impulse response when the head is rotated toward the affected side. Any patient with unexplained asymmetric vestibular function (e.g., no prior history of vestibular neuritis) or asymmetric sensorineural hearing loss (documented on audiometry) should undergo MRI of the internal auditory canals, including gadolinium administration, to rule out a schwannoma.
Bilateral vestibular hypofunction
Patients with bilateral loss of vestibular function also typically do not have vertigo, since vestibular function is lost on both sides simultaneously, thus there is no asymmetry of vestibular input. Symptoms include loss of balance, particularly in the dark, where vestibular input is most critical, and oscillopsia during head movement, such as while walking or riding in a car. Bilateral vestibular hypofunction may be (1) idiopathic and progressive, (2) part of a neurodegenerative disorder, or (3) iatrogenic, due to medication ototoxicity (most commonly gentamicin or other aminoglycoside antibiotics). Other causes include bilateral vestibular schwannomas (neurofibromatosis type 2), autoimmune disease, meningeal-based infection or tumor, and other toxins. It also may occur in patients with peripheral polyneuropathy; in these patients, both vestibular loss and impaired proprioception may contribute to poor balance. Finally, unilateral processes such as vestibular neuritis and Ménière’s disease may involve both ears sequentially, resulting in bilateral vestibulopathy.
Examination findings include diminished dynamic visual acuity (see earlier in this chapter) due to loss of stable vision when the head is moving, abnormal head impulse responses in both directions, and a Romberg sign. In the laboratory, responses to caloric testing are reduced. Patients with bilateral vestibular hypofunction should be referred for vestibular rehabilitation therapy. Vestibular suppressant medications should not be used, as they will increase the imbalance. Evaluation by a neurologist is important not only to confirm the diagnosis but also to consider any other associated neurologic abnormalities that may clarify the etiology.
Psychological factors play an important role in chronic dizziness. First, dizziness may be a somatic manifestation of a psychiatric condition such as major depression, anxiety, or panic disorder. Second, patients may develop anxiety and autonomic symptoms as a consequence or comorbidity of an independent vestibular disorder. One particular form of this has been termed variously phobic postural vertigo, psychophysiologic vertigo, or chronic subjective dizziness. These patients have a chronic feeling (months or longer) of dizziness and disequilibrium, an increased sensitivity to self-motion and visual motion (e.g., movies), and a particular intensification of symptoms when moving through complex visual environments such as supermarkets (visual vertigo). Although there may be a past history of an acute vestibular disorder (e.g., vestibular neuritis), the neurootologic examination and vestibular testing are normal or indicative of a compensated vestibular deficit, indicating that the ongoing subjective dizziness cannot be explained by a primary vestibular disorder. Anxiety disorders are common in patients with chronic dizziness and contribute substantially to the morbidity. Thus, treatment with antianxiety medications (selective serotonin reuptake inhibitors [SSRIs]) and cognitive/behavioral therapy may be helpful. Vestibular rehabilitation therapy is also sometimes beneficial. Vestibular suppressant medications generally should be avoided. This condition should be suspected when the patient states, “My dizziness is so bad, I’m afraid to leave my house” (agoraphobia). General treatment of vertigo consists of vestibular suppressant medications and vestibular rehabilitation therapy.
Table 11-2 provides a list of commonly used medications for suppression of vertigo. As noted, these medications should be reserved for short-term control of active vertigo, such as during the first few days of acute vestibular neuritis, or for acute attacks of Ménière’s disease. They are less helpful for chronic dizziness and, as previously stated, may hinder central compensation. An exception is that benzodiazepines may attenuate psychosomatic dizziness and the associated anxiety, although SSRIs are generally preferable in such patients.
TREATMENT OF VERTIGO
Vestibular rehabilitation therapy promotes central adaptation processes that compensate for vestibular loss and also may help habituate motion sensitivity and other symptoms of psychosomatic dizziness. The general approach is to use a graded series of exercises that progressively challenge gaze stabilization and balance.