Dizziness

Educational Objectives

The goal of this program is to improve management of dizziness. After hearing and assimilating this program, the clinician will be better able to:

1. Identify benign and malignant causes of dizziness and near-syncope.

2. Perform a thorough physical examination of a patient presenting with dizziness.

Summary

Patient history: patients may use “dizziness” to describe vertigo, spinning sensation, lightheadedness, near-syncope or syncope, decreased balance, or disequilibrium; ask patient what he or she was doing at time of dizziness (eg, standing up from sitting position; turning in bed); precipitating factors — vomiting and diarrhea (consider volume depletion); tinnitus or hearing deficits (consider middle ear problem [eg, Meniere disease]); ask about new medications

Differential diagnosis: helpful to consider 3 overall groupings (cerebral hypoperfusion, peripheral lesions, central lesions)

Cerebral hypoperfusion: due to decrease in cardiac output and insufficient blood flow to brain; consider arrhythmias, aortic stenosis, orthostatic hypotension; carotid ultrasonography, magnetic resonance imaging (MRI) of neck, and computed tomography (CT) angiography of neck not helpful; suspect carotid stenosis in patients with focal symptoms (eg, weakness, numbness on one side, loss of vision in one eye)

Peripheral lesions: vestibular neuronitis; labyrinthitis; Meniere disease; perilymph fistula; superior semicircular canal dehiscence syndrome; vestibular benign paroxysmal positional vertigo — loose crystals in canals cause vertiginous feeling, especially with changes in head position; treated successfully with Epley maneuver; Dandy syndrome — bilateral vestibular hypofunction; look for oscillopsia (up and down movement of eyes); can be caused by toxicity of medications, tumor, infection, trauma, Meniere disease

Central lesions: ischemic vertebrobasilar insufficiency; mass lesion; acoustic neuroma; do not overlook possibility of stroke or tumor

Computed tomography: eliminating indiscriminate use of CT could save estimated $1 billion per year; 80% of initial CT in patients with stroke negative; use of imaging studies in patients with dizziness has quadrupled since 1995

Syncope protocols: San Francisco Syncope Rule — risk factors include history of congestive heart failure, hematocrit <30%, abnormal electrocardiography (ECG), shortness of breath (SOB), triage systolic blood pressure (BP) <90 mm Hg; negative predictive value 2% to 5%; Boston Syncope Rule — risk factors include chest pain, SOB, abnormal ECG, worrisome cardiac history, positive family history of sudden death, significant heart murmur, signs of conduction disease, volume depletion, persistent abnormal (vs primary) central nervous system event; negative predictive value 1%

Identifying cause of syncope: cause identified only 48% of time; postural BP change has 58% yield; patient history has 20% yield; money spent effectively only 1.7% of time

Orthostatic hypotension: important to check orthostatic BP as soon as patient presents; involves drop in systolic BP of ≥20 mm Hg, or drop in diastolic BP of ≥10 mm Hg, within 3 min of standing; check for rise in pulse; delayed orthostatic hypotension — orthostatic hypotension that occurs after 3 min; same mechanism and long-term complications as orthostatic hypotension

Physical examination: listen to heart; check BP; horizontal head impulse test — ask patient to focus on spot on wall; move patient’s head back and forth while asking patient to stay focused on spot; fast, corrective eye movements indicate benign form of dizziness; slow or lagging eye movements indicate problem; Dix-Hallpike maneuver — while patient sitting on examination table, turn patient’s head 30° to 45° to one side, then quickly tilt patient so that patient’s head hangs 20° over edge of table; check eyes (if no nystagmus, repeat maneuver while turning patient’s head to other side); nystagmus usually occurs after 5 to 10 sec, and likely due to benign positional vertigo; fast-phase or rotatory nystagmus is toward affected ear (eg, eye that turns from patient’s right to left when left ear down suggestive of dysfunction in left labyrinthine system); skew deviation — eyes do not move together; neurologic problem; send to emergency department

Dizziness protocol: must be evidence-based, efficient, and cost-effective; criteria must be inclusive

Baptist Health South Florida Hospital criteria for benign causes of dizziness: symptoms lasting ≥72 hr (literature suggests symptoms lasting >24 hr associated with lower likelihood of ischemic event); no history of stroke or cancer; no cardiac history or symptoms; normal neurologic examination; no orthostatic hypotension; positive Dix-Hallpike maneuver; normal laboratory studies

Risk stratification for stroke in acute dizziness: age — >60 yr (1 point); blood pressure — >140/90 mm Hg (1 point); clinical features — focal findings (2 points); speech difficulty (1 point); duration — <1 hr (1 point); >1 hr (2 points); diabetes (1 point); if score <4 points, stroke risk ≤1%; if score >4 points, stroke risk ≥8.1%

Treatment: meclizine — not effective when used as needed; half-life ≈6 hr; should be taken 3 to 6 times daily; causes drowsiness; start low (12.5 mg 3 times daily); scopolamine transdermal patch — placed behind ear; reasonably effective; patients should wash hands after handling patch (contact with eye can cause dilation of pupil)

Readings

Evren C et al: Diagnostic value of repeated Dix-Hallpike and roll maneuvers in benign paroxysmal positional vertigo. Braz J Otorhinolaryngol. 2016 Apr 22. pii: S1808-8694(16)30039-8; Hogue JD: Office evaluation of dizziness. Prim Care. 2015 Jun;42(2):249-58; Kim HA et al: Recent advances in orthostatic hypotension presenting orthostatic dizziness or vertigo. Neurol Sci. 2015 Nov;36(11):1995-2002; Obermann M et al: Long-term outcome of vertigo and dizziness associated disorders following treatment in specialized tertiary care: the Dizziness and Vertigo Registry (DiVeR) Study. J Neurol. 2015 Sep;262(9):2083-91; Ozono Y et al: Differential diagnosis of vertigo and dizziness in the emergency department. Acta Otolaryngol. 2014 Feb;134(2):140-5; Schmitt LG, Shaw JE: Alleviation of induced vertigo. Therapy with transdermal scopolamine and oral meclizine. Arch Otolaryngol Head Neck Surg. 1986 Jan;112(1):88-91; Susanto M: Dizziness: if not vertigo could it be cardiac disease? Aust Fam Physician. 2014 May;43(5):264-9; Wipperman J: Dizziness and vertigo. Prim Care. 2014 Mar;41(1):115-31.

Disclosures

For this program, the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Gran was recorded in Marco Island, FL, at the 15th Annual Primary Care Focus Symposium, presented June 24-26, 2016, by Baptist Health South Florida. Please visit http://cme.baptisthealth.net/PFS/ for information about next year’s symposium (June 30-July 2, 2017, Marco Island, FL). The Audio Digest Foundation thanks the speakers and Baptist Health South Florida for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

FP644201

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.