Dizziness And Vertigo

Basics

Description

  • Dizziness: A nonspecific term describing a range of sensations, including lightheadedness, imbalance, or a feeling of movement instability
  • Vertigo: The sensation of spinning or movement due to an acute asymmetry in the vestibular system, affecting the inner ear, brainstem, or cerebellum
  • Acute vestibular syndrome (AVS) – acute onset of continuous dizziness lasting >24 hr
  • Triggered episodic vestibular syndrome (tEVS) – short, triggered dizziness by movements of head or body (eg, benign paroxysmal positional vertigo [BPPV], orthostatic hypotension)
  • Spontaneous episodic vestibular syndrome (sEVS) – recurrent, spontaneous dizziness (eg, vestibular migraine, TIA)
  • Dizziness accounts for 2.1–3.6% of all ED visits
  • Annual US ED costs exceed $10 billion
  • 3 times more common in women and affecting nearly 20% of all adults
  • Approximately 50% of all ED patients with dizziness have general medical causes
  • 35–67% of dizzy patients have episodic symptoms​
  • About 12% of posterior circulation strokes have prior isolated dizziness​
  • BPPV is the most common cause of triggered episodic dizziness​
  • Vestibular migraine is a leading cause of spontaneous episodic dizziness

Etiology

Vertigo (Illusory Movement Perception)

  • AVS:
    • Vestibular neuritis
    • Labyrinthitis
    • Posterior circulation stroke
    • Cerebellitis and otomastoiditis (more common in pediatrics)
    • Multiple sclerosis
    • Ménière disease (endolymphatic hydrops)
    • Wernicke encephalopathy
    • Herpes zoster oticus
    • Space-occupying lesions
    • Acoustic neuroma and other posterior fossa tumors
  • tEVS:
    • BPPV
    • Central positional paroxysmal vertigo (CPPV)
    • tympanic membrane rupture
    • Round window rupture
    • Labyrinthine concussion
    • Perilymphatic fistula
  • sEVS:
    • Vestibular migraine
    • Ménière disease
    • TIA (posterior circulation)
    • Vertebral artery dissection
    • Postconcussive syndrome
    • Labyrinth or CN VIII damage
    • Subclavian steal syndrome
    • Temporal lobe epilepsy:
      • Associated with hallucinations, aphasia, trance-like states, convulsions
    • Postconcussive syndrome or damage to labyrinth or CN VIII secondary to basilar skull fracture
    • Panic attacks
    • Otitis media and serous otitis with effusion

Dizziness Due To Physiologic Alterations

  • Arrhythmias (bradycardia, tachycardia, atrial fibrillation) – sudden, recurrent episodes
  • Structural heart disease (aortic stenosis, cardiomyopathy) – exertional dizziness
  • Myocardial infarction
  • Orthostatic hypotension
  • Dehydration
  • Carotid sinus hypersensitivity – common in older adults, triggered by neck movements
  • Acute anemia (eg, from GI bleeding)
  • Hypoglycemia

Lightheadedness (Nonspecific Dizziness, Often Psychological Or Systemic)

  • Panic attacks/anxiety – hyperventilation-induced dizziness
  • Depression – chronic dizziness without clear trigger
  • Somatization disorders – persistent dizziness with no organic cause
  • DM
  • Hypothyroidism
  • Recreational drugs (eg, alcohol, barbiturates, salicylates)
  • Electrolyte disturbances
  • Systemic infections
  • Ototoxic drugs:
    • Aminoglycosides
    • Antimalarials
    • Erythromycin
    • Furosemide
  • Alcohol intoxication or withdrawal
  • Carbon monoxide poisoning

Disequilibrium (Impaired Balance Without Movement Illusion)

  • Due to impaired integration of visual, proprioceptive, or vestibular inputs
  • Parkinson disease – progressive postural instability
  • Cerebellar ataxia (stroke, tumor, chronic alcoholism)
  • Peripheral neuropathy (diabetes, B12 deficiency)
  • Cervical spondylosis – dizziness with neck movement

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