All language subtitles for Dizziness and Vertigo

The term dizziness can be used to refer to a number
of related symptoms like precyncope,

disequilibrium, what's called non-specific
dizziness, and vertigo. Asking individuals

specific questions about how they experience
dizziness can help clarify the symptom. So let's

go through each of these. Pre-syncope is the
prodromal phase that occurs before syncope.

Individuals often complain of seconds to minutes
of nearly blacking out or nearly fainting and

feeling light-headed when standing, along with
palpations, sweating, a feeling of warmth,

nausea, or even blurry vision. Sometimes there's
a history of cardiac disease, such as congestive

heart failure, or coronary artery disease may be
present. Pre-syncope could be due to vasovagal

syncope, orthostatic hypotension, or cardiac
arrhythmias. So the workup usually includes an

electrocardiogram, or ECG. Dizzequilibrium
refers to a sense of imbalance, specifically when

walking, and is usually due to a neurologic
disorder like Parkinson's disease, cerebellar

disorders, peripheral neuropathy, or cervical
spine disease. This is often described as feeling

the ground moving or feeling like you're on a boat.
Nonspecific dizziness is a more vague term that

has a variety of causes ranging from anxiety or
panic attacks to hypoglycemia or side effects of

medications like anticholinergics. Finally,
there's vertigo, which can be thought of as having

an illusion of self-motion or movement of the
surrounding environment. We've all experienced

vertigo. It's that spinny sensation you get after
swinging a small child around or the woozy feeling

of seasickness. Yeah, that's vertigo. Vertigo
arises when there's a mismatch between other

sensory systems and the vestibular system. The
vestibular system is made of the vestibular

apparatus, including the three semicircular
canals, the utricle and the saccule, the

vestibular nerve, and the vestibular structures
in the brainstem and cerebellum. Vertigo can be

broken down into peripheral vertigo, which is due
to damage to the vestibular apparatus or damage to

the vestibular nerve, and central vertigo, which
is due to damage to the vestibular structures in

the brainstem or cerebellum. Major causes of
peripheral vertigo include benign paroxysmal

positional vertigo, or BPPV, vestibular
neuritis, minieres disease, and an acoustic

neuroma. Causes of central vertigo include a
posterior circulation stroke, a brainstem

tumor, a migraine, and multiple sclerosis. Now in
both types of vertigo, nystagmus, which is a

rhythmic oscillation of the eye, can occur. The
nystagmus can be present at rest, or they can be

provoked by the Dick's Hullpike maneuver. But
there are subtle nuances in the nystagmus that

differentiate peripheral from central vertigo.
In central vertigo, the direction of the

nystagmus can be horizontal, torsional, or
rotary, and vertical. In peripheral vertigo,

nystagmus can be horizontal or torsional, but
never vertical. Also, in central vertigo, there

is usually no lag time between the Dick's Hullpike
maneuver and the onset of nystagmus, and the

nystagmus usually lasts for more than one minute.
In peripheral vertigo, there is usually a 2-40

second lag time between the maneuver and the onset
of nystagmus, and the nystagmus lasts for less

than one minute. Finally, the Dick's Hullpike
maneuver usually provokes mild vertigo in

central vertigo, compared to more severe vertigo
in peripheral vertigo. Other associated

symptoms can also provide a clue. For example, the
4Ds, dyplopia, dysphagia, dysarthria, or

dysmetria often suggest central vertigo.
Whereas auditory symptoms, like hearing loss or

tinnitus, suggest peripheral vertigo. Okay, so
benign positional paroxysmal vertigo, or BPPV,

is by far the most common cause of peripheral
vertigo. See, we normally have calcium carbonate

crystals in the utricle and saccule, but the
problem arises when they sneak into the

semicircular canals, most commonly the
posterior canal. The crystals obstruct the

normal flow of endolymph in the canals when the
head moves in a specific direction, like stones

causing turbulence in a smooth river. Without
normal endolymphatic flow, the semicircular

canal can't properly detect angular
acceleration, causing vertigo. BPPV causes

recurrent episodes of vertigo that are provoked
by a specific and predictable change in head

position, such as rolling out of bed. Episodes
last less than one minute and are usually

accompanied by nausea or vomiting. Hearing loss
and tinnitus are usually absent in BPPV. The

diagnosis is confirmed by exacerbation of
vertigo or nystagmus on one side during the

Dicks-Hallpike maneuver. To perform the
Dicks-Hallpike maneuver, you have to extend the

neck and turn it to one side while the individual is
sitting. Then you have to rapidly place them in a

supine position so that their head hangs over the
edge of the bed. After 30 seconds, there might be

nystagmus or vertigo symptoms. If no nystagmus or
vertigo symptoms occur, then return the

individual to the upright position and then wait
for another 30 seconds. After that, you repeat the

maneuver for the other side as well. The treatment
of BPPV is the Epley maneuver, which aims at

guiding the lost crystals back into the utricle
where they belong. So let's say an individual has

right-sided BPPV based on the Dicks-Hallpike
maneuver. With the individual upright, grasp

their head on both sides and rapidly position them
to the supine position with the right ear pointing

downwards. Then immediately rotate the head to
the left side so that the right ear points upwards.

Hold this position for 30 seconds. Next, ask the
individual to turn their body to the left side and

then rotate their head until their nose is
pointing towards the floor. Hold this position

for 30 seconds, then rapidly lift the individual
back to the upright position. Works like magic.

Because BPPV can reoccur, individuals are taught
a modified version of the Epley maneuver that they

can do themselves. First, in the sitting
position, the individual should turn their head

about 45 degrees to the affected side, let's say
the right side. Then lie down supine and wait for 30

seconds. Then without raising the head, turn it 90
degrees to the left and wait for another 30

seconds. Next, turn the body 90 degrees to the left
and wait another 30 seconds. Finally, sit up on the

left side. The modified Epley maneuver should be
performed three times a day until the individual

has no symptoms for at least 24 hours. Vestibular
neuritis, or labyrinthitis, is inflammation of

the vestibular portion of the 8th cranial nerve.
In comparison with BPPV, vestibular neuritis

causes acute, severe, constant peripheral
vertigo lasting several days. Head movement can

worsen the symptoms, but the symptoms can occur at
rest and don't rely on a specific position. Also,

unlike BPPV, there may be hearing loss.
Individuals with vestibular neuritis sometimes

have a prior viral upper respiratory tract
infection. The diagnosis is based on the

symptoms, and although there's conflicting
evidence, corticosteroids can be given to help

the inflammation. Alright, now, Meniere's
disease is also called endo-emphatic hydrops,

and it's due to having excess endo-emphatic fluid
in the semicircular canals. Meniere's disease

tends to occur in people over the age of 65 who
develop a classic triad of symptoms. Recurrent

episodic vertigo, hearing loss, and tinnitus.
Audio call, transcript. Audio call, transcript.

Audio call, transcript. Audio call, transcript.
A HINTS exam is an acronym for three physical

examination maneuvers. Head impulse testing,
nystagmus, and the test of skew. In the first 24 to

48 hours of isolated vertigo, when performed by an
expert, the HINTS exam is better than the MRI in

ruling out posterior circulation stroke. Now, to
do a head impulse test, you sit opposite a person

and ask them to fix their gaze on your nose. Next,
you passively turn their head to one side.

Normally, the vestibuloocular reflex rapidly
corrects the eyes back to the center so that their

eyes remain fixed on your nose. An abnormal head
impulse test is when that doesn't happen, and

there's a lag time until their eyes are able to
remain fixed on your nose. So an abnormal or

positive test indicates a peripheral cause of
vertigo, while a normal or negative test

indicates a more concerning central cause, like
stroke. It's one of the few times in medicine where

an abnormal test is the less concerning outcome.
Next is nystagmus, which has two phases, a fast

phase and a slow phase. The fast phase is when the
eyes move quickly in one direction, and the slow

phase is when the eyes swing back slowly in the
other direction. When we talk about the direction

of nystagmus, we're referring to the fast phase.
In peripheral vertigo, the fast phase is usually

directed to one side only, for example, the right
side only. A nystagmus in which the fast phase

alternates in direction is concerning for a
posterior circulation stroke. Finally, the test

of skew involves asking the individual to look at
their nose while covering one eye. If the covered

eye deviates away from its original position and
then corrects back when it's uncovered, that

suggests a central cause. If any one out of the
three parts of the hands exam indicates a central

cause, then a brain MRI should be done to look for a
posterior circulation stroke. Alright, now

multiple sclerosis is a central nervous system
demyelinating disease that can cause central

vertigo. Individuals typically have a variety of
neurological symptoms that localize to

different parts of the brain and occur at
different points in time. Treatment of multiple

sclerosis includes disease modifying agents
such as interferon beta and corticosteroids for

acute attacks. Another cause is a brainstem tumor
such as a pylocytic astrocytoma which can

encroach on the vestibular structures in the
brainstem causing vertigo. Treatment depends on

the type of tumor. It may include surgical
resection as well as chemo or radiotherapy. Also,

a rare type of migraine called a vertebro-basilar
migraine can present with vertigo following the

migraine headache. Unfortunately, the usual
migraine abortive medications like tryptins and

ergotomies do not relieve the vertigo in these
individuals. Therefore, it's best to avoid

triggers such as stress and smoking and provide
prophylactic treatment with medications like

rapamil. Finally, there are some medications
like aminoglycosides, anticonvulsants like

vanidawin and the antimalarial quinine that are
toxic to the vestibular system. These

medications usually affect both the right and
left vestibular symptoms roughly equally. They

balance each other out so individuals rarely
experience vertigo. Instead, the vestibular

ocular reflex is impaired in the individual's
experience ocelopsia, which is an illusion of a

moving environment when the individual looks in
any direction. As a result, there's an abnormal

head impulse test in these individuals. Alright,
now symptoms of vertigo, regardless of the cause,

can be treated with anihistamines such as
mycocline and diphenhydramine, antiemetics

such as ondanzotron or metaclopramide, and
benzodiazepines such as diazepam. These

medications should be given for a short duration
and stopped once the symptoms are relieved

because they can interfere with the long-term
recovery of the vestibular system. Alright, this

is a quick recap. Dizziness is a common complaint
that uses four different entities. Pre-syncope,

disequilibrium, nonspecific dizziness, and
vertigo. Pre-syncope may indicate a cardiac

cause like arrhythmias, while disequilibrium
usually indicates a neurological issue like

migraines. Psychiatric disorders like
depression and anxiety may cause a nonspecific

dizziness. Vertigo is defined as an illusion of
movement, whether that's self-movement or

movement of the surrounding environment.
Vertigo is classified into peripheral and

central vertigo, which can be differentiated
based on the features of nystagmus on a physical

exam. In central vertigo, the nystagmus can be
horizontal, torsional, or vertical, and there's

usually no lag time between performing the
dicks-hull pike maneuver and the onset of

nystagmus, and the nystagmus lasts more than a
minute. In contrast, the nystagmus in peripheral

vertigo can be horizontal or torsional, but never
vertical. There's usually a lag time ranging from

2 to 40 seconds, and the nystagmus usually lasts
for less than a minute. Auditory symptoms like

tinnitus or hearing loss suggest a peripheral
cause, while a neurological symptom like

hemiparesis, numbness, dyplopia, dysphagia,
dysarthria, and dysmetria suggest a central

cause. Pre-referral causes include benign
paroxysmal positional vertigo, vestibular

neuritis, maniaeus disease, or acoustic
neuroma. Central causes include a posterior

circulation stroke, multiple sclerosis,
migraine, or a brainstem tumor. Certain

medications like immunoglycosides can be toxic
to the vestibular system, but because they affect

both vestibular systems equally, they don't
cause vertigo. Instead, they cause oscilopsia,

an illusion of environmental movement whenever
the individual moves their eyes. In an individual

presenting with acute vertigo, with other
neurological symptoms, an MRI is warranted to

look for a posterior circulation stroke, whereas
individuals with acute isolated vertigo should

have a HINDS exam, the head impulse, nystagmus,
and test of skew. If one of the three tests indicate