Standardizing your approach to dizziness and vertigo

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Standardizing your approach to dizziness and vertigo

J Fam Pract. 2018 August;67(8):490-492,495-498

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From The Journal of Family Practice | 2018;67(8):490-492,495-498.

References

1. Bisdorff A, Von Brevern M, Lempert T, et al. Classification of vestibular symptoms: towards an international classification of vestibular disorders. J Vestib Res. 2009;19:1-13.

2. Mendel B, Bergenius J, Langius-Eklöf A. Dizziness: a common, troublesome symptom but often treatable. J Vestib Res. 2010;20:391-398.

3. Gopinath B, McMahon CM, Rochtchina E, et al. Dizziness and vertigo in an older population: the Blue Mountains prospective cross‐sectional study. Clin Otolaryngol. 2009;34:552-556.

4. Post RE, Dickerson LM. Dizziness: a diagnostic approach. Am Fam Physician. 2010;82:361-368.

5. Sloan PD. Dizziness in primary care. Results from the National Ambulatory Care Survey. Fam Pract. 1989;29:33-38.

6. Kerber KA, Meurer WJ, West BT, et al. Dizziness presentations in US emergency departments, 1995–2004. Acad Emerg Med. 2008;15:744-750.

7. Newman-Toker DE, Hsieh YH, Camargo CA Jr, et al. Spectrum of dizziness visits to US emergency departments: cross-sectional analysis from a nationally representative sample. Mayo Clin Proc. 2008;83:765-775.

8. Ponka D, Kirlew M. Top 10 differential diagnoses in family medicine: vertigo and dizziness. Can Fam Physician. 2007;53:1959.

9. Chan Y. Differential diagnosis of dizziness. Curr Opin in Otolaryngol Head Neck Surg. 2009;17:200-203.

10. Staab JP, Ruckenstein MJ. Expanding the differential diagnosis of chronic dizziness. Arch Otolaryngol Head Neck Surg. 2007;133:170-176.

11. Kutz JW Jr. The dizzy patient. Med Clin North Am. 2010;94:989-1002.

12. Jahn K, Kressig RW, Bridenbaugh SA, et al. Dizziness and unstable gait in old age: etiology, diagnosis and treatment. Dtsch Ärztebl Int. 2015;112:387-393.

13. Thompson TL, Amedee R. Vertigo: a review of common peripheral and central vestibular disorders. Ochsner J. 2009;9:20-26.

14. Parnes LS, Agrawal SK, Atlas J. Diagnosis and management of benign paroxysmal positional vertigo (BPPV). CMAJ. 2003;169:681-693.

15. Newman-Toker DE, Dy FJ, Stanton VA, et al. How often is dizziness from primary cardiovascular disease true vertigo? A systematic review. J Gen Intern Med. 2008;23:2087-2094.

16. Newman-Toker DE, Edlow JA. TiTrATE: a novel, evidence-based approach to diagnosing acute dizziness and vertigo. Neurol Clin. 2015;33:577-599.

17. Shibao C, Lipsitz LA, Biaggioni I. ASH position paper: evaluation and treatment of orthostatic hypotension. J Clin Hypertens (Greenwich). 2013;15:147-153.

18. Kaufmann H. Consensus statement on the definition of orthostatic hypotension, pure autonomic failure and multiple system atrophy. Clin Auton Res. 1996;6:125-126.

19. Agarwal AK, Garg R, Ritch A, et al. Postural orthostatic tachycardia syndrome. Postgrad Med J. 2007;83:478-480.

20. Halker RB, Barrs DM, Wellik KE, et al. Establishing a diagnosis of benign paroxysmal positional vertigo through the dix-hallpike and side-lying maneuvers: a critically appraised topic. Neurologist. 2008;14:201-204.

21. Hilton MP, Pinder DK. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database Syst Rev. 2014;(12):CD003162.

22. Kattah JC, Talkad AV, Wang DZ, et al. HINTS to diagnose stroke in the acute vestibular syndrome. Stroke. 2009;40:3504-3510.

23. Hamaguchi T, Iwasa K, Okino S, et al. Carotid duplex ultrasonography during head-up tilt in patients with orthostatic hypotension. Eur Neurol. 2007;57:219-222.

24. Canadian Society of Otolaryngology - Head & Neck Surgery. Five Things Physicians and Patients Should Question [Internet]. Choosing Wisely Canada. 2016 [cited 2017 August 17]. Available at: https://choosingwiselycanada.org/wp-content/uploads/2017/02/Hospital-medicine.pdf. Accessed August 30, 2017.

25. Lee SH, Kim JS. Benign paroxysmal positional vertigo. J Clin Neurol. 2010;6:51-63.

26. Zatonski T, Temporale H, Holanowska J, et al. Current views of treatment of vertigo and dizziness. J Med Diagn Meth. 2014;2:150.

27. Wipperman J. Dizziness and vertigo. Prim Care Clin Office Pract. 2014;41:115-131

28. Murdin L, Hussain K, Schilder AG. Betahistine for symptoms of vertigo. Cochrane Database Syst Rev. 2016;(6):CD010696.

29. Han BI, Song HS, Kim JS. Vestibular rehabilitation therapy: review of indications, mechanisms, and key exercises. J Clin Neurol. 2011;7:184-196.

30. Jung JY, Kim JS, Chung PS, et al. Effect of vestibular rehabilitation on dizziness in the elderly. Am J Otolaryngol. 2009;30:295-299.

31. Semaan MT, Megerian CA. Meniere’s disease: a challenging and relentless disorder. Otolaryngol Clin North Am. 2011;44:383-403.

32. Pirker W, Katzenschlager R. Gait disorders in adults and the elderly. Wien Klin Wochenschr. 2017;129:81-95.

33. Kirby SE, Yardley L. Physical and psychological triggers for attacks in Ménière’s disease: the patient perspective. Psychother Psychosom. 2012;81:396-398.

More worrisome suspicions. Patients suspected of cardiac causes should have a full cardiac work-up performed.²²For suspected stroke, brain tumor, or head trauma, specific computed tomography or magnetic resonance imaging can be arranged.²² Carotid doppler can be used if dizziness is suspected to be caused by orthostatic hypotension or a vascular cause.²³

Audiologic and vestibular testing. Audiologic testing is not routinely recommended and is only warranted in instances when patients report hearing loss or changes. Referral to an otolaryngologist for vestibular testing is warranted once life-threatening and alternate etiologies have been ruled out, and a vestibular disorder remains at the top of the differential.²⁴

Treatment hinges on cause and may be multifaceted

Treatment hinges on the specific cause of the patient’s dizziness and may involve useful maneuvers, medication, physiotherapy, or perhaps even surgery.

Employ a particle repositioning maneuver for BPPV

A positive Dix-Hallpike test should prompt the use of a particle repositioning maneuver (PRM) to treat BPPV.²¹ The goal of PRMs, such as the Epley maneuver (see https://www.youtube.com/watch?v=9SLm76jQg3g for a demonstration of this maneuver), is to move the head in such a way as to return displaced otoliths in the semicircular canal back to the utricle. The Epley maneuver is specific for treating posterior semicircular canal BPPV, which is the most common variant.

Identifying true vertigo from among other sensations helps to limit the differential because true vertigo is caused by vestibular etiologies only.

Performing the Epley maneuver. To perform the Epley PRM for correction of an otolith in the left posterior semicircular canal, ask the patient to sit and look straight ahead. Lay the patient back, while asking the patient to turn his/her head 45 degrees to the left side. Then ask the patient to turn his/her head 45 degrees to the right side. Instruct the patient to maintain the same 45-degree head orientation, while rolling over to his/her right shoulder, ending in the right decubitus position. Conclude the maneuver by having the patient sit up.

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