More MS news articles for July 2002
I Assess and Manage a Patient With Acute Vertigo?
from Medscape Nurses
What is the best
way to evaluate a patient, without other known health problems, who presents
with an acute episode of vertigo?
from Judith Shannon
Lynch, MS, MA, 07/02/2002
More than 90 million
Americans aged 17 years and older experience vertigo or problems with balance.
This common symptom originates from a disturbance in the orientation-detecting
system and is frequently seen in clinical practice, accounting for 2.4%
of visits to physicians annually.
The prevalence of
vertigo increases with patient age, leading some researchers to identify
a "geriatric syndrome," which often reveals associations between vertigo
and cardiovascular, neurologic, psychological, and sensory disorders.
In about 10% of all
patients, no definite etiology is ever established. Vertigo imposes
many limitations on the patient's ability to meet daily responsibilities
and, when prolonged, will result in reduced quality of life as well as
frequent falls leading to serious morbidity.
Defining the Problem
The initial evaluation
question must be one that establishes the patient's perception of the word
"dizziness." Once a precise subjective statement has been made, this early
clue will lead the clinician to appropriate treatment strategies. Knowledge
of the 4 most common types of complaints will help to guide this assessment:
Type 1. Vertigo
is a definite rotational sensation in which the patient feels as if he
or the environment is rotating. The sensation often begins spontaneously,
is episodic, and, when severe, is usually accompanied by nausea, vomiting,
and a staggering gait. These symptoms of vertigo are almost always due
to a problem in the peripheral labyrinth.
Type 2. Presyncope
is a sensation of an impending faint or loss of consciousness, often starting
with dimming of vision and roaring in the ears. This sensation usually
implies an inadequate supply of blood or nutrients to the entire brain
rather than a focal ischemic event. Presyncope is usually gradual in onset
and often suggests a metabolic disorder such as hypoglycemia or orthostasis.
Type 3. Disequilibrium
is a sense of impaired balance and gait and is frequently due to impaired
motor function control.
Physiology of Vertigo
Type 4. Lightheadedness
is an ill-defined symptom often referred to as a sensation of "wooziness"
or "feeling drunk" and is usually a diagnosis of exclusion. It may occur
with psychiatric problems, hyperventilation, various encephalopathies,
and as part of the geriatric syndrome already mentioned. Lightheadedness
is also a common side effect of many medications prescribed for other health
is largely automatic but complex. Continued sensory monitoring assesses
the position of the body in space, in relation to the surrounding environment.
The 5 sensory modalities constantly sample position and motion: vision,
vestibular sensation, proprioception, touch and pressure, and hearing.
Normally the brain integrates the input from each of these sensory modalities
giving a comprehensive image of position and motion in space. This process
enables us to maintain balance, move about, and interact with other objects.
When the orienting image is unreliable, we become uncertain of position
and the result is a sensation of spinning or vertigo. When a patient presents
with this type of dizziness, the clinician must next determine whether
the symptom is central (brain) or peripheral (inner ear, 8th cranial nerve)
Central vertigo is
the least common type of vertigo and is usually caused by:
from recurrent episodes of reversible hypoperfusion or from a cerebrovascular
accident (CVA). The brainstem and the cerebellum are the cerebral areas
that produce a vertiginous sensation. There are usually accompanying neurologic
deficits, especially with brainstem involvement. MRI scan is the gold standard
to rule out a CVA.
including multiple sclerosis and Parkinson's syndrome must be considered
in prolonged vertigo episodes refractory to traditional medical treatment.
a rare cause of vertigo. Even acoustic neuroma (a benign growth on the
8th cranial nerve) causes vertigo in only about 20% of cases.
Head trauma with
concussion is usually observable and acute in nature.
in which vertigo may be part of the cluster of symptoms found in some cases
of Lyme disease, syphilis, systematic lupus erythematosus (SLE), etc. when
the disease attacks the central nervous system.
The most common peripheral
vestibular disorder causing vertigo results from inner ear pathology and
is known as benign paroxysmal positional vertigo (BPPV). Other less common
causes of peripheral vertigo include:
Migraine, which presents
symptoms of vertigo over a number of hours and is seen only in patients
with a positive history of headache.
syndrome: an inner ear disorder characterized by recurrent episodes of
vertigo lasting for several hours to days, fluctuating and progressive
sensorineural hearing loss, tinnitus, and a perception of fullness in the
affected ear. Ménière's syndrome is very difficult to diagnose,
often taking several years, as symptoms are intermittent and there may
be a long latency period between episodes.
Head trauma, especially
in patients younger than 50 years of age.
Otitis media, acute
sinusitis, whiplash injury to cervical spine, and degenerative changes
associated with aging.
BPPV is almost always
sudden in onset. A main characteristic of BPPV is nystagmus, a rapid involuntary
oscillation of the eyeballs. Patients will often complain of abrupt awakening
with a spinning sensation while turning in bed. Other triggers include
sudden head movements, changes in position (bending over, straightening
up), and riding in a fast car or on an amusement park ride. Episodes usually
last for several seconds only and are always precipitated by sudden movements
of the head. Etiology is uncertain but symptoms are thought to result
from the formation of small crystals (usually calcium carbonate) that become
loosened from the otolithic organs in the inner ear. These crystals begin
to float in the posterior semicircular canal causing the perception of
dizziness. The problem may be unilateral or bilateral. Frequently there
is associated nausea and vomiting. After a few seconds, the symptoms abate
and can often be easily controlled by a simple steadiness of head position.
Over 50% of patients will have no identified etiology for these episodes.
Thus, the diagnosis
of vertigo must be based on a thorough collection of historical data and
on a physical examination to rule out other types of peripheral vertigo.
It is helpful to have a patient questionnaire in the chart to simplify
the patient history. (A sample dizziness questionnaire is available
in Blair or at http://www.medscape.com/viewarticle/422863_2)
must include all of the following components:
Orthostatic blood pressure
A complete examination
of the middle ear with Weber and Rinne testing to determine gross audiologic
status and presence/absence of fluid behind the middle ear
if equipment is available (audiogram and tympanometry)
A complete nasal and
sinus evaluation to determine presence of sinus infection
Cervical spine palpation
to rule out degenerative disease and trauma
Romberg, tandem walk,
and march-in-place testing. Patient will often be unable to accomplish
these tasks if there is disequilibrium present.
if psychiatric disorders are suspected
A complete assessment
of the eyes including:
Diagnosis can be made
on history and physical examination results. No laboratory or radiologic
testing is needed for an acute episode of BPPV unless an underlying cause
Pupil assessment, especially
following head trauma
testing for nystagmus
The most accurate test in primary care is the Bárány or Dix-Hallpike
maneuver. The patient is asked to turn his head. A rapid change in position
from sitting to supine (with head hanging over the edge of the examination
table) will produce active rotatory nystagmus when head is turned so that
the affected ear is facing the floor. This may be accompanied by nausea.
If the patient is
acutely ill, supportive treatment is necessary. The following measures
Clear fluids when there
is nausea and vomiting
Diazepam (a benzodiazepine)
5-10 mg. Administration 2-3 times daily can be valuable in the acute period.
It acts as a muscle relaxant and an antianxiety agent, allowing the patient
to rest. Alternatively, meclizine hydrochloride (an antihistamine) 12.5-25
mg 3 times daily may be used.
A combination of the
above agents may be used. The patient may not drive during this course
It is essential that
these agents be used only short-term, as they can mask important clues
in refractory vertigo.
A soft cervical collar
may be used to reduce head movement.
If symptoms continue,
the Epley canalith repositioning maneuver may be performed by a trained
audiologist. The patient is placed in the head-hanging position, with the
affected ear to the floor. At 30-second intervals, specific head rotations
permit the misplaced otolithic material to transit through the posterior
semicircular canal and be returned to the utricle, removing the cause of
Patient should return
for follow-up within 7 days for re-evaluation.
After the Epley maneuver,
the patient should be given the following instructions:
Keep head erect for
The Epley maneuver eliminates
vertigo in about 80% of patients after 1 treatment. There may be frequent
vertigo recurrence over the next 6-10 weeks and the maneuver can be repeated
a second time if necessary. Symptoms usually taper off gradually with no
episode matching the intensity of the original attack. The Epley maneuver
may be performed in the primary care setting only with proper instructions.[1,2]
Traditionally, an audiologist integrates this maneuver as part of a complete
Avoid reaching for objects
in high places, looking up suddenly, or bending over
is also valuable when vertigo improves but does not disappear. A vestibular
rehabilitation program can be easily ordered and is covered by most third-party
If vertiginous episodes
last longer than 2 weeks without improvement, become more intense, or occur
with greater frequency, the patient will need further evaluation. If a
central cause is suspected, immediate referral to the appropriate specialist
With cases of prolonged
vertigo, blood analysis is sometimes helpful. The following tests should
be included in a vertigo screen:
rate (ESR), rheumatoid factor, antinuclear antibody (ANA) titer, Lyme titer
-- to rule out autoimmune disease
lipid profile to rule
out possible fat emboli that infrequently affect the 8th cranial nerve
rapid plasmin reagin
(RPR) test to rule out undiagnosed syphilis
If the above screening
fails to reveal an etiology, referral to an otolaryngologist is warranted.
The patient will need a complete audiometric evaluation as well as possible
advanced testing to differentiate between central and peripheral vertigo.
blood glucose, CBC,
and thyroid-stimulating hormone (TSH) to rule out metabolic problems and
Although a patient
who presents with vertigo may seem initially puzzling to the primary care
provider, a systematic approach to this common symptom can successfully
uncover the majority of causes in a cost-effective manner. Although not
usually life-threatening, vertigo is certainly life-altering and patients
will be grateful for a quick response to therapy.
Blair C. The dizzy patient.
Am J Nurs. 1999;99:61-65, 67. [A helpful dizziness questionnaire can be
found on p. 62.]
Drachman DD. Clinical
crossroads: a 69 year-old man with chronic dizziness. JAMA. 1998;280:2111-2118.
Tinetti ME, Williams
CS, Gill TM. Dizziness among older adults: a possible geriatric syndrome.
Ann Intern Med. 2000;132: 337-344.
Drachman DD. Occam's
razor, geriatric syndromes, and the dizzy patient [editorial]. Ann Intern
Med. 2000;132: 403-405.
Ruckenstein MJ. Managing
dizziness and vertigo in older women. Womens Health Primary Care. 2001;4:241-250.
Judith Lynch, Assistant
Clinical Professor of Nursing, Yale School of Nursing, New Haven, Conn;
and Nurse Practitioner, ENT and Facial Plastic Surgery Associates, Fairfield
and Trumbull, Conn.
4(2), 2002. © 2002 Medscape