The Dizzy Patient

There can be no physician so dedicated to their art that they do experience a slight decline of the spirits when they learn that their

patients chief complaint is of dizziness

• History– “head rush” or– “like being on a roundabout”– Other focal neurological features– Hearing loss– If episodic – duration of episodes and provoking features– If chronic – variability ?

• Acute– Vestibular neuronitis

• Single acute attack of continuous vertigo often with nausea and vomiting for several days

• Positive head impulse test, unidirectional nystagmus horizontal and rotational

• No other neurological deficit, furniture walking

• Rx – bed rest, antiemetics for 3 days only and strong encouragement to mobilise

• Gradual recovery over weeks but 50% will have canal paresis detectable on vestibular function testing at 1 year

Head Impulse Test

• Red flags (for posterior circulation stroke)– Normal head impulse– Can’t walk– Focal neurological signs– Hearing loss, abnormal otoscopy– New headache

• Recurrent episodic– NOT vestibular neuronitis

– BPPV• Attacks lasting seconds to a

minute• Positional, turning over in bed

– Migraine• Attacks lasting 10-30 minutes to

a minute with associated migraine features

• The commonest cause of recurrent dizziness we see

– Menieres• Attacks lasting minutes to several hours with roaring tinnitus, ear fullness and unilateral deafness

• Dizziness: A practical approach to diagnosis and management. Bronstein and Lempert.

• Epley (following a positive Dix-Hallpike)

– Youtube (accurate and safe)