9/24/2018 Differential Diagnosis Objectives • Review various vestibular diagnoses • Recognize central vs. peripheral causes of dizziness • Learn different diagnoses related to dizziness • Recognize alternative causes of dizziness What is Dizziness? There are many different forms of dizziness • Lightheadedness • Floating or passing out sensation • Weakness • Vertigo • Spinning or illusion of movement • Imbalance • Unsteady, off balance • Disorientation 1 9/24/2018 Identifying Dizziness • When does it occur? • Duration of symptoms • Aggravating/relieving factors • Static versus dynamic • Concurrent symptoms • Tinnitus, hearing changes, numbness, headache • Associated falls – • frequency, mechanism • Pain: head, chest, abdomen, extremities Multisensory Dizziness • Most common symptoms are imbalance, weakness, or unsteadiness • Balance relies on the coordination of several sensory systems • Cataracts & age related eye changes can result in low vision • B12 deficiency or diabetes can cause lower extremity neuropathy • Losses in one or more of these systems can result in dizziness/imbalance Neuro-otological Dizziness • Loss or inadequate function of vestibular organ • Unilateral or bilateral dysfunction • Compromised blood flow or infection to inner ear • Results in decreased sensory input • Examples: Labyrinthitis, Vestibular neuritis • Assess with vestibular function testing 2 9/24/2018 BPPV • Canalithiasis • Cupulolithiasis • Causes dizziness with positional changes such as rolling in bed or turning head quickly • Symptoms can be severe & relatively short duration • Symptoms can recur, episodic • BPPV vs VBI (Vertebrobasilar Insufficiency) Lee, 2010 Vestibular Migraine • Migraine Associated Vertigo (MAV) or Vestibular Migraine • Migraine and Vestibular Dysfunction • Triggers for Migraine • Mechanisms of Migraine • Evaluation and Testing • Treatment • Medication • Vestibular rehabilitation • Lifestyle Modifications VEDA, n.d. PPPD • PPV - Phobic Postural Vertigo • CSD- Chronic Subjective Dizziness • PPPD- Persistent Postural-Perceptual Dizziness • Symptoms & Mechanisms • Diagnosis • Behavioral factors • Treatment VEDA, n.d. 3 9/24/2018 Pediatric Vestibular Disorders • Vertigo/dizziness • Oscillopsia/gaze stability • Diminished balance • Diminished motor abilities • Youth Concussion • Headache; lack of coordination; lack of concentration; memory loss and confusion; nausea & vomiting; dizziness; tinnitus; sleepiness; excessive fatigue VEDA, n.d. Meniere’s Disease • Idiopathic Syndrome of Endolymphatic Hydrops • Causes • Progression of Symptoms • Treatment Prognosis VEDA, n.d. Acoustic Neuroma/Vestibular Neuroma/Vestibular Schwannoma • Cause and progression • Diagnosis • Treatment VEDA, n.d. 4 9/24/2018 Shy-Drager Syndrome • Multiple System Atrophy (MSA) • Related Orthostatic Hypotension • Treatment • Prognosis VEDA, n.d. Cardiovascular Dysfunction • Cardiovascular problems can present as dizziness • Often a sensation of lightheadedness or pre-syncope • Can be worse with physical exertion • May be accompanied by chest pressure, dyspnea • Arrhythmia • Bradycardia, tachycardia, or irregular heart beats • Warrants cardiology referral American Heart Association, 2018 Orthostatic Hypotension • May be a result of autonomic nervous system changes or a medication side- effect • Dizziness that occurs with vertical position changes • Can be immediate or up to 3 minutes following transition • Result of a blood pressure drop • >20 mmHg systolic or >10 mmHg diastolic • Blood pools & not enough gets back to the heart temporarily • May be accompanied by pallor or Neurology, 1996 clammy skin 5 9/24/2018 Diabetes • Hypoglycemia • Hyperglycemia • Diabetic Autonomic Neuropathy • Post-prandial hypotension NewLifeOutlook, 2018 Dehydration • Can occur with certain medications • Diuretics • Ensure proper hydration particularly in higher temperature or with illness WebMD, 2018 Cervicogenic Dizziness • Diagnosing Cervicogenic Dizziness • Symptoms • Evaluation • Treatment VEDA, n.d. 6 9/24/2018 Concussion • PHYSICAL SYMPTOMS OF CONCUSSION • Headache • Fuzzy or blurry vision • Nausea or vomiting (early on) • Dizziness • Sensitivity to noise or light • Balance problems • Feeling tired, having no energy • POST-CONCUSSION SYNDROME VEDA, n.d. CVA/ STROKE • Vertebrobasilar artery occlusion • Cranial nerve involvement • Arnold-Chiari Malformation • H.I.N.T.S. Test • Peripheral vs Central Vertigo Hain, T., 2018 Newman-Toker, et al., 2009 Multiple Sclerosis • Demyelinating Acute Vestibular Syndrome (AVS) • Vertigo • Nystagmus • Nausea and vomiting • Head-motion intolerance • Unsteady gait VEDA, n.d. 7 9/24/2018 Parkinson’s Disease • Hallmark signs of PD • Rigidity • Bradykinesia • Tremor • Postural instability • Causes of Dizziness in PD De Leon, 2016 Age-related Dizziness and Imbalance • Age-related physiological changes • Vision- cataract, microdegeneration, glaucoma, presbyopia • Sensation – decrease in reaction time • Inner ear-: loss in inner ear function • Weakness • Fall Risks- make sure you make gait evaluations (including Gait Speed) • Fall Prevention and Treatment • Lifestyle Changes/ Home Modification • Therapy and Exercise • Education • Medications Postural Instability • Age-related musculo- skeletal changes • Displacement of center of mass • Decreased amplitude of movements results in ineffective balance strategies 8 9/24/2018 Mal De Debarquement • Causes • Symptoms • Diagnosis • Treatment VEDA, n.d. Drug-Induced Dizziness • Medications can cause dizziness • Antipsychotics, antidepressants, benzodiazepines, anxiety drugs, narcotics, nitroglycerin, erectile dysfunction drugs, PD medications, antihypertensive • Over-the-counter medications • Herbal supplements/Complementary and Alternative Medicines (CAMs) • Ginkgo Biloba, St. John’s Wort, melatonin, medical marijuana • The more medications that have “dizziness” as a side effect, the more likely it will occur • Drugs for treatment of Dizziness: Meclizine, etc. WebMD, 2018 Ototoxic Drugs • Aspirin and Quinine-chloroquine; quinidine; quinine (including Q-vel); tonic water, etc. • Synthetic Drugs- Quinolines- > Neurotoxicity • Loop Diuretics- Bumex, Lasix, Decrin, Demadex • Aminoglycosides- gentamicin; streptomycin; et. • Anti-neoplastics- Cisplatin, Carboplatin • Environmental chemicals- carbon monoxide, mercury, tin, lead, manganese, etc. VEDA, n.d. 9 9/24/2018 References • American Heart Association. (2018). About arrhythmia. American Heart Association [Website]. Retrieved from https://watchlearnlive.heart.org/CVML_Player.php?moduleSelect=arrhyt • De Leon, M. (2016). Common causes and treatments of dizziness in PD. Defeat Parkinsons [Website]. Retrieved from https://defeatparkinsons.com/2016/02/06/common-causes-treatments-of-dizziness- in-pd-by-dr-de-leon/ • Hain, T. (2018) Dizziness and balance.com [Website]. Retrieved from https://www.dizziness-and- balance.com/disorders/central/cerebellar/chiari.html • Herdman, S. and Clendaniel, R. (2014). Vestibular Rehabilitation. 4th ed. Philadelphia: F.A. Davis Company. • Lee S-H, Kim JS. (2010). Benign Paroxysmal Positional Vertigo. Journal of Clinical Neurology 2, 51-63. doi:10.3988/jcn.2010.6.2.51. • Neurology. (1996). Consensus statement on the definition of orthostatic hypotension, pure autonomic failure, and multiple system atrophy. The Consensus Committee of the American Autonomic Society and the American Academy of Neurology, 46 (5); doi: 10.1212/WNL.46.5.1470. References (continued) • Newman-Toker, D.E., Kattah, J.C., Talkad, A.V., Wand, D.Z. Hsieh, Y., (2009) H.I.N.T.S. to Diagnose Stroke in the Acute Vestibular Syndrome —Three-Step Bedside Oculomotor Exam More Sensitive than Early MRI DWI. Stroke. 40(11): 3504–3510. doi:10.1161/STROKEAHA.109.551234. • Matin, T. and Kessler, M. , 2016, Cerebrovascular Accidents, Neurologic Intervention for Physical therapy, 3rd ed., p. 303. • NewLifeOutlook (2018). What causes Diabetes dizziness? Retrieved from https://dm2.newlifeoutlook.com/diabetes-dizziness/ • Pula, J.H., Newman-Toker, D.E., Kattah, J.C. Multiple sclerosis is the cause of the vestibular syndrome, Journal of Neurology260 (6). doi: 10.1007/s00415-013-6850-1, pp. 1649-1654 • VEDA, n.d. About Vestibular Disorders, VEDA [Website]Retrieved from https://vestibular.org/understanding-vestibular-disorder • WebMD. (2018) What are other causes of dizziness? Retrieved from https://www.webmd.com/brain/qa/what-are-other-causes-of-dizziness Thank You! 10.