PRACTITIONER’S GUIDE TO THE DIZZY PATIENT Alan L. Desmond, AuD Wake Forest Baptist Health Otolaryngology ABOUT THE PRACTITIONER’S GUIDE TO THE DIZZY PATIENT The information in this guide has been reviewed for accuracy by specialists in Audiology, Otolaryngology, Neurology, Physical Therapy and Emergency Medicine ABOUT THE AUTHOR Alan L. Desmond, AuD, is the director of the Balance Disorders Program at Wake Forest Baptist Medical Center and a faculty member of Wake Forest School of Medicine. He is the author of Vestibular Function: Evaluation and Treatment (Thieme, 2004), and Vestibular Function: Clinical and Practice Management (Thieme, 2011). He is a co-author of Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo. He serves as a representative of the American Academy of Audiology at the American Medical Association and received the Academy Presidents Award in 2015 for contributions to the profession. He also serves on several advisory boards and has presented numerous articles and lectures related to vestibular disorders. HOW TO MAKE AN APPOINTMENT WITH THE WAKE FOREST BAPTIST HEALTH BALANCE DISORDERS TEAM Physician referrals can be made through the STAR line at 336-713-STAR (7827). PRACTITIONER’S GUIDE TO THE DIZZY PATIENT TABLE OF CONTENTS How to Use the Practitioner’s Guide to the Dizzy Patient . 2 Typical Complaints of Various Vestibular and non-Vestibular Disorders . 3 Structure and Function of the Vestibular System . 4 Categorizing the Dizzy Patient . 5 Timing and Triggers of Common Disorders . 6 Initial Examination Checklist for Acute Vertigo: Peripheral versus Central . 7 Diagnosing Acute Vertigo . 8 Fall Risk Questionnaire . 10 Physician’s Guide to Fall Risk Questionnaire . 11 Detailed Dizziness History Questionnaire . 12 Short Form Dizziness Questionnaire . 14 Vestibular Function Tests . 16 MOTT (Most of the Time) List . 17 Common Vestibular and Non-Vestibular Disorders PRACTITIONER PATIENT REVIEWS EDUCATION Benign Paroxysmal Positional Vertigo (BPPV) . 18 . 19 Acute Vestibular Syndrome: Vestibular Neuritis / Labyrinthitis . 20 . 21 Ménière’s Disease . 22 Vestibular Migraine . 24 . 25 Superior Canal Dehiscence Syndrome . 26 . 27 Anxiety/Hyperventilation . 28 . 29 Orthostatic Hypotension . 30 . 31 Multifactorial Dysequilibrium . 32 . 33 Central Dizziness . 34 . 35 Canalith Repositioning . 36 . 37 Vestibular and Balance Exercises . 38 . 39 Blood Pressure Log . 40 THE PRACTITIONER’S GUIDE TO THE DIZZY PATIENT | 1 HOW TO USE THE PRACTITIONER’S GUIDE TO THE DIZZY PATIENT This guide is intended to be used as quick access to information when seeing a patient complaining of dizziness . There are many different sensations, with many different causes, that a patient may describe as “feeling dizzy .” The most common causes of dizziness are covered in this guide, but there are many causes of dizziness that are not covered here . The goal of this guide is to increase efficiency and accuracy, while minimizing time spent gathering pertinent case history information and disseminating patient educational information . This guide begins with the typical complaints of various disorders causing dizziness, imbalance, and/or vertigo on a short, easy access list . This list is also displayed on the inside back cover of this guide . This can be kept by the practitioner’s side during the case history interview . As the patient relays their symptoms, the practitioner can flip to the appropriate page to assist in gathering additional relevant information . For each disorder there is a Practitioner Review page and a Patient Education page . The information on the Practitioner Review page lists typical complaints associated with each disorder .* Since many patients do not provide a clear description of their symptoms, there are defining questions to extract more detailed information . Medical history questions may provide a connection between the patient’s current complaints and a previously diagnosed medical condition . A short diagnosis/definition of the disorder is listed on each practitioner review page, followed by some management options. The Patient Education page is designed as a patient handout . These are brief, informative, and written in non-medical terminology . There are several options included that may be used as intake forms . One option is to copy the inside back cover and have the patient circle the block that best describes their symptoms . There is a two-page traditional dizziness history questionnaire, and an eight-question short form questionnaire with an interpretation guide . The short form questionnaire also appears in the accompanying Balance Disorders Program brochure . There is a fall risk questionnaire with an interpretation guide to help explore the multiple factors that can lead to increased fall risk . These should be given to the patient to fill out prior to their appointment . * A patient education page for Ménière’s disease is not included, due to the detailed and controversial nature of this condition . A specific patient education handout is recommended in the text of the practitioner review . 2 | THE PRACTITIONER’S GUIDE TO THE DIZZY PATIENT TYPICAL COMPLAINTS OF VARIOUS VESTIBULAR AND NON-VESTIBULAR DISORDERS Benign Paroxysmal Positional Vertigo (BPPV) Superior Canal Dehiscence PAGES 26–27 PAGES 18–19 “ I get dizzy around loud noise or when I blow my “I woke up and the bed was spinning .” nose .” “ I bent over (rolled over, turned quickly, laid down, “My voice sounds like I am in a barrel .” sat up from bed, etc .) and everything started “ I hear my pulse or chewing louder than I should .” spinning around .” “ Every time I tried to get up I fell back on to the Anxiety/Hyperventilation PAGES 28–29 bed .” “ I felt like my heart was pounding out of my chest .” Vestibular Neuritis/Labyrinthitis PAGES 20–21 “I felt like I was dying .” “ I had constant spinning and nausea for about three days .” “I couldn’t breathe .” “ After the worst of it (vertigo and nausea) I was okay if I didn’t move . If I moved I was off balance Orthostatic Hypotension PAGES 30–31 and would get nauseous if I moved too much .” “I get dizzy and off balance when I stand up .” Ménière’s Disease PAGES 22–23 “ I get up and start to walk and feel like I am going to fall over .” “ I have had several episodes of severe vertigo with nausea, lasting for hours at a time .” “When I get up quickly, I feel like I could faint .” “I feel so much pressure in my head (ear) .” Multifactorial Dysequilibrium PAGES 32–33 “My ear was roaring .” “I have had several falls .” “ After an episode, I need to sleep for several “ I feel very unsteady when I am in a crowd or hours .” unfamiliar setting .” Vestibular Migraine PAGES 24–25 “ I want to hold on to someone/something when I walk .” “ I have episodes of spinning and nausea that come on without warning, but had no ear symptoms .” Central Dizziness PAGES 34–35 “ I felt a sudden wave come over me, like the floor “I stagger when I walk .” shifted .” “If I lose my balance, I just go over .” “ I can’t stand any type of motion . It never “I have this constant feeling in my head .” bothered me when I was a kid .” THE PRACTITIONER’S GUIDE TO THE DIZZY PATIENT | 3 STRUCTURE AND FUNCTION OF THE VESTIBULAR SYSTEM: A BRIEF OVERVIEW The primary role of the balance system is saccule registers primarily vertical movements to allow us to interact and maintain contact such as the sensation experienced when moving with our surroundings in a safe and efficient in an elevator . The utricle senses horizontal manner . As we move through our environment, movements such as moving forward in a car . information is gathered through our visual, The vestibular-ocular reflex (VOR) can be defined somatosensory and vestibular senses and sent as reflexive eye movement in response to head to our brainstem for integration, then finally on movement . The role of the VOR is to allow stable to our cortex for perception and processing . Our gaze or clear, focused vision while the head is visual and somatosensory reference information moving . It performs this function by causing eye is constantly changing as we move, but our movements that are equal to and opposite of vestibular reference — gravity — is unchanging . head movement — in effect, visually canceling As long as the information coming in from these out head movement . A simple demonstration of sources is predictable and non-conflicting, our the VOR can be done while reading this page . equilibrium is stable and we move about freely Simply hold this page 18 inches (or so) in front of with little thought regarding balance . When you, and move your head back and forth at the a sensory conflict occurs, the brainstem must maximum speed that still allows for clarity and efficiently and quickly (reflexively) adjust the level easy reading . Then, with your head stationary, of priority given to the conflicting information, move the page back and forth in front of you at or a sensation of imbalance may occur . Since the the speed nearly equal to the speed at which you known constant in the mix is gravity, the brainstem moved your head . A noticeable degradation in tends to rely more on vestibular information for visual acuity occurs . It is impossible to voluntarily maintenance of balance . When the vestibular move the eyes at speeds that are needed system is compromised, the patient may become to maintain visual acuity during typical head more dependent of visual and tactile feedback for movements . The latency of the response for the maintenance of balance and orientation . VOR is five times faster than the fastest voluntary The peripheral vestibular apparatus (labyrinth) eye movement, and ten times faster than the consists of matched pairs of sensors that are typical eye movement . stimulated by any type of head movement, The VOR is compromised with damage to one with specific sensors responsible for specific or both peripheral vestibular apparatus .