1. Differential Diagnosis of
Dizziness
Sarah Guarino
Ithaca College

2. What can cause dizziness?
 Vertigo
 Benign Paroxysmal Positional Vertigo (BPPV): Brief and intense (10-20
seconds) sensation of spinning with rapid head movements due to
displacement of inner ear crystals.
 Infection
 Labyrinthitis: sudden hearing loss or vertigo from viral (ex: flu) or bacterial
irritation, a side effect of medication, allergies or ear infection that causes
swelling of the inner ear.
 Vestibular neuritis
 Migraine
 Sometimes coupled with light and noise sensitivity
 Meniere’s disease
 Episodes of vertigo (minutes to hours) caused by build up of fluid in the
inner ear.
 Hearing loss, tinnitus, feeling of a plugged ear
 Blood pressure

3.  Circulatory condition
 Cardiomyopathy, MI, heart arrhythmia, TIA or decrease in BV
 Neurological condition
 PD, MS, stroke
 Acoustic Neuroma
 Benign tumor on the vestibular nerve
 Tinnitus and gradual hearing loss; usually no vertigo
 Medication
 Anxiety
 Panic attacks can cause dizziness or lightheadedness
 Anemia
 Coupled with fatigue, weakness and pale skin
 Hypoglycemia
 DM (insulin dependent): coupled with sweating and anxiety
 Dehydration
 Hyperthermia
 Especially with pts. with heart complications on heart medications

4. Orthostatic Hypotension
 A sudden drop in systolic BP causes lightheadedness often when pt.
stands up too quickly from sitting or laying down.
 Lasts seconds to minutes.
 Blurred vision, weakness, confusion, nausea, faintness
 Causes: dehydration, CV disease, NS disorders (PD, MS), endocrine
problems (hypoglycemia), after eating meals
 Risk factors: age, medications, disease, pregnancy, bed rest,
disease, alcohol
 Complications: falls, stroke, CV disease
 Systolic drop >20 mm Hg
 Diastolic drop of >10 mm Hg

6. Medications
 Anti-seizure
 Antidepressants
 PD
 Sedatives
 Antipsychotics
 Tranquilizers/ muscle
relaxants
 Erectile dysfunction
 Narcotics
 HBP meds (lower BP too
much)
 Diuretics
 Alpha blockers
 Beta blockers
 ACE inhibitors
 Nitrates
 Calcium channel blockers

7. Cerebellar
 ~3% of pts who present to ED with vertigo actually have cerebellar
infarction.
 Misdiagnosis rate is as high as 35%
 Mortality rate can be as high as 40%
 Symptoms reach maximal intensity at onset.
 Risk factors: hypertension and CV disease
 Exam:
 Negative head thrust test
 Severe ataxia*
 Inability to walk without support
 Multidirectional nystagmus*
 Imaging:
 Hemorrhagic = CT and MRI are equally effective
 Ischemic = MRI has 83% sensitivity and CT has 26%

8. Vestibular Neuritis
 Constant vertigo due to a viral infection of the vestibular nerve.
 Gradual onset that improves over days however full recovery takes
weeks to months.
 Symptoms are persistent and ongoing.
 Nausea and vomiting
 Exam:
 Normal neurological exam
 Normal limb coordination
 Positive head thrust test
 Nystagmus: fast phase is towards affected ear
 Horizontal and torsional in a unidirectional manner
 Alexander’s Law: nystagmus is accentuated when looking away from the
affected ear.

9. Where do you start?
 Detailed history to rule out central involvement:
 Red Flags
 Persistent vertigo
 Progressively worsening symptoms
 Vertical eye movements
 Severe headache (especially in morning when ICP is high)
 5 D’s (diplopia, dysarthria, dysphasia, drop attack, dizziness)
 3 N’s (numbness, nausea, nystagmus)
 Vomiting
 Ataxia
 Cerebellar signs
 CV palsies
 Papilloedema
 Fever
 Weakness
 Horner’s sign

10. Disequilibrium
 Cervical spine screen first!
 Visual, sensory or vestibular
disturbance?
 Eye exam:
 CN III, IV, VI = H test/ visual
field tracking
 Saccades
 VOR
 Head thrust test
 Sensory exam:
 Light touch
 Vibration
 Balance exam:
 EO on firm surface
 EC on firm surface
 EO on variable surface
 EC on variable surface

11. Benign Paroxysmal Positional
Vertigo
B: not life threatening
P: sudden, brief spells
P: triggered by head position or movement
V: false sense of rotational movement
 Lifetime occurrence: 2.4%
 Re-occurrence rate: 50% in first 5 years
 90% of pts. respond in 1-3 treatments
Canalithiasis: otoconia are in the canals, symptoms resolve <60
seconds
Cupulolithiasis: otoconia adhere to the cupula and symptoms last
for >60 seconds

12. Anterior canal = rotation around sagittal
plane (nodding head)
Posterior canal = rotation around
coronal plane (side bending)
Horizontal canal = rotation
around a vertical axis (cervical
rotation)

13. Nystagmus
 The result of a miscommunication between the vestibular and
visual systems that causes rapid uncontrollable eye
movements.
 BPPV specific:
 Latency of 5-10 seconds
before onset of nystagmus
 Lasts 5-120 seconds
 Positional
 Repeated stimulation causes fatigue or disappearance
 Rotatory/torsional component present
 Geotropic: towards the ground
 Ageotropic: away from the ground
 Visual fixation will suppress intensity

14. Treatment of BPPV
 Cupulolithiasis:
 Liberatory Maneuver: utilize rapid head movements in the plane of the
affected canal to dislodge the crystals first
 Canalithiasis:
 Anterior canal (<5%)
 Dix-Hallpike Test (R cervical rotation tests the R inner ear)
 Semont Maneuver (L cervical rotation treats the R inner ear) : 90.3% success rate
 Horizontal canal (10-15%)
 Roll Test
 Roll Maneuver
 * Posterior canal *
 Dix-Hallpike Test
 Epley Maneuver: 90.3% success rate
 Brandt-Daroff exercises (HEP)
 Habituation method which is similar to the Semont Maneuver
 The pt. rolls onto the unaffected side and the head is rotated towards the
affected side
 5-10 reps, 3x a day until pt. is symptom free at least 2 days

15. Epley
Maneuver
Dix Hallpike
Test

16. Semont
Maneuver
Roll
Maneuver

17. Case study
A 60 year old woman reports sudden dizziness when she arises
from bed. She feels nauseous and had been vomiting. She
recently had a severe cold. Her vomiting has settled, but she is
dizzy on turning her head to the right. She is frightened to leave
her house.
 Rising from bed: postural hypotension
 Vomiting: peripheral vestibular disease
 Cold: vestibular neuritis
 Positional symptoms: BPPV
 Anxiety: impedes central adaptation

18. References
 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC552814/
 http://www.mayoclinic.org/diseases-
conditions/dizziness/basics/tests-diagnosis/con-20023004
 https://medlineplus.gov/ency/article/001054.htm
 http://vestibular.org/autoimmune-inner-ear-disease-aied#
 http://vestibular.org/understanding-vestibular-disorders/types-
vestibular-disorders/benign-paroxysmal-positional-vertigo
 http://www.neuropt.org/docs/vsig-physician-fact-sheets/beyond-
posterior-canal-bppv.pdf?sfvrsn=2
 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2791733/