898_의학강좌- 임현우, 채성원

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1 Continuing Education Column DOI: /jkma pissn: eissn: Evaluation and treatment of the patient with acute dizziness in primary care Hyun Woo Lim, MD Sung Won Chae, MD Department of Otolaryngology-Head and Neck Surgery, Korea University College of Medicine, Seoul, Korea * Corresponding author: Sung Won Chae, schae@kumc.or.kr Received July 27, 2010 Accepted August 11, 2010 Abstract Dizziness is a very common symptom encountered by primary care physicians. Dizziness can be divided into five subgroups according to symptoms. These subgroups can be determined by a patient's history and allow the physician to deduce the etiology. A careful and systematic approach to dizzy patients is the key to a correct diagnosis and finding the optimal treatment. Physicians should obtain a detailed history from the patient in an open-ended fashion. Brief and comprehensive bedside neuro-otologic examinations, such as cranial nerve examinations, the Dix- Hallpike test, and the head thrust test cannot be omitted for an accurate diagnosis. Knowledge about the numerous disease entities that may contribute to dizziness can be essential for differential diagnosis. In addition, this article provides information about frequently prescribed drugs, including vestibular suppressants and antiemetics. Keywords: Acute dizziness; History- taking; Examination; Drug therapy c Korean Medical Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 898

2 Evaluation and treatment of the patient with acute dizziness in primary care Table 1. Types of dizziness according to mechanism and etiology Type of dizziness Mechanism Etiology Imbalance of tonic vestibular BPPV, VN, MD, VBI, cerebellar Vertigo signal infarction etc. Symmetric vestibular loss, Bilateral vestibulopathy, Disequilibrium proprioceptive loss, cerebellar damage, basal cerebellar damage ganglia lesion etc. Presyncope Orthostatic hypotension, Diffusely diminished cerebral hypoglycemia, cardiac blood flow/blood sugar arrhythmia etc. Abnormality in the integration Depression, panic attack, Psychogenic nervous system of afferent signal by central anxiety etc. Others ocular mismatch, multisensory Cataract surgery, dizziness in abnormality, others elderly etc. BPPV, benign paroxysmal positional vertigo; VN, vestibular neuritis; MD, Meniere s disease; VBI, vertebrobasilar insufficiency 899

3 Lim HW Chae SW Table 2. Differential diagnosis of dizziness according to historytaking Peripheral Frequently Vertigo type Central Auditory symptoms: common rare Variable type dizziness Neurologic symptoms: rare common Aggravated by head or body Not proportioned to movement dizziness Nausea or vomiting Not proportioned to proportioned to dizziness dizziness Compensated rapidly Compensated slowly (days to weeks) (months) or rare Loss of consciousness (-) Loss of consciousness (-)-(+) Ataxia, postural instability Ataxia, postural instability (±)-(-) (+)-(++) 900

4 Evaluation and treatment of the patient with acute dizziness in primary care Table 3. Differential diagnosis according to spontaneous nystagmus Appearance Visual fixation Peripheral cnystagmus Combined horizontal or torsional Decreased with fixation Central nystagmus Alexander s law Consistent Inconsistent Pure vertical, pure torsional or oblique Persists with fixation or Increased with fixation Direction Typically unidirectional Bidirectional, Direction changed Duration From minutes to weeks From weeks to months 901

5 Lim HW Chae SW Table 4. Considerations in obtaining imaging in acute vertigo Unilateral or asymmetric hearing loss Brainstem or cerebellar symptoms other than vertigo Stroke risk factors (diabetes, hypertension, history of MI) Acute onset associated with neck pain Direction changing spontaneous nystagmus New onset severe headache (especially occipital) Inability to stand or walk Acute vertigo with an intact head thrust test 902

6 Evaluation and treatment of the patient with acute dizziness in primary care Head rotation Head rotation Loss of Visual fixation Left horizontal canal activated Visual fixation maintained Loss of left labyrinthe Catch-up saccade Figure 1. Physiology of the head thrust test. Head movement towards a canal will cause activation of that canal. Reflex movement of the eyes in the opposite direction-that is, away from the canal (A). Head movement towards a defunct canal will result in the failure of activation of the vestibulo-ocular reflex and thus the visual target will be lost from fixation during sudden head movements (B). A B 903

7 Lim HW Chae SW F E Figure 2. Sit the patient upright. Turn the patient's head to the affected side at a 45 degree angle (A). The patient is brought into the supine position with the head extended below the level of the bed (Dix-Hallpike position) (B). Maintain up to 30 seconds after nystagmus disappears (C). Turn the patient s head 90 degrees to the other side (D). The patient s head is further rotated to the opposite side by rolling until the patient is face down (E). The patient is brought back to the upright position (F). D A B C 904

8 Evaluation and treatment of the patient with acute dizziness in primary care 905

9 Lim HW Chae SW Table 5. Diagnostic criteria about migraine-associated vertigo Definite migraine associaled vertigo A. Episodic vestibular symptoms of at least moderate severity B. Current or previous history of migraine according to the 2004 criteria of the IHS C. One of the following migrainous symptoms during two or more attacks of vertigo: migrainous headache, photophobia, photophobia, visual aura, or other aura D. Other causes ruled out by appropriate investigations Comment: Vestibular symptoms are rotational vertigo or another illusory self-or object motion. They may be spontaneous or positional. Vestibular symptoms are moderate if they interfere with but do not prohibit daily activities and severe if patients cannot continue daily activities. Probable migraine associated vertigo A. Episodic vestibular symptoms of at least moderate severity B. One of the following: 1. Current or previous history of migraine according to the 2004 criteria of the IHS 2. Migrainous symptoms during vestibular symptoms 3. Migraine precipitants of vertigo in more than 50% of attacks: food triggers, sleep irregularities, or hormonal change 4. Response to migraine medications in more than 50% of attacks C. Other causes ruled out by appropriate investigations 906

10 Evaluation and treatment of the patient with acute dizziness in primary care Table 6. Medical therapy of dizziness Class Drug Dose Side effect FDA class (ADEC) Antihistamine Dimenhydrinate 50 mg p.o. q4-6h or i.m. q4-6h or Moderate sedation, B (A) (dramamine) 100 mg suppository q8-10h dry mouth, glaucoma, difficulty urinating etc. Anticholinergics Scopolamine 0.6 mg p.o. q4-6h or Mild sedation, dry mouth, C (B2) transdermal patch:1q 3days amnesia etc. GABA analogues Diazepam 5 or 10 mg p.o. b.i.d.- q.i.d. drowsiness, lethargy, D (C) i.m. q4-6h or dependency, i.v. q4-6h Withdrawal symptoms, apnea (i.v) etc. Lorazepam 0.5 or 1.5mg p.o. b.i.d. Similar as above D (C) Clonazepam 0.5 mg p.o. t.i.d. Similar as above D (C) Calcium channel Flunarizine 10 mg p.o. q.d. Weight gain, depression, contraindication blockers reversible parkinsonism etc. Cinnarizine 75 mg p.o. q.d.-t.i.d. Similar as above contraindication Dopamine Metoclopramide 5 or 10 mg p.o q8h, dysmyotonia,agitation,lethargy, B (A) antagonists 10 or 20 mg i.v. q8-12h tardive dyskinesia etc. p.o, by mouth; i.m, intramuscularly; i.v, intravenous b.i.d, twice a day; t.i.d, three times a day; q.i.d, four times a day; q.d, every day FDA, Food and Drug Administration; ADEC, Australian Drug Evaluation Committee 907

11 Lim HW Chae SW REFERENCES 11. Nazareth I, Landau S, Yardley L, Luxon L. Patterns of presentations of dizziness in primary care-a cross-sectional cluster analysis study. J Psychosom Res 2006; 60: Karatas M. Central vertigo and dizziness: epidemiology, differential diagnosis, and common causes. Neurologist 2008; 14: Colledge NR, Wilson JA, Macintyre CC, MacLennan WJ. The prevalence and characteristics of dizziness in an elderly community. Age Ageing 1994; 23: Kroenke K, Lucas CA, Rosenberg ML, Scherokman B, Herbers JE Jr, Wehrle PA, Boggi JO. Causes of persistent dizziness. A prospective study of 100 patients in ambulatory care. Ann Intern Med 1992; 117: Dieterich MMD. Dizziness. Neurologist 2004; 10: Chawla N, Olshaker JS. Diagnosis and management of dizziness and vertigo. Med Clin North Am 2006; 90: Egger S, Zee D. Central vestubular disorders. In: Cummings C, Flint P, Harker L, editors. Otolaryngology, Head and Neck Surgery. 4 ed. St. Louis: Mosby; p Farrehi PM, Santinga JT, Eagle KA. Syncope: diagnosis of cardiac and noncardiac causes. Geriatrics 1995; 50: Eckhardt A, Tettenborn B, Krauthauser H, Thomalske C, Hartmann O, Hoffmann SO, Hopf HC. [Vertigo and anxiety disordersresults of interdisciplinary evaluation]. Laryngorhinootologie 1996;75: Chan Y. Differential diagnosis of dizziness. Curr Opin Otolaryngol Head Neck Surg 2009; 17: Hullar T, Zee D, Minor L. Evaluation of the Patient with Dizziness. In: Flint P, Haughey B, Lund V, et al, editors. Cummings Otolaryngology Head&Neck Surgery. 5 ed. Philadelphia: Mosby; p Hüfner K, Barresi D, Glaser M, Linn J, Adrion C, Mansmann U, Brandt T, Strupp M. Vestibular paroxysmia: Diagnostic features and medical treatment. Neurology 2008; 71: Kroenke K, Mangelsdorff AD. Common symptoms in ambulatory care: incidence, evaluation, therapy, and outcome. Am J Med 1989; 86: Brandt T, Strupp M. General vestibular testing. Clin Neurophysiol 2005; 116: Baloh RW. Approach to the patient with dizziness, in Dizziness, Hearing Loss, and Tinnitus. Baloh RW, editor. Philadelphia: F.A. Davis Company;

12 Evaluation and treatment of the patient with acute dizziness in primary care 16. Hain T, Micco A. Neuroanatomical localization and syndromes, cranial nerve III: VESTIBULOCOCHLEAR SYSTEM. In: Goetz C, Pappert E, editors. Textbook of Clinical Neurology. 1 ed. Philadelphia: WB saunders company; p Baloh RW. Vertigo. Lancet 1998; 352: Cha CI. Differential diagnosis of dizziness. In: Korean society of otorhinolaryngology, editor. Otorhinolaryngology Head and Neck Surgery. 2nd ed: Ilchokak; p Solomon D. Distinguishing and treating causes of central vertigo. Otolaryngol Clin North Am 2000; 33: Seemungal BM. Neuro-otological emergencies. Curr Opin Neurol 2007; 20: Chae SW. Acute spontaneous vertigo. J Korean Bal Soc 2008; 7: Harvey SA, Wood DJ, Feroah TR. Relationship of the head impulse test and head-shake nystagmus in reference to caloric testing. Am J Otol 1997; 18: Chung W, Chung K. Diagnostic Approach to a Patient with Dizziness. J Korean Bal Soc 2007; 6: Epley JM. New dimensions of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 1980; 88: Prokopakis EP, Chimona T, Tsagournisakis M, Christodoulou P, Hirsch BE, Lachanas VA, Helidonis ES, Plaitakis A, Velegrakis GA. Benign paroxysmal positional vertigo: 10-year experience in treating 592 patients with canalith repositioning procedure. Laryngoscope 2005; 115: Bhattacharyya N, Baugh R, Orvidas L, Barrs D, Bronston L, Cass S. Clinical practice guideline: Benign paroxysmal positional vertigo. Otolaryngology-Head and Neck Surgery 2008; 139: S47-S Bergenius J, Perols O. Vestibular neuritis: a follow-up study. Acta Otolaryngol 1999; 119: Minor LB, Schessel DA, Carey JP. Meniere s disease. Curr Opin Neurol 2004; 17: Crane BT, Schessel DA, Nedzelski J, Minor LB. Peripheral vesibular disorders. In: Flint P, Haughey B, Lund V, editors. Cummings Otolaryngology Head&Neck Surgery. Philadelphia: Mosby; p Lempert T, Neuhauser H. Migrainous vertigo. Neurol Clin 2005; 23: , vi. 31. Neuhauser HK, Lempert T. Diagnostic criteria for migrainous vertigo. Acta Otolaryngol 2005; 125: Furman JM, Marcus DA, Balaban CD. Migrainous vertigo: development of a pathogenetic model and structured diagnostic interview. Curr Opin Neurol 2003; 16: Lee H, Cho YW. A case of isolated nodulus infarction presenting as a vestibular neuritis. J Neurol Sci 2004; 221: Lee H, Sohn SI, Jung DK, Cho YW, Lim JG, Yi SD, Lee SR, Sohn CH, Baloh RW. Sudden deafness and anterior inferior cerebellar artery infarction. Stroke 2002; 33: Baloh RW. Clinical practice. Vestibular neuritis. N Engl J Med 2003; 348: Tighilet B, Leonard J, Lacour M. Betahistine dihydrochloride treatment facilitates vestibular compensation in the cat. J Vestib Res 1995; 5: Shinkawa H, Kimura RS. Effect of diuretics on endolymphatic hydrops. Acta Otolaryngol 1986; 101:

13 Lim HW Chae SW Peer Reviewers Commentary 910

975_983 특집-한규철, 정원호

975_983 특집-한규철, 정원호 Focused Issue of This Month Gyu Cheol an, MD Department of Otolaryngology ead & Neck Surgery, Gachon University of College Medicine E - mail : han@gilhospital.com Won-o Jung, MD Department of Otolaryngology