What is Evaluation of the Dizzy and Unbalanced Patient?
Dizziness is a common reason why people visit doctors in both community clinics and emergency rooms, often leading to hospital stays. Typically, dizziness is grouped into four different kinds: vertigo (a spinning sensation), presyncope (a feeling of faintness or passing out), lightheadedness, and disequilibrium (a loss of balance). However, the reality is that it’s not always this straightforward. Patients often struggle to describe their unique dizziness symptoms, making it hard to categorize.
What Causes Evaluation of the Dizzy and Unbalanced Patient?
Dizziness can be caused by a wide variety of factors. Generally, these causes fall into three categories: neurological (relating to the brain and nerves), vestibular (related to balance and spatial orientation), or cardiovascular (related to the heart and blood vessels).
Neurological causes might include conditions like strokes affecting the cerebellum or brainstem (parts of the brain), or TIAs (transient ischemic attacks, which are ‘mini-strokes’ that temporarily restrict blood flow to the brain).
Vestibular causes can include a range of conditions affecting balance. Examples include vestibular schwannomas (a type of benign tumor growing on the nerve responsible for balance and hearing), vestibular migraines (a type of migraine characterized by dizziness and problems with balance), Meniere’s disease (an inner ear disorder that causes episodes of vertigo), benign paroxysmal positional vertigo (BPPV – a disorder where changes in the position of your head lead to sudden episodes of dizziness), and a couple more complex conditions related to our balance system.
Cardiovascular triggers for dizziness could be conditions like orthostatic hypotension (a form of low blood pressure that happens when you stand up from sitting or lying down), presyncope (a feeling of faintness or lightheadedness), vertebral artery dissection (a flap-like tear of the inner lining of the vertebral artery, which is located in the neck and supplies blood to the brain), or dysrhythmias (abnormal, irregular heartbeats).
Risk Factors and Frequency for Evaluation of the Dizzy and Unbalanced Patient
Dizziness is a common reason why people go to the emergency department or their primary doctor, accounting for about 3% of visits each year. The older a person gets, the more likely they are to experience dizziness. It’s estimated that 15 to 20% of adults feel dizzy each year, leading to 7.5 million people seeking help. This condition is up to three times more common in females than in males.
It’s worth noting that when someone feels dizzy or unsteady, it could be because of a specific type of stroke that affects the cerebellum or brainstem. About 10% of these strokes present only with vertigo, a sensation of feeling off balance. More than half of patients with vertebral artery dissections, a condition that can lead to stroke, report symptoms of dizziness or vertigo.
Signs and Symptoms of Evaluation of the Dizzy and Unbalanced Patient
When diagnosing cases of dizziness and imbalance, doctors typically consider factors such as:
- How sudden the symptoms began
- How long the symptoms last
- Whether the symptoms were triggered by something or just happened spontaneously
- The medications the patient is currently taking, and any recent changes to these
- The intake of substances like alcohol or caffeine
- Any recent head injuries
- Additional symptoms pointing to a neurologic or cardiovascular cause like difficulties with speech, swallowing, double vision, or signs of heart-related problems
In addition to these considerations, physical examination needs to be done to check for symptoms like nystagmus, a condition where the eyes make repetitive, uncontrolled movements. Other tests like the “HINTS” exam, which consists of three parts, are carried out. This exam aids clinicians in distinguishing between neurologic and vestibular causes for dizziness and imbalance.
There are different types of diseases that can cause vertigo and dizziness, such as Meniere’s disease, vestibular neuritis, and superior canal dehiscence. Each disease has its diagnostic criteria and can result from different situations. For example, an abrupt onset of vertigo lasting 24 hours or more may be indicative of vestibular neuritis, but the presence of additional symptoms like hearing loss could instead suggest labyrinthitis. Conditions like vestibular migraine and superior canal dehiscence have their criteria that involve factors such as the severity and duration of symptoms, as well as the presence of additional symptoms related to vision, hearing, or balance.
Given the wide variety of possible conditions, it’s crucial for clinicians to conduct a comprehensive evaluation, particularly when the cause of dizziness and imbalance appears to be neurological. Doctors utilise various assessment tools and algorithms to help pinpoint the likely diagnosis, taking into account the patient’s symptoms and their timing and triggers, as well as any relevant medical history or risk factors.
Testing for Evaluation of the Dizzy and Unbalanced Patient
If you’re feeling dizzy, your doctor will use your medical history and a physical exam to guide them in finding out why. Lab tests or imaging (like X-rays or scans) won’t usually diagnose dizziness by themselves. Instead, these tools help confirm what your doctor already suspects based on your symptoms and their examination.
Depending on your symptoms, your doctor may test your blood sugar using a quick, at-the-spot test, and do an EKG, which is a test that checks how your heart is working. Very low blood sugar (hypoglycemia) and heart rhythm problems (arrhythmias) can cause dizziness and be life-threatening if not treated quickly.
If your doctor thinks your dizziness might be due to a problem in your brain, you may get a head CT scan (a type of X-ray that gives detailed pictures of your brain), CTAs of the head and neck (special CT scans that show the blood vessels in these areas), and an MRI of the head (a scan that uses magnetic fields to create detailed images of your brain). You might also get an echocardiogram with a bubble study and carotid doppler ultrasounds—all tools that can help your doctor know if a stroke might be causing your symptoms. An echocardiogram, which is a type of ultrasound that shows how your heart is beating and pumping blood, can also help rule out heart problems as a cause of your dizziness.
In some cases, your doctor might need more specific tests and scans to diagnose your dizziness. For example, if they think your dizziness might be caused by a condition called superior canal dehiscence (a hole in the bone that separates your inner ear from your brain), they might order a high-resolution temporal bone CT scan. Or if they suspect vestibular neuritis (an inflammation of the balance nerve in your inner ear), a special MRI with a contrast dye could be used.
Treatment Options for Evaluation of the Dizzy and Unbalanced Patient
The treatment for vertigo (a sensation of feeling off balance) greatly depends on what’s causing the condition. Here are some ways these underlying conditions might be managed:
Benign Paroxysmal Positional Vertigo (BPPV), a condition which makes you feel like your surroundings are spinning, can be treated with medications like meclizine. The Epley maneuver, a series of head movements which can help reset the balance in your inner ear, might also be used. Vestibular rehabilitation, a type of physical therapy focused on improving balance and reducing problems related to dizziness, can also be an option.
When vertigo is caused by Meniere’s disease (a disorder of the inner ear), treatment usually starts with lifestyle changes like reducing the amount of salt in your diet and taking water pills (diuretics). In severe cases, you might need ear surgery or injections into the ear of medications like dexamethasone (a steroid) or gentamicin (an antibiotic).
Vestibular neuritis, an inflammation of the inner ear causing dizziness, is typically managed with supportive care and anti-nausea medicines. Therapies to suppress the spinning sensation, such as antihistamines, benzodiazepines, or dopamine antagonists can also be used. Other options include vestibular rehabilitation or possibly steroids.
Vestibular migraines, which result in dizziness and problems with balance, are usually managed by making lifestyle changes. However, medications like metoprolol (a beta-blocker), amitriptyline (an antidepressant), topiramate, valproic acid (used to control seizures), or flunarizine may be needed to prevent these migraines.
Superior canal dehiscence, a condition characterized by an opening (or dehiscence) in the bone that covers one of the inner ear canals, requires surgical intervention.
Idiopathic Perilymphatic fistulas, a condition where there’s an abnormal connection (fistula) leaking fluid from the inner ear into the middle ear, are typically managed by avoiding activities that could increase pressure in the ear and brain. If this condition has a known cause, surgery could be the treatment of choice.
Orthostatic Hypotension, a form of low blood pressure that happens when you stand up from sitting or lying down, can usually be improved by drinking more water, adjusting your medications, making changes to your lifestyle, or taking medications like Midodrine or mineralocorticoid medicines.
What else can Evaluation of the Dizzy and Unbalanced Patient be?
As we’ve mentioned before, many different things can cause dizziness, simply because there are numerous kinds of dizziness and it can be brought on by a myriad of things. When a patient feels as though they are about to faint or feels lightheaded, this could be a sign of a heart-related or an autonomic issue. For example, Orthostatic Hypotension occurs when a person gets up from lying or sitting, and their systolic blood pressure drops by at least 20 mmHg or the diastolic blood pressure drops by at least 10 mmHg. This might cause less blood flow to the brain, resulting in dizziness.
In addition to physical causes of dizziness, there are also multiple non-physical causes for this symptom. One of the most commonly noted causes is dizziness brought on by medications. Not all instances can be listed and discussed here, but it’s good to be aware of common classifications of drugs that might cause dizziness. These include:
- Blood pressure lowering drugs (antihypertensives)
- Antibiotics
- Water pills (diuretics)
- Pain and inflammation medication (NSAIDs)
- Medication for epilepsy (antiepileptics)
- Antidepressants
What to expect with Evaluation of the Dizzy and Unbalanced Patient
The outcome of treating dizziness completely depends on figuring out what’s causing it and how successfully it’s diagnosed. If the dizziness is caused by a peripheral issue which means it’s related to problems in your outer ear or nerves, the prognosis is generally better. However, if it comes from central causes (issues in the brain) or cardiac causes (heart-related issues), it can lead to higher chances of disease and death, particularly in older people.
Possible Complications When Diagnosed with Evaluation of the Dizzy and Unbalanced Patient
The biggest problem with dizziness is the increased risk of getting hurt, as it often leads to balance problems and falls.
Older people are particularly affected by dizziness, and sadly, they’re also more prone to serious injuries if they fall. A single fall can cause a disabling injury that can drastically alter a person’s life. Dizziness can also make it difficult for them to live independently and do their everyday activities.
- Increased chances of injury due to dizziness
- Balance problems leading to falls
- Older people being more susceptible to dizziness
- Severe injuries from falls, especially in older people
- Possibility of a life-changing injury from a fall
- Daily activity restriction due to dizziness
Preventing Evaluation of the Dizzy and Unbalanced Patient
If a patient is diagnosed with a less serious reason for feeling dizzy or having issues with balance, we must tell them about the more serious causes and symptoms to look out for. It’s also crucial to warn them that they might have a higher chance of getting hurt because their symptoms could make them more likely to fall.
