CHAPTER 12 Dizziness

Dizziness is a symptom of a variety of conditions, including vertigo, lightheadedness, and loss of balance. In children the symptom is frequently a new sensation, and is usually poorly defined. Family members often state that the child has trouble walking or is irritable or that the child’s behavior is different. Older children, like adults, tend to categorize everything from lightheadedness and unsteadiness to spinning and falling as dizziness. This chapter is limited to the discussion of vertigo. Patients with vertigo have the sensation of either their body moving (subjective vertigo) or their environment moving around them (objective), usually described as a spinning or rotary motion.

The sensation of balance depends on interconnections among the visual, vestibular, and sensory systems. Vertigo can be thought of as a disruption of one of these three systems. Vertigo can be central, involving the brainstem or cerebellum; be peripheral, involving the inner ear or vestibular apparatus; or result from systemic causes.

Central vertigo is generally either neoplastic or vascular in origin, although any central nervous system disorder, such as multiple sclerosis, that disrupts the pathway between the vestibular apparatus and the brain can result in dizziness. Common vascular causes include recurrent intermittent vascular insufficiency, transient ischemic attack, or stroke. Migraine headache is a vascular-related central cause of vertigo.

Peripheral vertigo is typically produced by disruption of the inner ear or vestibular apparatus. Common causes include idiopathic etiologies, vestibular nerve inflammation, inner ear inflammation or infection, or tumor. Systemic origins include psychogenic, cardiovascular, and metabolic causes. Mixed or other causes include trauma and ototoxicity.

Diagnostic reasoning: focused history

What does the patient mean by dizziness?

Key questions

Can you describe how you feel when you are dizzy?

Do you feel as though you or the room is spinning?

Do you feel as though your balance is off?

Do you feel like you are about to faint?

Sensation

Vertigo produces the sensation of either the patient spinning or the environment spinning around the patient. Some patients describe a sensation of their body moving forward or accelerating.

Patients can also report loss of equilibrium accompanying the vertigo. Neoplasms and progressive vestibule loss typically produce a change in vestibular function that is slow in onset and manifested as imbalance.

Loss of balance and lack of coordination in the absence of vertigo can be the result of degenerative, neoplastic, vascular, or metabolic disorders. With these symptoms, look for other nervous system abnormalities. Imbalance can also occur in adults as a result of impaired sensory input, either visual or kinetic, such as occurs with peripheral neuropathy.

Children who have a vague sense of unsteadiness can have peripheral neuropathy or a dysfunction of the vestibular or cerebellar system, whereas children who report a feeling of motion are more likely to have an abnormality of the vestibular system.

In contrast to dizziness and imbalance, lightheadedness is the feeling that one is about to faint (near syncope). Some patients describe it as a generalized weakness and the feeling that they are about to pass out if they do not lie down. True syncope, or a sudden transient loss of consciousness with concurrent loss of postural tone, always has a spontaneous recovery (see Chapter 30).

Orthostatic hypotension is a frequent cause of lightheadedness and is most common in elderly persons, occurring as a result of abnormal regulation of blood pressure. Neurological causes of orthostatic hypotension are less common and are usually accompanied by neurological findings.

In both children and adults, a report of lightheadedness can accompany anemia, hypoglycemia, or hyperventilation syndrome.

Does the vertigo result from a systemic cause?

Key questions

What other medical problems do you have?

Would you describe yourself as anxious or nervous?

Do the episodes occur with any specific activity or movement?

Other medical problems

Cardiovascular problems are a common cause of vertigo that is systemic in origin. The mechanism of vertigo can include vasomotor instability that decreases systemic vascular resistance, venous return, or both; severe reduction in cardiac output that obstructs blood flow within the heart or pulmonary circulation; or cardiac dysrhythmia that leads to transient decline in cardiac output. Patients with hypertension can experience vertigo while taking antihypertensive or potassium-depleting medications or as a result of postural hypotension.

Anxiety

Psychogenic dizziness is one of the most common causes of vertigo. Symptoms tend to be vague and can include other symptoms such as fatigue, fullness in the head, lightheadedness, and a sense of feeling apart from the environment. Patients can describe themselves as anxious or nervous. Patients can also have other psychiatric diagnoses. Stressors and tensions affecting children, such as divorce, custody battles, and day care, can cause vertiginous-like symptoms in the older child. Anxiety with hyperventilation can cause lightheadedness in a child, who then reports the symptom as dizziness.

Relationship to activity or movement

Dizziness when turning, especially when rolling over in bed, is usually due to vertigo. However, unsteadiness while walking is often considered to be disequilibrium, which can be caused by many factors. Dizziness on standing can be the result of decreased cerebral perfusion.

In children, attacks that occur with sudden changes of posture can be the result of hypotension, vascular disease, or positional vertigo.

Is the vertigo central (brainstem or cerebellar) or peripheral (vestibular) in origin?

Key questions

Do you have migraine headaches?

Do you have other symptoms that bother you?

Do you have nausea and vomiting?

When do the episodes occur?

Headaches

Headache is a vascular-related cause of central vertigo. Approximately one third of patients with migraine headaches experience vertigo. The vertigo can appear as an aura, occurring during the headache, or can occur separately. Some of these persons have additional symptoms that are consistent with vertebrobasilar circulation abnormalities. Migraine both with and without headache is recognized as a source of dizziness in children.

Other symptoms

Patients with central vertigo nearly always have neurological symptoms, such as double vision, facial numbness, and hemiparesis.

Cerebellar causes can produce other symptoms, such as loss of balance, that closely resemble those of a peripheral disorder; therefore neurological examination findings are important in differentiating the two. Pay particular attention to reports of motor dysfunction or lack of coordination.

Vertigo that is peripheral in origin does not produce additional neurological symptoms or signs. If the patient has nausea and vomiting, suspect a peripheral vestibular apparatus problem rather than a central cause. Nausea and vomiting are common with vestibular neuronitis and labyrinthitis and occur less often with brainstem lesions.

Timing

Vertigo that occurs on first arising in the morning is usually the result of a vestibular disorder. Vertigo that occurs while turning over in bed is characteristic of benign paroxysmal positional vertigo (BPPV) (peripheral).

What do characteristics of the episodes tell me?

Key questions

How long do the episodes of dizziness last?

Is the onset sudden or gradual?

Do you have any hearing loss?

Do you have ringing in your ears?

Duration of episodes

Episodes that last a few seconds are typically caused by BPPV and are usually elicited by a rapid head movement. Episodes lasting minutes to hours can be caused by Meniere disease or recurrent vestibulopathy.

Episodes that last days or weeks are commonly produced by vestibular neuronitis. Patients can feel better when they lie completely still. Stroke can also produce long-lasting episodes. The two can be differentiated based on medical history and physical examination findings.

Sudden onset of prolonged dizziness (lasting ≥60 minutes) suggests central causes, such as infection, brainstem infarction, inflammation, or vestibular hemorrhage. Trauma can also produce prolonged dizziness.

The child with chronic recurrent dizziness (episodes lasting <30 minutes) can have central causes, such as seizure problems or migraine headache. The cause can also be peripheral, such as BPPV. Chronic persistent episodes can indicate brainstem lesions, anemia, diabetes, thyrotoxicosis, or a psychosomatic disorder.

Onset

A gradual onset of dizziness is typical of an acoustic neuroma or other neoplastic process that is slow-growing. BPPV can also have a gradual onset.

Acute or sudden onset of vertigo is characteristic of labyrinthitis, Meniere disease, stroke, or vertebrobasilar causes.

Recurrent episodes are typical of BPPV, vertebrobasilar causes, and Meniere disease.

Hearing loss and tinnitus

A classic triad of symptoms—vertigo, hearing loss, and tinnitus—defines Meniere disease. Patients can also report a sensation of fullness in the ears. The hearing loss can be unilateral or bilateral. Patients with secondary or early tertiary syphilis can have symptoms identical to those of Meniere disease. Tinnitus, hearing loss, and pain in the ear point to lesions in the inner ear or cranial nerve VIII.

Patients with labyrinthitis and perilymphatic fistulas can also experience hearing loss but without tinnitus. An acoustic neuroma will produce unilateral hearing loss with tinnitus. Patients with recurrent vestibulopathy usually do not report hearing loss.

What else should I consider?

Key questions

What medications are you taking?

Are you now or have you recently been ill?

Have you had any recent injury to your head? Did you have dizziness before the head injury?

Have you had any previous ear surgery?

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