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Dizziness, Vertigo, and Imbalance

  • Author: Hesham M Samy, MD, PhD; Chief Editor: Robert A Egan, MD  more...
 
Updated: Aug 07, 2015
 

Background

Dizziness and vertigo are among the most common symptoms causing patients to visit a physician (as common as back pain and headaches). Falling can be a direct consequence of dizziness in this population, and the risk is compounded in elderly persons with other neurologic deficits and chronic medical problems.

The overall incidence of dizziness, vertigo, and imbalance is 5-10%, and it reaches 40% in patients older than 40 years. The incidence of falling is 25% in subjects older than 65 years. A report reviewing presentation to US emergency departments (EDs) from 1995 through 2004 indicated that vertigo and dizziness accounted for 2.5% of presentations.[1] The estimated number of 2011 US ED visits for dizziness or vertigo was 3.9 million.[2]

A report using data from the Swedish National study on Aging and Care (SNAC) found that in patients younger than 80 years, the prevalence of falls was 16.5% and that of dizziness was 17.8%, whereas in patients older than 80 years, the prevalence of falls was 31.7% and that of dizziness was 31.0%.[3] The younger patients tended to have more specific predictive factors, whereas the older patients tended to have more general ones.

Mild hearing loss is the most common disability worldwide. The incidence of hearing loss is 25% in people younger than 25 years, and it reaches 40% in persons older than 40 years. About 25% of the population report tinnitus.

Vertigo, dizziness, tinnitus, and hearing loss are typically associated with inner-ear diseases as opposed to central nervous system (CNS) diseases. Migraine is more prevalent (10%) than Ménière disease (< 1%). About 40% of patients with migraine have vertigo, motion sickness, and mild hearing loss. Therefore, differentiating migraine from primary inner-ear disorders is sometimes difficult.

Primary care physicians evaluate most cases of dizziness and related symptoms. Their role and that of neurologists in this setting has increased over the past decade. This article outlines the clinical approach to dizziness with emphasis is on differentiating peripheral from central dizziness and on office management of the most common diseases. It also addresses indications for referral to an otolaryngologist or neuro-otologist and for specialized auditory and vestibular testing.

The patient’s history and findings on vestibular examination are critical in identifying underlying causes. Auditory, vestibular, complementary blood and radiologic tests help in narrowing the differential diagnosis and tailoring treatment. Vestibular tests should be ordered after careful history taking and examination because they do not provide the clinician with diagnostic information.

Most patients are treated medically and with vestibular rehabilitation. In addition to the appropriate medical and rehabilitative managements, safety must be emphasized and discussed with patients and their families. Occupational and physical therapists are helpful in addressing home safety and providing a structured balance-rehabilitation program.

For patient education resources, see the Brain and Nervous System Center and the Ear, Nose, and Throat Center, as well as Benign Positional Vertigo, Dizziness, Ménière Disease, and Tinnitus.

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Etiology

The most common causes of peripheral vertigo include BPPV, vestibular neuronitis, Ménière disease, and immune-mediated inner-ear disease. The most common cause of central dizziness is migraine, frequently referred to as vestibular migraine or migraine-associated dizziness. Other central causes include demyelination, acoustic tumors, and brainstem or cerebellar vascular lesions.

There are numerous inner ear pathologies that are the direct result of disrupted ion homeostasis. While the initial cause may be something else (eg, inflammation, ototoxicity, noise), the ultimate impact on the ear is the interference of some ion or water transport mechanism. Thus, impaired ion homeostasis is essentially the final common pathway for many inner ear diseases.[4]

In a retrospective review of 907 adults presenting to an academic ED from 2007 through 2009 with a primary complaint of dizziness, vertigo, or imbalance, 49 patients had a serious neurologic diagnosis (eg, cerebrovascular disease).[5] Benign causes of dizziness included peripheral vertigo (294 cases) and orthostatic hypotension (121 cases). Factors associated with serious diagnoses included abnormalities on focal examination, age greater than 60 years, and imbalance as the chief complaint.

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Epidemiology

The overall incidence of dizziness, vertigo, and imbalance is 5-10%, and it reaches 40% in patients older than 40 years. The incidence of falling is 25% in subjects older than 65 years. A report reviewing presentation to US emergency departments (EDs) from 1995 through 2004 indicated that vertigo and dizziness accounted for 2.5% of presentations.[1] The estimated number of 2011 US ED visits for dizziness or vertigo was 3.9 million.[2]

A report using data from the Swedish National study on Aging and Care (SNAC) found that in patients younger than 80 years, the prevalence of falls was 16.5% and that of dizziness 17.8%, whereas in patients older than 80 years, the prevalence of falls was 31.7% and that of dizziness 31%.[3] The younger patients tended to have more specific predictive factors, whereas the older patients tended to have more general ones.

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Contributor Information and Disclosures
Author

Hesham M Samy, MD, PhD Medical Director, Hearing and Balance Clinic, Egypt

Hesham M Samy, MD, PhD is a member of the following medical societies: American Auditory Society, Association for Research in Otolaryngology, American Academy of Audiology, Egyptian Society of Otorhinolaryngology

Disclosure: Nothing to disclose.

Coauthor(s)

Mohamed A Hamid, MD, PhD Founder and Medical Director, The Cleveland Hearing and Balance Center; Clinical and Adjunct Professor of ENT, Case-MetroHealth, Medical College of Virginia, and Ain Shams University, Egypt

Mohamed A Hamid, MD, PhD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Otological Society, American Neurotology Society

Disclosure: Nothing to disclose.

Marc Friedman, DO, FAAN Consultant in Otoneurology, The Cleveland Hearing and Balance Center

Disclosure: Nothing to disclose.

Chief Editor

Robert A Egan, MD Director of Neuro-Ophthalmology and Stroke Service, St Helena Hospital

Robert A Egan, MD is a member of the following medical societies: American Academy of Neurology, American Heart Association, North American Neuro-Ophthalmology Society, Oregon Medical Association

Disclosure: Received honoraria from Biogen Idec for speaking and teaching; Received honoraria from Teva for speaking and teaching.

Acknowledgements

Marc Friedman, DO Chief of Neurology, Parma Hospital, Consultant, Department of Neurology-Neurotology, Cleveland Hearing and Balance Center

Disclosure: Nothing to disclose.

Spiros Manolidis, MD Associate Professor of Otolaryngology and Neurological Surgery, Columbia University

Spiros Manolidis, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Auditory Society, American Head and Neck Society, American Medical Association, Canadian Society of Otolaryngology-Head & Neck Surgery, Society of University Otolaryngologists-Head and Neck Surgeons, and Texas Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Reference Salary Employment

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Example of Frenzel goggles used for evaluation in neuro-otology clinic.
Typical example of computer and headgear equipment used in neuro-otology clinic.
Table. Features Differentiating Peripheral from Central Nystagmus
System or Reflex Peripheral Lesions Central Lesions
Oculomotor Spontaneous nystagmus with eyes closed Saccades (velocity, accuracy), internuclear ophthalmoplegia, saccadic pursuit, gaze-evoked nystagmus
Vestibulo-ocular reflex (VOR) Nystagmus without fixation, nystagmus after head shaking, eye-head mismatch, unilateral and bilateral vestibular loss Hyperactive VOR, FFS, positional nystagmus, bilateral vestibular loss
Vestibulospinal reflex (VSR) Cautious gait; normal spontaneous movement; normal, spontaneous, and correct movement Wide-based gait, minimal spontaneous movement
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