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.
Dizziness, including vertigo, affects about 15% to more than 20% of adults yearly in large population-based studies. [1] 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. [2] The estimated number of 2011 US ED visits for dizziness or vertigo was 3.9 million. [3]
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%. [4] The younger patients tended to have more specific predictive factors, whereas the older patients tended to have more general ones.
Etiology
The most common causes of peripheral vertigo include benign paroxysmal positional vertigo (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. [5]
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). [6] 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.
Epidemiology
Dizziness, including vertigo, affects about 15% to more than 20% of adults yearly in large population-based studies. [1] 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. [2] The estimated number of 2011 US ED visits for dizziness or vertigo was 3.9 million. [3]
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%. [4] The younger patients tended to have more specific predictive factors, whereas the older patients tended to have more general ones.
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Example of Frenzel goggles used for evaluation in neuro-otology clinic.
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Typical example of computer and headgear equipment used in neuro-otology clinic.
Tables
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, failure of fixation suppression (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 |
