Download Dizziness

Dizziness
A Patient Complaint That Can
Make the Doctor’s Head Spin.
What Is Dizziness ?
• A non-specific term used to describe a
number of signs and symptoms
– Unsteadiness
– Giddiness
– Light-headed
– Disequilibrium
– Vertigo
Focus of Diagnostic Workup
• Vertigo – auditory and Vestibular system
• Near-faint dizziness– cardiovascular
system
• Psychophysiological dizziness - psychiatric
• Hypoglycemic dizziness- metabolic
assessment
• Disequilibrium – peripheral nerves, spinal
cord, inner ear, vision, CNS
Dizziness, Hearing Loss, and
Tinnitus/ Baloh,R.W
oC sivaD.A.F,1998
Vertigo
• An illusion of movement in space
– Rotation (most common)
– Linear
– Tilt
History of the Dizzy Patient
• Detailed description of dizziness
• Differentiate vertigo from non-vertigo
• Determine onset, length, and if recurrent
• Associated neurological or systemic signs
• Any hearing loss?
• Current medications
• Differentiate Peripheral vs. Central cause
Peripheral or Central Cause?
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Peripheral
Labyrinth or
vestibular nerve
dysfunction
Recurrent
Nystagmus-horizontal
Position change
Moderate to severe
vertigo
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Central
Cerebellum or brain
stem dysfunction
Continuous
Nystagmus-vertical
Mild vertigo
Non-positional
Differential Diagnosis and
Management for the Chiropractor,
Aspen Publishers, Inc 2001
Peripheral Vestibular Disorders
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BPPV
Labrynthitis
Meniere’s disease
Acoustic Neuroma
Motion sickness
Cervicogenic
Perilymphatic fistula
• Vestibular neuronitis
• Semicircular canal
•
infection
Semicircular canal
water penetration
Assessment of the dizzy patient,
Australian Family Physician Vol.
2002 tsuguA ,8 .oN ,31
Central Vestibular Disorders
• Brain stem lesion
• Basilar artery
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migraine
TIA
Stroke
MS
Cerebellar lesions
• Metastatic Tumor
• Meningioma
Assessment of the dizzy patient,
Australian Family Physician Vol.
2002 tsuguA ,8 .oN ,31
Anatomic and Physiologic
Components of Balance
• Vestibular – labyrinth, vestibular nuclei
• Visual – CN III, IV, VI
• Proprioceptive – upper cervical ms and
joints
Types of Vertigo
• Subjective vertigo
– The patient feels that
they are spinning
• Objective vertigo
– The patient feels still
but objects appear to
be moving around
them
Causes of Vertigo
• Ear disease
• Toxic conditions (alcohol, food poisonings)
• Postural hypotension
• Infectious disease
• Cervicogenic
• Disease of the eye or brain
• Psychological
Vertigo
Episodic
positional
Episodic
Non-positional
Non-episodic
Non-positional
Schimp D. A diagnostic algorithm
for the dizzy patient Chiropractic
Technique, vol 1994 voN )4(6
Episodic
positional
Benign
positional
Cervicogenic
Vertebobasilar
ischemia
sudden
sudden
gradual
Fades 30-60
seconds
persists
progression
Benign Paroxysmal Positional
Vertigo (BPPV) 20%
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Brief episodes – recurrent
Moderate to severe
Associated with head position
Gradually diminishes over a month or two
No hearing loss
Latency or delayed onset of S/S
Positive Nylen-Barany maneuver
Caused by otoconia (debris) floating in PSC
Nylen-Barany AKA Dix-Hallpike
• Patient seated, head turned 45 degrees
• Patient quickly lays supine
• Latency period, then horizontal or
rotational nystagmus
• Nystagmus decreases after 10-20 seconds
• Affected ear is the side head is turned
toward when nystagmus and vertigo
occurs
Nylen-Barany Maneuver
Dizziness, Hearing Loss, and
Tinnitus R.W. Baloh, F.A. Davis
Company 1998
Treatment Options for BPPV
• Epley’s
• Sermont’s
• Habituation exercises (Brandt-Daroff)
• Cervical adjusting
Modified Epley’s Maneuver
• Patient placed supine with head turned 45
degrees toward the affected ear (30 sec.)
• Dr. turns head 90 degrees so affected ear
is up. (30 sec.)
• Patient rolls on to side, head looking
toward the floor (30 sec.)
• Patient is lifted into sitting position
• Procedure is repeated until no nystagmus
Modified Epley Maneuver
Dizziness,Hearing Loss, and
Tinnitis R.W. Baloh, F.A. Davis
Company 1998
Sermont’s Maneuver
• Patient can be instructed to do this at
home.
• Patient turns head 45 degrees away from
the affected side
• Quickly lays down maintaining head
position (4 minutes)
• Brought up and placed on other side with
same head position. (4 min) Sit up normal
Sermont’s Maneuver
Archives Otolaryngol Head Neck
Surgery, Vol 1993 ,452p ,119
Post Maneuver Instructions
• Patient waits 10 min. before leaving office.
• Other person drives them home.
• Sleep half-reclined 2-3 days.
• Avoid laying on bad side.
• Avoid extreme head extension for 2-3
days
Cervicogenic Vertigo
• Hx of neck trauma, muscle spasm
• Limited cervical ROM
• Positive chair rotation test (Fitz-Ritson)
• Patients may complain of dysequilibrium
(tilt) more than rotational vertigo
• Overstimulation of upper cervical
proprioceptors
• May overlap BPPV or Meniere’s disease
Vertebrobasilar Insufficiency
TIA’s
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Vertigo with associated Neurological signs
Diplopia
Ataxia
Drop attacks
Dysarthria
Paralysis/weakness/Numbness
Headache
Risk factors (HTN, Diabetes, Coronary Disease)
Episodic non-positional
Meniere’s
Perilymph fistula
Meniere’s Disease
• Sudden and recurrent (paroxysmal) attack
of severe vertigo (4th leading cause)
• Low-tone hearing loss
• Low-tone tinnitis
• Sense of fullness in the ear
• Vertigo lasts for hours to a day then burn
out
• Hearing loss may progress
Cause of Meniere’s
• Overproduction or retention of endolymph
• Possible autoimmune etiology
• Head trauma
• Previous infection
• Pregnant females are more prone
Management of Meniere’s
• Salt-restriction diet
• Diuretic therapy
• Cervical adjusting (overlaps with
cervicogenic vertigo
Perilymphatic Fistula
• Hx of barometric pressure changes
(airplane or weight lifting)
• Opening develops between middle and
inner ear (oval window rupture)
• Rare cause of vertigo
• Bearing down reproduces s/s
• Tx - surgical
Non-episodic
Non-positional vertigo
Labyrinthitis
Acoustic neuroma
Cerebral hemorrhage
Labyrinthitis
• Sudden severe vertigo that last days to
weeks
• Maybe nausea and vomiting
• Viral infection - no hearing loss
• Bacterial infection hearing loss
Acoustic Neuroma
• Mild but constant hearing loss
• Dizziness with possible tinnitis
• Gradual onset
• Benign schwannoma of 8th CN
• Other CN findings as tumor grows
• Surgical excision
Cerebral Hemorrhage
• Sudden vertigo and nausea
• Vomiting associated with a headache
• Inability to stand
• Nystagmus, nuchal rigidity, facial paralysis,
ataxia, dysrythmia, small reactive pupils
• Hx of HTN in 2/3 of patients
When to refer to a specialist
• Serious vertigo that is disabling
• Ataxia out of proportion to vertigo
• Vertigo longer than 4 weeks
• Changes in hearing
• Vertical nystagmus
• Focal neurological signs
• Systemic disease or psychological origin
Australian Family Physician Vol.
2002 tsuguA ,8 oN ,31