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Case 1
Male 40 years old,
" Linesman " (Hydro Ontario)
Referred for severe « dizzy spells »
PRESENT ILLNESS:
• First episode March 1997 (1h) and June 1997 (2h45)
• Daily DIZZY SPELLS, completely incapacitating,
since fall 97
• Stopped working 3 1/2 years ago
• 2 operations on the left ear in 1998
Ottawa
Case 1
Male 40 years old,
Past history: Negative
Rx: None
Functional inquiry: Negative
- No neurological symptoms
- Anxiety ++: fear of MS
Physical:
BP 130/84
HR 72
- ENT: Decreased hearing left ear
- Lungs: Normal
- Heart: S1-S2 normal; no murmur
- Neuro: Normal
Diagnosis: ???
Ottawa
" DIZZINESS " evaluation
Type I:
Vertigo
(Vestibular - Central Nervous System)
Type II:
Presyncope
(Cardiovascular)
Type III:
Walking disequilibrium
(Neuromuscular)
Type IV:
Light headedness (Plus non specific symptoms)
(Hyperventilation)
“Dizziness”
Type 1: VERTIGO
(temporary disequilibrium, rotating movement)
(Vestibular – Central nervous system)
History
Vertigo
VESTIBULAR
CENTRAL NERVOUS
SYSTEM
Symptoms - Signs:
Diplopia - Dysarthria
Bilateral Loss of vision
Hemiparesis - Hypoesthesia –
Ataxia – Cranial nerves
Nystagmus
Peripherical vestibular vertigo
Syndrome
Duration
Periodicity
Other
Labyrinthitis (Vest.N.)
2 days-2 weeks
0
0
Recurrent neuronitis
10 min - 20 hrs.
+ recurrent
0
Meniere’s disease
10 min – 20 hrs.
++ recurrent
Tinnitus
Hearing
Positional vertigo
< 1 minute
+++ recurrent
∆ Position
Dix Hallpike
Dix Hallpike
Dix Hallpike
POSITIVE
Positive
confirms the diagnosis
" Subjective ": suggests the diagnosis
" Objective ":
NEGATIVE
Négative
Does not rule out the diagnosis!
History
Epley’s manoeuver
Positional vertigo:
Inform the Patient
Inform the Patient
Day 1: vertical position - sleeping, head elevated
Normal activities afterward
Recurrence rate: 15% (Mobile otoliths)
Recurrence
Recurrence
Provoke vertigo in left -right decubitus (Identifies involved ear)
Repeat posterior canal manoeuvre (Patient himself)
Horizontal canal?: specific manoeuvre
Epley’s manoeuvre: FAILURE?
1) Wrong diagnosis
2) Wrong ear: cervical arthrosis
3) Wrong position: position “C”
4) Wrong “timing”: >1 1/2 min in each position
5) Wrong canal: horizontal canal? (other manoeuvre)
“Yes
we can
President Obama
“YES
WE!”CAN…!
President Obama
RECOMMANDATIONS:
“Clinical practice guideline:
Benign paroxysmal positional vertigo”
Otolaryngology-Head and neck Surgery; November 2008: 139: S47-S81
1) BPV diagnoses is certain: BPV clinical history + Dix-Hall Pike (+)
2) “Clinicians should not obtain radiographic imaging, vestibular testing,
or either in a patient diagnosed with BPV.”
3) “Clinicians should not routinely treat BPV with vestibular suppressant
medications such as antihistamines or benzodiazepines.” (no Serc)
4) “Clinicians should treat patients with posterior canal BPV with particle
repositioning maneuver.” (Epley)
5) Clinicians should revaluate the patient one month after repositioning
maneuver.
Case 4
Male 51 years old
ER 14/09/02: Presented 2 “dizzy spells” in the morning while
attending a conference
Presents with episodes of sudden “fatigue” or “weakness”
lasting 5 minutes for 10 years. Frequency 4 to 6 a year.
Has been treated for “hypoglycemia”.
Does not drive his car outside Montreal, fearing a spell while driving!
PAST HISTORY: Bilroth II
0 Rx
0 Alcohol
FUNCTIONAL INQUIRY: NEGATIVE (Neuro.- Cardio - Vascular)
PHYSICAL: BP 140/82 HR 72 reg.
OTHERWISE: NORMAL (Cardiovascular)
Presyncope
Presyncope = cardiovascular syncope
Syncope
System
Onset
Recovery
• Cardiovascular (90%)
Sudden
Sudden
•Neuro (epilepsy)
Sudden
Slow
•Metabolic
Slow
Slow
Presyncope
« MER »
Mechanical:
Aortic Stenosis - Left atrium Myxoma
Electric:
Bradycardia, tachycadia (supra. or ventricular)
AV block, prolonged sinus pauses...
Reflex:
Vagal - " cardiac reflex " - micturition - etc.
Presyncope
Initial evaluation
• History (sens. 95% - spec. 45%)
• Physical
• ECG
Opinion
Specific diagnosis
Normal heart/Sick heart
Presyncope
Normal
Heart
• Reflex: 70%
Sick
Heart
• Electric: > 70%
LV Dysfonction: ventricular
tachycardia
History
Reflex
Cardiac
Normal Heart
Sick Heart
• Past history
• Past History - Medication
• Onset: Young age
• Onset: Advanced age
• Position: Standing
• Position: Lying down
• Activity: Micturition - cough - etc.
• Stimulus: Pain - Discomfort
• Concomitant Symptoms:
– Nausea - Vomiting
– Yawning - Fatigue +++
• Concomitant Symptoms:
– Chest pains
– Palpitations
Physical
• BP Lying - Standing:
orthostatic hypotention
• BP < 90 mmHg or ∆ BP systolic: > 20 mmHg standing position
• Carotid sinus massage
• Aortic murmur
• Heart failure signs:
•
jugular veins - pulmonary rales
• S3(+) - Legs oedema
Electrocardiogram
• Sinus bradycardia
(diagnostic if < 40) - sinus pause > 3 seconds
• Bifascicular bundle branch block
• Second degree AV block (Mobitz I)
• Prolonged QT (> 500 milliseconds)
• WPW
• Brugada’s syndrome
• Supraventricular or ventricular tachycardia
• Myocardial infarction (old or new)
Specific Evaluation
Normal
Heart
Sick
Heart
• Ambulatory Monitoring
• Carotid Sinus Massage
• Loop Recorder
• Hospit - Ambul. Monitoring
• Echo - Treadmill
• Loop Recorder
• Tilt Table Test
• EPS
Case 3
Woman 48 years old
First evaluation: 21-08-2001
“Dizzy spells”: 2 types
• Vertigo < 1 min changing position, with nausea - vomiting
• (Left lateral decubitus) - recurrent since a car accident in 1993
Dix Hallpike (+) left: Epley left ear
• Presyncope - syncope (Sudden onset - recovery). Began at age 16
always in standing position, more often with stimulus (dysmenorrhea
and sometimes with nausea induced by BPV)
Case 3
Woman 48 years old (continued)
Second evaluation: 12-12-2001
Severe disabling “dizzy spells”
• Weakness – Light headedness - " spins in the head "
• Concentration difficulty
• Palpitations - Shortness of breath - " Lasts all day " followed by intense
fatigue feeling
• Since 08/ 01 no “vertigo” while changing position - no syncope
Past history - Functional inquiry - Physical : NORMAL
Diagnosis: ???
Provoke patient’s hyperventilation
• Identification by the patient of the cause of his symptoms
• Explanation of “respiratory alcalosis”
• Recognition of stopping the symptoms by breath holding
• Elaboration of strategies for stress management
“Break vicious circle”
« Dizziness, Syncope »
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History