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Download Benign Paroxysmal Positional Vertigo (BPPV)
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Vertigo Dr Tharaka Chandrakumar GPST2 Dr Emma Humphreys GPST1 The Mill Medical Practice, Godalming Case discussion Case discussion • 58 yr old lady Case discussion • 58 yr old lady • Awoke feeling room was spinning Case discussion • 58 yr old lady • Awoke feeling room was spinning • Vomited twice Case discussion • • • • 58 yr old lady Awoke feeling room was spinning Vomited twice Seemed anxious Case discussion • • • • • 58 yr old lady Awoke feeling room was spinning Vomited twice Seemed anxious Slightly unsteady on her feet Case discussion • • • • • • 58 yr old lady Awoke feeling room was spinning Vomited twice Seemed anxious Slightly unsteady on her feet Hyperventilating Case discussion • • • • • • • 58 yr old lady Awoke feeling room was spinning Vomited twice Seemed anxious Slightly unsteady on her feet Hyperventilating No fever, but had sore throat Case discussion • • • • • • • • 58 yr old lady Awoke feeling room was spinning Vomited twice Seemed anxious Slightly unsteady on her feet Hyperventilating No fever, but had sore throat Slight difficulty swallowing Case discussion On examination • Red throat • Positionally induced nystagmus was sustained Case discussion On examination • Red throat Case discussion On examination • Red throat • Positionally induced nystagmus was sustained “I felt dizzy Doctor” “I felt dizzy Doctor” Light-headedness • Presyncope, eg transient hypotension • Disequilibrium of elderly • Anxiety or hyperventilation “like I’d just got off a roundabout” “like I’d just got off a roundabout” Vertigo • illusory sense of movement or orientation • disorder of labyrinth or brainstem “like I’d just got off a roundabout” Vertigo • illusory sense of movement or orientation • disorder of labyrinth or brainstem But which? Differential Diagnosis Peripheral Central Differential Diagnosis Peripheral – Benign Positional Paroxsymal Vertigo (BPPV) – Acute Vestibular Neuritis – Meniere’s Disease Central Differential Diagnosis Peripheral – Benign Positional Paroxsymal Vertigo (BPPV) – Acute Vestibular Neuritis – Meniere’s Disease Central – Brainstem stroke / tumour / demyelination – Vertiginous Migraine (dx of exclusion) History • Headache? History • Headache? • Hearing? History • Headache? • Hearing? • Tinnitus? History • • • • Headache? Hearing? Tinnitus? Positional vertigo? History • • • • • Headache? Hearing? Tinnitus? Positional vertigo? Vision? History • • • • • • Headache? Hearing? Tinnitus? Positional vertigo? Vision? Swallowing? Examination • Cranial nerves Examination • Cranial nerves • Eye movements (?nystagmus) Examination • Cranial nerves • Eye movements (?nystagmus) • Ears Examination • • • • Cranial nerves Eye movements (?nystagmus) Ears Hearing Examination • • • • • Cranial nerves Eye movements (?nystagmus) Ears Hearing Gait (?unsteady) Examination • • • • • • Cranial nerves Eye movements (?nystagmus) Ears Hearing Gait (?unsteady) Coordination Examination • • • • • • • Cranial nerves Eye movements (?nystagmus) Ears Hearing Gait (?unsteady) Coordination Head Thrust test or Hallpike Manouevre (positional provocation tests) Red flags • • • • Neurological symptoms or signs New headache (esp occipital) Acute deafness Vertical nystagmus Anatomy and pathophysiology Tharaka Chandrakumar Objectives • Labyrinthine cavity (inner ear) - osseous labyrinth - membranous labyrinth • Membranous labyrinth - endolymph - vestibular - cochlear - semicircular canals • Hair cells • Pathology Middle and inner ear Vestibule Bony Vestibule - lateral wall - medial wall - roof - posterior - anterior Membranous vestibule - utricle (close to semicircular canals - saccule (close to cochlea) Hair cells within membranous vestibule Kinetic labyrinth; semicircular canals Pathology • • • • • Meniere’s disease Meniere’s syndrome BPPV Vestibular neuritis Labyrinthitis ; viral/bacterial Acute Vestibular Neuritis Acute Vestibular Neuritis • • • • • • Common ?preceding viral infection Sustained vertigo Unsteady gait Unidirectional horizontal nystagmus Positive ocular reflex (“head thrust”) Halmagyi Head Thrust Halmagyi Head Thrust • http://www.youtube.com/watch?feature=play er_detailpage&v=CZXDNLLGG8k Acute Vestibular Neuritis • • • • Self-limiting Acute illness up to a week Several weeks to resolve completely Symptomatic relief Prochlorperazine (Stemetil) • Vestibular rehab exercises BD Benign Paroxysmal Positional Vertigo (BPPV) • • • • • • • Common Female: male = 2:1 Brief episodes (<1 min) Specific positions Posterior canal common Intense vertigo +/- nausea Prolonged dizziness may last hours Benign Paroxysmal Positional Vertigo (BPPV) Risk Factors: • Advancing age • Head trauma • Migraine • Inner ear disease • General anaesthesia BPPV – How to diagnose • Hallpike Manouevre • http://www.youtube.com/watch?v=ttgaqpIv_ wM • Typical rotatory nystagmus • Careful explanation BPPV – How to Treat • Epley Manoeuvre • http://www.youtube.com/watch?v=LsPURdtM jac BPPV – How to Treat • Semont Manoeuvre Final Part of Case • More careful questioning elicited facial numbness and slight clumsiness of left hand • On admission to hospital the patient; • Sustained nystagmus on positioning Take-Home Messages • • • • Vestibular problems common Ensure no red flags Vestibular sedatives short term use only Learn Hallpike and Epley or Semont AKT QUESTIONS QUESTION 1 • A 45-year-old man presents with dizziness and rightsided hearing loss to his GP. Which one of the following tests would most likely indicate an acoustic neuroma? • • • • A.Jerky nystagmus B.Left homonymous hemianopia C.Tongue deviated to the left D.Fasciculation of the tongue E.Absent corneal reflex QUESTION 2 • Which one of the following medications is most useful for helping to prevent attacks of Meniere's disease? • • • • A.Promethazine B.Prochlorperazine C.Betahistine D.Chlorphenamine E.Cinnarizine QUESTION 3 • Which one of the following statements regarding Meniere's disease is correct? • • • • A.More common in patients from the Indian Subcontinent B.Symptoms resolve in the majority of patients after 6-12 months C.It is very rare that patients develop permanent hearing loss D.More common in children E.Approximately equal incidence in males and females References • Barraclough & Bronstein Vertigo:diagnosis in general practice, BMJ 2009; 339:b3493 http://www.bmj.com/content/339/bmj.b3493 • Bronstein BPPV - Diagnosis and Physical Treatment, ACNR Vol 5 No 3, July/Aug 2005 http://www.acnr.co.uk/pdfs/volume5issue3/v 5i3revbbpv.pdf references • Anatomy and Physiology, 7th edition, Seeley, Stephens, Tate 2005 • http://projects.cbe.ab.ca/Diefenbaker/Biology/Bio%20Website %20Final/notes/nervous_system/9_the_ear.html • Clinical Medicine 5th edition, Kumar and Clark • Vertigo: A Review of Common Peripheral and Central Vestibular Disorders Timothy L. Thompson, MD and Ronald Amedee, MD Ochsner J. 2009 Spring; 9(1): 20–26. • http://emedicine.medscape.com/article/1948907-overview • Vertigo, K.Barraclough, A Bronstein, Diagnosis in General practice, BMJ Sept 2009 Vol 339 • Lateral medullary infarct, West Indian med. j. vol.61 no.7 Mona Oct. 2012 Manoeuvres • Epley http://www.youtube.com/watch?v=59EIKztATiw • Semont http://www.youtube.com/watch?v=pg_SjWG-L9c • Brand-Daroff exercises http://www.youtube.com/watch?v=NWuEJxJ5s7c • Have a practice!
