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Dizziness Prof. H. Almuhaimed Objective to be addressed: Difference between dizziness and vertigo. • Diagnostic approach to True vertigo. • Characteristics of peripheral vertigo. • Characteristics of central vertigo. • Treatment Considerations. Patients refer to Dizziness as: • Light headedness • Faintness • Giddy • Imbalanced • “out-of-it” Most dizzy patients can be placed in to one of four categories: 1- True Vertigo (50%) 2-Pre-syncope: Transient sensation that a faint in about to occur. • May present as nausea ,weakness, or change in vision. • Transient. 3-Dysequilibrium: A sensation of imbalance when standing or walking. • No illusion. • No sense of faintness. 4-Vague lightheadedness: Holds the reminder of symptoms of dizziness (which can’t fit to the other categories) 1.Psychiatric disorders, 2.Hyperventilation syndrome 3.Encephalopathies What is Vertigo? True vertigo: Defined as an “illusion” or “hallucination” of movement. • Both vertigo and dysequilibrium imply a loss of balance, but vertigo involves a sense of motion. How do we maintain equilibrium? Visual input equilibrium Proprioceptiual Vestibular input input labyrinths. Anatomy: Semicircular canals Semicircular Canals (SCC) Cupula Horizontal Anterior Posterior End organ receptors Endolymph Anatomy: Utricle Utricle Connected to SCC Contains endolymph Otoliths (otoconia) Calcium carbonate Attached to hair cells Macule (end organ) Vestibular system Tells brain which way the head moves without looking SCC: angular acceleration Utricle: linear acceleration How can we clinically evaluate the patient with vertigo? CN VIII labyrinth Cerebellum (Vestibular portion) Vertigo Brainstem Vestibular nuclei Vertigo Central peripheral Key points in History: •Is true vertigo present? •Are there associated neurologic symptoms? •What is the pattern of onset ? •What is the duration of the symptoms? •Have there been auditory symptoms? •Are there other associated symptoms? •What medications is the patient taking? •What is the patient’s past medical history? •Any recent or remote head or neck injury? Key points in the physical examination: •Vital signs •Ear exam •Eye exam •Positional testing •Neurological exam (including gait) SPINNED PERIPHERAL CENTRAL Sudden (Onset) Positional Intensity Nausea/Diaphoresis Yes Yes Severe Slow, gradual No Ill defined Frequent Infrequent Nystagmus Torsional/horizontal Vertical Ear (hearing loss) Can be present Absent Duration CNS signs Paroxysmal Absent Carvalho et al. Constant Usually present CTU , Oct, 2004 Peripheral vertigo: •Approximation 85% of ED patients with vertigo. •Due to dysfunction of one of vestibular organs. •Asymmetry of input •Sensation of rotation •Associated with nausea, pallor and diaphoresis. Differential Diagnosis Benign paroxysmal positional vertigo (BPPV) (50%) Vestibular neuritis Labyrinthitis (suppurative, serous, toxic, chronic) Meniere’s disease FB in ear canal A cute otitis media Perilymphatic fistula. BPPV Benign Paroxysmal Positional Vertigo Age 60- 70 (F:M 2:1) Head trauma Characteristic story Turn head After a few seconds delay, vertigo occurs Resolves within 1 minute if you don’t move If you turn your head back, vertigo recurs in the opposite direction “BPPV” “B” = Benign Not a brain tumor Can be severe and disabling “BPPV” “P” = Paroxysmal Episodic, not persistent Helpful feature in the differential diagnosis “BPPV” “P” = Positional Occurs with position of head Turning over in bed Looking up Bending over “BPPV” “V” = Vertigo An illusion of motion “The room is spinning” Other descriptions Rocking Tilting Somersaulting Descending in an elevator Pathophysiology of BPPV Otoliths become detached from hair cells in utricle Inappropriately enter the posterior semicircular canal . Parnes LS, McClure JA. Laryngoscope 1992;102:988-92. Physiology Normal situation As one turns head to the right Endolymph moves SCC receptors fire “head turning right” Stop turning head endolymph stops moving SCC receptors stop firing “head has stopped moving” Pathophysiology of BPPV BPPV Stop turning head otoliths keep moving drag endolymph receptors continue to fire inappropriately “head is still moving” Eyes “head is NOT moving” Brain room must be spinning in the opposite direction Dix-Hallpike Maneuver •The diagnosis of BPPV is generally from the history. •Can confirm the diagnosis of BPPV •First described by Dix and Hallpike in 1952. •Also called the Nylen-Bárány, Bárány, Nylen, or Hallpike maneuver Dix-Hallpike Maneuver They include: 1- Nystagmus 2- Provocative head position 3- Brief latency to symptoms after change in position 4- Short duration of attack 5- Fatigability of nystagmus on repeat testing 6-Reverse of nystagmus on returning to upright position. Lab studies In a straightforward case, no lab studies are needed! Hemoglobin Fingerstick glucose Electrolytes if prolonged vomiting Epley Maneuver: Randomized controlled trials reported success rates ranging from 44% - 88% •Froehling et al. •Wolf et al. Mayo clin proc Clin otolaryngol •Asawarichianginda et al. Jul 2000 feb 1999 ENT J Sep 2000 Epley maneuver Canalith repositioning maneuver 5 step head hanging maneuver Moves otoliths out of the posterior semicircular canal and back into utricle where they belong Epley maneuver 1. Repeat Hallpike Previously performed diagnostic Hallpike test tells you the starting position (right or left) Epley maneuver 2. Turn head 90 degrees in the other direction Epley maneuver 3. Patient rolls onto shoulder, rotates head and looks down towards floor Epley maneuver Epley maneuver Repeating the Epley maneuver Post procedure Remain upright for 8-24 hours The Epley Maneuver Contraindications Unstable heart disease High grade carotid stenosis Severe neck disease Ongoing CNS disease (TIA/stroke) Pregnancy beyond 24th week gestation (relative) Furman JM, Cass SP. N Engl J Med 1999;341:1590-96 Complications Vomiting Converting to horizontal canal BPPV Labyrinthitis and Vestibular neuronitis A cute unilateral loss of peripheral vestibular function Associated with vertigo, N/V, and nystagmus Worsened by head movement Occurs in healthy young to middle-aged adults Often after respiratory infections self-limiting Perilymphatic fistula: Due to a traumatic “fistula” at the round or oval window. After forceful cough, sneeze, scuba diving or direct blow to the ear. Recurrence of vertigo with pneumootoscopy (Hennebert’s sign) Self-limiting Meniere’s disease: Characterized by triad of: • vertigo • tinnitus • hearing loss (sensorineural) Chronic relapsing illness (? familial) Due to a build-up of endolymphatic pressure in the labyrinth. Treatment: vestibular suppressants. Meniere’s disease Central vertigo May include disorders with significant potential morbidity. Warrants the initiation of further work-up. SPINNED PERIPHERAL CENTRAL Sudden (Onset) Positional Intensity Nausea/Diaphoresis Yes Yes Severe Slow, gradual No Ill defined Frequent Infrequent Nystagmus Torsional/horizontal Vertical Ear (hearing loss) Can be present Absent Duration CNS signs Paroxysmal Absent Carvalho et al. Constant Usually present CTU , Oct, 2004 Differential Diagnosis: Vertebral-basilar circulation events: 1. Vestibular nuclei (TIA or stroke) 2. Cerebellar infarction or hemorrhage 3. Lateral medullary infarction (Wallenberg’s syndrome) 4. Vertebral artery dissection Migraine Post concussive syndrome. Tumors (acoustic reuromas) Multiple sclerosis Infection (encephalitis, meningitis) The end