dizziness prof. h. almuhaimed. objective to be addressed: difference between dizziness and vertigo....
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DizzinessDizziness
Prof. H. AlmuhaimedProf. H. Almuhaimed
Objective to be Objective to be addressed:addressed: Difference between dizziness and vertigo.Difference between dizziness and vertigo.
• Treatment Considerations.
• Characteristics of central vertigo.
• Characteristics of peripheral vertigo.• Diagnostic approach to True vertigo.
Patients refer to Dizziness Patients refer to Dizziness as:as:
• “out-of-it”
• Imbalanced
• Giddy
• Faintness
• Light headednessLight headedness
Most dizzy patients can be placed Most dizzy patients can be placed in to one of four categories:in to one of four categories:
1- True Vertigo (50%)
2-Pre-syncope:2-Pre-syncope: Transient sensation that a faint in Transient sensation that a faint in
about to occur.about to occur.
• Transient.
• May present as nausea ,weakness, or change in vision.
3-Dysequilibrium:3-Dysequilibrium: A sensation of imbalance when A sensation of imbalance when
standing or walking.standing or walking.
• No sense of faintness.
• No illusion.
4-Vague 4-Vague lightheadedness:lightheadedness: Holds the reminder of symptoms Holds the reminder of symptoms
of dizziness (which can’t fit to of dizziness (which can’t fit to the other categories)the other categories)
1.Psychiatric disorders, 2.Hyperventilation syndrome3.Encephalopathies
What is Vertigo?What is Vertigo?
True vertigo:True vertigo: Defined as an “illusion” or Defined as an “illusion” or
“hallucination” of movement.“hallucination” of movement.• Both vertigo and dysequilibrium imply a loss of balance, but vertigo involves a sense of motion.
How do we maintain How do we maintain equilibrium?equilibrium?
Visual inputVisual input
Proprioceptiual
input
Vestibular input
labyrinths.
equilibrium
Anatomy: Semicircular Anatomy: Semicircular canalscanals
Semicircular Canals Semicircular Canals (SCC)(SCC) HorizontalHorizontal AnteriorAnterior PosteriorPosterior
CupulaCupula End organ receptorsEnd organ receptors
EndolymphEndolymph
Anatomy: UtricleAnatomy: Utricle UtricleUtricle
Connected to SCCConnected to SCC Contains Contains
endolymphendolymph Otoliths (otoconia)Otoliths (otoconia)
Calcium carbonateCalcium carbonate Attached to hair Attached to hair
cellscells Macule (end organ)Macule (end organ)
Vestibular systemVestibular system Tells brain which way the head Tells brain which way the head
moves without lookingmoves without looking SCC: angular accelerationSCC: angular acceleration Utricle: linear accelerationUtricle: linear acceleration
How can we clinically How can we clinically evaluate the patient with evaluate the patient with
vertigo?vertigo?
labyrinthCN VIII
(Vestibular portion)
Vestibular
nuclei
Brainstem
VertigoCerebellum
VertigoVertigo
Central peripheral
Key points in History: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 Key points in the physical examination:examination:
•Vital signs •Ear exam •Eye exam•Positional testing•Neurological exam (including gait)
SPINNEDSPINNED SSudden (Onset)udden (Onset) YesYes Slow, gradualSlow, gradualPPositionalositional YesYes NoNoIIntensityntensity SevereSevere Ill definedIll definedNNausea/ausea/DiaphoresisDiaphoresis
FrequentFrequent InfrequentInfrequentNNystagmusystagmus Torsional/Torsional/
horizontalhorizontalVerticalVertical
EEar (hearing loss)ar (hearing loss) Can be presentCan be present AbsentAbsentDDurationuration ParoxysmalParoxysmal ConstantConstantCNS signsCNS signs AbsentAbsent Usually Usually
presentpresent
PERIPHERAL CENTRAL
Carvalho et al. CTU , Oct, 2004
Peripheral vertigo: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 DiagnosisDifferential Diagnosis Benign paroxysmal positional Benign paroxysmal positional
vertigo (BPPV) (50%)vertigo (BPPV) (50%) Vestibular neuritisVestibular neuritis Labyrinthitis (suppurative, serous, Labyrinthitis (suppurative, serous,
toxic, chronic) toxic, chronic) Meniere’s diseaseMeniere’s disease FB in ear canalFB in ear canal A cute otitis mediaA cute otitis media Perilymphatic fistula.Perilymphatic fistula.
BPPVBPPV Benign Paroxysmal Positional Benign Paroxysmal Positional
VertigoVertigo Age 60- 70 (F:M 2:1)Age 60- 70 (F:M 2:1) Head traumaHead trauma
Characteristic storyCharacteristic story
Turn headTurn head After a few seconds delay, vertigo After a few seconds delay, vertigo
occursoccurs Resolves within 1 minute if you don’t Resolves within 1 minute if you don’t
movemove If you turn your head back, vertigo If you turn your head back, vertigo
recurs in the opposite directionrecurs in the opposite direction
““BBPPV”PPV” ““B” = BenignB” = Benign
Not a brain Not a brain tumortumor
Can be Can be severe and severe and disablingdisabling
““BBPPPV”PV” ““P” = ParoxysmalP” = Paroxysmal
Episodic, not persistentEpisodic, not persistent Helpful feature in the differential Helpful feature in the differential
diagnosis diagnosis
““BPBPPPV”V” ““P” = PositionalP” = Positional
Occurs with position of headOccurs with position of head Turning over in bedTurning over in bed Looking upLooking up Bending overBending over
““BPPBPPVV”” ““V” = VertigoV” = Vertigo
An illusion of motionAn illusion of motion ““The room is spinning”The room is spinning” Other descriptionsOther descriptions
RockingRocking TiltingTilting SomersaultingSomersaulting Descending in an elevatorDescending in an elevator
Pathophysiology of BPPVPathophysiology of BPPV Otoliths become Otoliths become
detached from detached from hair cells in hair cells in utricleutricle
Inappropriately Inappropriately enter the enter the posterior posterior semicircular semicircular canalcanal. Parnes LS, McClure JA. Laryngoscope 1992;102:988-92.
PhysiologyPhysiology Normal situationNormal situation
As one turns head to the rightAs one turns head to the right Endolymph moves Endolymph moves SCC receptors SCC receptors
fire fire “head turning right” “head turning right” Stop turning headStop turning head endolymph endolymph
stops moving stops moving SCC receptors stop SCC receptors stop firing firing “head has stopped moving” “head has stopped moving”
Pathophysiology of BPPVPathophysiology of BPPV BPPVBPPV
Stop turning head Stop turning head otoliths otoliths keep movingkeep moving drag endolymph drag endolymph receptors continue to fire receptors continue to fire inappropriately inappropriately “head is still “head is still moving”moving”
Eyes Eyes “head is NOT moving” “head is NOT moving”
Brain Brain room must be spinning room must be spinning in the opposite directionin the opposite direction
Dix-Hallpike ManeuverDix-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-BárányBárány, BárányBárány, Nylen, or Hallpike maneuver
Dix-Hallpike ManeuverDix-Hallpike ManeuverThey include:
1- Nystagmus
2- Provocative head position
3- Brief latency to symptoms after change in position
4- Short duration of attack5- Fatigability of nystagmus on repeat testing
6-Reverse of nystagmus on returning to upright position.
Lab studiesLab studies
In a straightforward case, no In a straightforward case, no lab studies are needed! lab studies are needed!
HemoglobinHemoglobin Fingerstick glucose Fingerstick glucose Electrolytes if prolonged Electrolytes if prolonged
vomitingvomiting
Epley Maneuver:Epley Maneuver:
Randomized controlled trials Randomized controlled trials reported success rates ranging fromreported success rates ranging from
44% - 88%44% - 88%
•Froehling et al. Mayo clin proc Jul 2000
•Wolf et al. Clin otolaryngol feb 1999
•Asawarichianginda et al. ENT J Sep 2000
Epley maneuverEpley maneuver
Canalith repositioning maneuverCanalith repositioning maneuver 5 step head hanging maneuver5 step head hanging maneuver
Moves otoliths out of the Moves otoliths out of the posterior semicircular canal and posterior semicircular canal and back into utricle where they back into utricle where they belongbelong
Epley maneuverEpley maneuver 1. Repeat 1. Repeat
Hallpike Hallpike Previously Previously
performed performed diagnostic diagnostic Hallpike test tells Hallpike test tells you the starting you the starting position (right or position (right or left)left)
Epley maneuverEpley maneuver
2. Turn head 90 2. Turn head 90 degrees in the degrees in the other directionother direction
Epley maneuverEpley maneuver 3. Patient rolls 3. Patient rolls
onto shoulder, onto shoulder, rotates head and rotates head and looks down looks down towards floortowards floor
Epley maneuverEpley maneuver
Epley maneuverEpley maneuver
Repeating the Epley maneuverRepeating the Epley maneuver Post procedurePost procedure
Remain upright for 8-24 hoursRemain upright for 8-24 hours
The Epley ManeuverThe Epley Maneuver ContraindicationsContraindications
Unstable heart diseaseUnstable heart disease High grade carotid stenosisHigh grade carotid stenosis Severe neck diseaseSevere neck disease Ongoing CNS disease (TIA/stroke)Ongoing CNS disease (TIA/stroke) Pregnancy beyond 24Pregnancy beyond 24thth week week
gestation (relative)gestation (relative)
Furman JM, Cass SP. N Engl J Med 1999;341:1590-96
ComplicationsComplications VomitingVomiting Converting to horizontal canal Converting to horizontal canal
BPPVBPPV
Labyrinthitis and Vestibular Labyrinthitis and Vestibular neuronitisneuronitis
A cute unilateral loss of peripheral A cute unilateral loss of peripheral vestibular functionvestibular function
Associated with vertigo, N/V, and Associated with vertigo, N/V, and nystagmusnystagmus
Worsened by head movementWorsened by head movement Occurs in healthy young to middle-Occurs in healthy young to middle-
aged adultsaged adults Often after respiratory infections Often after respiratory infections self-limitingself-limiting
Perilymphatic fistula:Perilymphatic fistula: Due to a traumatic “fistula” at the Due to a traumatic “fistula” at the
round or oval window.round or oval window. After forceful cough, sneeze, scuba After forceful cough, sneeze, scuba
diving or direct blow to the ear.diving or direct blow to the ear. Recurrence of vertigo with pneumo-Recurrence of vertigo with pneumo-
otoscopy (Hennebert’s sign)otoscopy (Hennebert’s sign) Self-limitingSelf-limiting
Meniere’s disease:Meniere’s disease: Characterized by triad of:Characterized by triad of:
• vertigovertigo• tinnitustinnitus• hearing loss (sensorineural)hearing loss (sensorineural)
Chronic relapsing illness (? familial)Chronic relapsing illness (? familial) Due to a build-up of endolymphatic Due to a build-up of endolymphatic
pressure in the labyrinth.pressure in the labyrinth. Treatment: vestibular suppressants.Treatment: vestibular suppressants.
Meniere’s diseaseMeniere’s disease
Central vertigoCentral vertigo May include disorders with May include disorders with
significant potential significant potential morbidity.morbidity.
Warrants the initiation of Warrants the initiation of further work-up.further work-up.
SPINNEDSPINNED SSudden (Onset)udden (Onset) YesYes Slow, gradualSlow, gradualPPositionalositional YesYes NoNoIIntensityntensity SevereSevere Ill definedIll definedNNausea/ausea/DiaphoresisDiaphoresis
FrequentFrequent InfrequentInfrequentNNystagmusystagmus Torsional/Torsional/
horizontalhorizontalVerticalVertical
EEar (hearing loss)ar (hearing loss) Can be presentCan be present AbsentAbsentDDurationuration ParoxysmalParoxysmal ConstantConstantCNS signsCNS signs AbsentAbsent Usually Usually
presentpresent
PERIPHERAL CENTRAL
Carvalho et al. CTU , Oct, 2004
Differential DiagnosisDifferential Diagnosis:: Vertebral-basilar Vertebral-basilar
circulation events:circulation events:1.1. Vestibular nuclei (TIA or Vestibular nuclei (TIA or
stroke)stroke)2.2. Cerebellar infarction or Cerebellar infarction or
hemorrhagehemorrhage3.3. Lateral medullary Lateral medullary
infarction (Wallenberg’s infarction (Wallenberg’s syndrome)syndrome)
4. Vertebral artery dissection4. Vertebral artery dissection MigraineMigraine Post concussive syndrome.Post concussive syndrome. Tumors (acoustic reuromas)Tumors (acoustic reuromas) Multiple sclerosisMultiple sclerosis Infection (encephalitis, Infection (encephalitis,
meningitis)meningitis)
The endThe end
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