r in ’reilly gp dolphin house ware
TRANSCRIPT
Dr Fin O’Reilly
GP Dolphin House Ware
Aims What are the four types of “dizziness”
Vertigo
What are the differentials for vertigo
How to get the history right
What do we examine
Hallpikes
How do we treat
What is Epleys?
Epidemiology Common
0.5% of the population consult their GP each year with vertigo
1% of the population consult their GP each year with dizziness or unsteadiness
Women are more commonly affected than men.
It’s all about the history
“It’s Hard to explain doctor”
“Dizzified”
“Any old how “
“Just Whoops a daisy”
“Giddy”
“Giddified”
Spinny
“Floppsy”
“Heady”
“Vertigoey”
Lightheaded
Fainty
“”Whoosy”
Forget RCGP/Roger Neigbour/ Cambridge Calgary for 30 seconds…
Closed Questions
Vertigo Vertigo is an illusion of movement, often horizontal
and rotatory.
Other Questions:
o Do you get the feeling of rotation?
o Does the surroundings spin around?
o Is there a tendency to fall to one side with the spinning?
Associated nausea and vomiting indicate a peripheral rather than central cause.
Third to half of cases of dizziness are vertigo.
Presyncope Caused by cardiovascular disorders reducing cerebral
perfusion. “ I feel faintish” Main causes: low BP
o “blame yourself” first ie. medications… o “Fainter..” o Mixed picture Parkinsons, neuropathies..
Bradycardia o “blame yourself” first betablockers, digoxin, verapamil,
diltiazem.. o Sinus pauses, complete heart block etc.
Dysequilibrium occurs when the brain receives inadequate
information about the body's position from the somatosensory, visual, and vestibular systems.
Common causes
o peripheral neuropathy
o eye disease
o peripheral vestibular disorders.
Lightheadedness is non-specific and hard to find true diagnoses
Causes:
It may result from panic attacks with hyperventilation
Dysfunctional breathing
Lung function tests…
What’s your differential?
1. benign paroxysmal positional vertigo 2. vestibular neuronitis (no auditory Sx) 3. Ménière's disease
BPPV Commonest cause of vertigo
Number one vestibular disorder accounting for a 20-30% of referrals to vertigo clinics.
BPPV – What is it? Otoconia (crystals) float
about in the fluid of the labyrinth
Then escape into posterior semi-circular canal
Crystals then rub against the cilia and bombards messages down the vestibular nerve
Aetiology Idiopathic – vast majority, elderly linked to
?degeneration of vestibular system
Other – head trauma, mastoid surgery, vestibular neuronitis
Life time prevalence of 2.4%
Any Age group
Most common after 40 years (50-70 commonest)
Woman 2:1 Men
Clinical Features Brief (< 1 minute) recurrent attacks of vertigo
Provoked by changes in head position – classically: rolling over in bed
bending over
looking upward
Nausea common vomiting rare
Occur in spells – several attacks in a week or over course of 1 day
Usually self limiting but may last week to months +…
Presence of hearing loss, tinnitus, or feeling of fullness of the ears indicates another diagnosis
“Vestibular Neuritis”
“Acute Vestibular Failure”
“Labyrinthitis” - officially different as has associated deafness
Acute inflammation of the vestibular nerve. the cause unknown - thought to be precipitated by
sinusitis, influenza, and upper respiratory tract viral illnesses in the young or vascular disease in the elderly
commonly seen in previously well young or middle aged adults (usually between 20 and 40 years old).
Clinical Features incapacitating sustained (non-positional) vertigo in a
previously healthy young or middle aged adult. vertigo may be abrupt (in 73%) or increase over a few hours
(27%)
commonly occurs on first awakening the patient may feel very unwell and they often lie still in bed
unidirectional, predominantly horizontal nystagmus and an unsteady gait
nausea and vomiting are common
absent tinnitus or deafness
no other neurological symptoms or signs
After 2-5 days of the acute attack, a steady resolution usually occurs over a period of 6 to 12 weeks.
Clinical Features Attacks of:
o vertigo.
o fluctuating, progressive, unilateral or bilateral hearing loss.
o tinnitus.
o a sensation of fullness or pressure in one or both ears
o loud noises unpleasant and distorted
Meniere’s Disease Idiopathic (10% have Family Hx)
Usually affects only one ear but in around 30% cases both ears may be affected
The incidence is between 1:1000 and 1:2000 of the population
Both sexes are affected equally
Generally common in the fourth to sixth decades of life and consequently the incidence of new onset disease is low
A GP may expect to come across a new case only a few times in their career
Clinical Features Attack 20 minutes to several hours. (always less than 24
hours)
often sleepy afterwards and unsteady next day
Ear sx first then onset of vertigo. Intensity of vertigo increases rapidly and patients may be forced to lie still.
some patients can predict an acute attack while in others a random pattern can be observed
an attack may be triggered by diet, menstrual cycle or psychosocial stresses
Attacks may be frequent, or occur only every few months or longer.
Sometimes they come in clusters of several attacks in quick succession.
On average, there may be 6-11 clusters a year.
Central Causes
Peripheral Causes
The central causes of dizziness include: cerebellar degeneration
multiple sclerosis
brain stem vascular disease
Arnold-Chiari malformation
vestibular epilepsy
congenital nystagmus
episodic ataxia
multisystem atrophy
vestibular aura of migraine
The peripheral causes of dizziness include: middle ear disease:
perilymph fistula
glomus tumour
peripheral vestibular dysfunction:
Ramsay Hunt syndrome
ischaemia
basal meningitis
concussion
Acoustic Neuroma
More History…..
3 Questions
Duration? Lasts for several seconds to a few minutes include:
benign paroxysmal positional vertigo
Lasts for several minutes to one hour include:
transient ischemic attack, perilymphatic fistula
Lasts for several hours include
Meniere's disease, perilymphatic fistula, migraine, acoustic neuroma
Lasts for days include
acute vestibular neuronitis (labrynthitis), CVA, migraine, multiple sclerosis
Precipitating Factors? spontaneous episodes are
acute vestibular neuronitis;
cerebrovascular disease,
meniere's disease,
migraine,
multiple sclerosis
changes in position of the head
acute vestibular neuromits
benign positional paroxysmal vertigo,
perilymp fistula
acoustic neuroma
multiple sclerosis
Hearing affected? Deafness o Meniere’s
o Labyrinthitis
o Acoustic Neuroma
o Perilymph fistula
Not Deaf o vestibular neuronitis
o benign positional vertigo
o acute vestibular dysfunction
o stroke
o multiple sclerosis
o Cerebella tumour
What’s the diagnosis?
Scenario 1 45 year old lady
Got up to go to toilet this morning, had to sit straight back down as whole head went round
Fine when lies flat
If moves head then room spins again
Spinning lasts for 30 seconds
Feels sick but not vomited
No hearing sx
Had a similar episode 5 years ago. Went away on its own
Scenario 2 28 year old man
Requesting home visit as keeps being sick, room spinning
Worse if moves head but even if lies still its bad
Cold for last few days
Not obviously deaf
“You don’t understand doctor….I feel awful”
Scenario 3 56 year old man
Recurrent episodes of room spinning lasts a few hours never more than a day
Not related to head movement
Does feel a bit deaf to r ear
Often feels ringing in ear
Marked pressure feeling to right ear
Stressed at work
Scenario 4
78 year old man
Previous MI and TIA
Sudden onset of dizziness, feels unsteady and struggling to walk since the night before
Vomited a few times
Not related to head movement
No hearing problem
Not getting better
Scenario 5 44 year old man
c/o on off dizziness for last few months
Dizziness can last seconds but can go on for minutes at a time or longer
Also feels dizziness becoming more frequent
Seen last month Epleys did not help
Now feels going more and more deaf to R ear
Well otherwise no vomiting with it – still working etc.
Scenario 6 72 year old lady
Last two weeks getting dizzy lasting 20-30 seconds if moves head feel sick on off most of day but no vomiting
Felt was getting better but now worse again
No ear symptoms
Diagnosis Made!
Give the patient a minute.. Ideas:
Inner Ear infection
Blood Pressure
Concerns: Brain tumour
Stroke
Deafness
Expectations: Look in ears
Check BP
MRI Scan
Anti-sickness Jab
Examine – confirm the diagnosis
Examination Patient’s ICE
?BP
?Look in ears
?Neurology
Eyes – obvious nystagmus at rest or moving?
Ears – Weber’s and Rinne’s
Hallpikes
Cure the patient
Treatment
1. Acute
2. Prevention
3. Long Term
Treatment – Acute Attack Supportive:
o the patient should lay down on a firm surface during the acute attack o drinking or sipping water should be avoided (this may cause vomiting) o the patient should be kept like this until the severe vertigo is passed o may get up very slowly, once the vertigo disappears.
Medical:
o oral medication used to suppress the symptoms of acute vestibular attacks (vestibular sedatives) include o cinnarizine, 15-30 mg t.d.s. or o prochlorperazine 5-10mg tds - regular long term basis is not
recommended, or o promethazine, cyclizine, or, metoclopramide, or, o benzodiazepine – can be used with caution for short periods
Prevention of acute attack Measures for prevention of acute attacks lifestyle interventions (dietary control) - the goal is to provide
stable body fluid/blood levels to avoid secondary fluctuations in the inner ear fluid food and fluid intake should be even throughout the day foods or fluids that have a high salt content should be avoided there should be adequate intake of fluids daily
may contain water, milk and low-sugar fruit juices
caffeine-containing fluids and foods (coffee, tea and chocolate) should be avoided.
alcohol intake should be limited to one glass of beer or wine each day
foods containing MSG (monosodium glutamate)also should be avoided
reducing or stopping smoking
Treatment – Long Term betahistine
a starting dose of 16 mg three times a day will result in a reduction of the frequency and severity of attacks
however there is limited evidence for a strong effect of betahistine in preventing attacks
diuretics although there is lack of evidence to support their use, diuretics may
sometimes be offered to patients
corticosteroids both oral steroids and intratympanic steroid injections have been used
in the treatment of acute and chronic symptoms
medical ablation used in patients with intractable vertigo intratympanic use of aminoglycosides (gentamicinin) to relieve vertigo
and preservation of hearing s
When To Refer? Refer if:
frequent severe attacks not responding to medical management e.g. use of prophylaxis in meniere's disease with betahistine 16mg tds
Red flag signs – unilateral deafness, atypical neuro signs etc.
Mean time consider trying vestibular compensation… Cawthorne Cooksey Exercises
Treatment
Vestibular Neuronitis Supportive:
o Reassurance
o Explanation
o Advice – Patient.co.uk PILS
Symptomatic treatment
o antivertiginous medications (e.g. prochlorperazine 5mg tds) should be given only in the first few days since they may delay recovery by affecting central compensation mechanisms.
When to refer? Dehydration – needed IV support.
associated auditory and/or neurological symptoms and signs
spontaneous nystagmus persists after 48 hrs
symptoms persist after a month
Mean time consider trying vestibular compensation… Cawthorne Cooksey Exercises
Treatment
1. Medical
2. Positional Manoeuvres
BPPV - Medical Treatment 1. Vestibular sedatives
(e.g. the calcium channel antagonist cinnarizine (adult dose 30mg tds) or the histamine analogue betahistine)
2. Anti-emetics
(e.g. prochlorperazine or promethazine or cyclizine)
BUT: no evidence in literature to suggest that these are effective in the treatment of BPPV or as a substitute for repositioning manoeuvres
BPPV – Re-Positioning the aim of this treatment is to redirect the otoconial
particles back to the utricle
GP treatment Epley manoeuver
home treatment
modified Epley manoeuver
Brandt-Daroff exercises
80% Cured
Post Epley Advice Debatable – Cochrane says do!
Standard Advice:
o Do not lie on the affected side for 1 week
o Avoid bending eg tying shoe laces etc for 1 week
o Do not lie flat for 48 hours
Medication:
o Betahistine
o Prochlorperazine
o Cinnarizine
PILS Leaflet