A Practical Approach to Assesment of Dizzy Patient

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A Practical Approach to Assesment of Dizzy Patient

  1. 1. a practical approach toassessment of the dizzy patient
  2. 2. practical assessment• easy – mainly based on the history• effective – diagnostic groups for investigation & treatment
  3. 3. ‘flavours’ of dizziness• near syncope• disequilibrium – ‘gait only’ or ‘global’• true vertigo• psychogenic
  4. 4. trajectory of dizziness over timeSYMPTOM SEVERITY TIME
  5. 5. dizziness associated with commonly useddrugs Drug Type of dizziness MechanismAminoglycosides Vertigo & dyseqm. VHC damage Antiepileptics Dysequilibrium Cerebellar toxicity Tranquilizers Intoxication CNS depressionAntihypertensives Near-syncope CBF, Postural & diuretics hypotension Amiodarone Dysequilibrium ? Alcohol Intoxic. & Position. CNS depression & cupula specific gravity Methotrexate Dysequilibrium Cerebellar toxicity Anticoagulants Vertigo Inner ear bleed
  6. 6. diagnostic matrix for acute vertigo VERTIGO EPISODIC PERSISTENT HEARING LOSS + Kentala & Rauch, 2003
  7. 7. diagnostic matrix for acute vertigo VERTIGO EPISODIC PERSISTENT HEARING LOSS + BPPV
  8. 8. benign paroxysmal positional vertigo• most common type of vertigo seen• causes: • closed head injury • vestibular neuritis – 20% will develop BPPV • ear surgery • prolonged bed rest
  9. 9. history : key features• vertigo • sudden attacks triggered by movement • last less than 30 seconds • occur in spells • time of day, sleeping habits • avoidance behaviour• disequilibrium • poor balance, light-headedness, nausea • abnormal postural stability (Herdman, 1995)
  10. 10. how do otoconia get into posterior SCC?
  11. 11. mechanisms cupulolithiasis • ‘heavy cupula’ theory • basophilic particles adherent to cupula canalithiasis • free floating particles in SCC
  12. 12. Dix-Hallpike test
  13. 13. Epley canalith repositioning procedure • first patient 1978 • presented 1980 • published 1992 • induced migration of canaliths by gravitation • otoconia dissolve in endolymph (Zucca, 1978)
  14. 14. CRP for left PSCC BPPV
  15. 15. Brandt-Daroff exercises (1980)
  16. 16. diagnostic matrix for acute vertigo VERTIGO EPISODIC PERSISTENT HEARING LOSS Meniere’s + disease BPPV
  17. 17. Meniere’s disease• repeated attacks of spontaneous vertigo (hours) with nausea & vomiting• unilateral hearing loss, tinnitus & aural fullness• occurs in clusters• otolithic crises of Tumarkin
  18. 18. Meniere’s disease : natural history• variable • single bout for a few months • relentless course• permanent loss of auditory & vestibular function as disease progresses• burnt-out Meniere’s disease• becomes bilateral in about 40-50%
  19. 19. Meniere’s disease : medical treatment• buccastem • salt restriction• stemetil <2000mg/day suppositories • life style changes • diuretics • betahistine • urea
  20. 20. Meniere’s disease : surgical treatment• aimed at destroying inner ear balance function • intra-tympanic gentamicin injections • labyrinthectomy • vestibular nerve section• ‘conservative’ surgery • endolymphatic sac surgery
  21. 21. diagnostic matrix for acute vertigo VERTIGO EPISODIC PERSISTENT HEARING LOSS Meniere’s + disease labyrinthitis BPPV vestibular neuritis
  22. 22. vestibular neuritis• sudden onset of intense vertigo, lasting several days with vomiting• spontaneous nystagmus away from affected ear• usually able to stand without support• disequilibrium may last for months• “labyrinthitis” – labyrinthine infarction with severe or total acute unilateral hearing loss
  23. 23. vestibular neuritis : natural history• only 50% recover peripheral vestibular function• 20% experience persistent subjective imbalance• 20% develop BPPV• bilateral sequential vestibular neuritis• Meniere’s disease
  24. 24. vestibular neuritis : treatment• no effective treatment• stop vestibular suppressants early• early mobilization• vestibular rehabilitation : Cawthorne-Cooksey exercises
  25. 25. conditions that do not fit ‘the matrix’• migraine-associated dizziness• progressive disequilibrium of aging• cervical vertigo
  26. 26. migraine-associated dizzinesspatterns of vestibular dysfunction• vertigo aura with hemi-cranial headache• migraine equivalent vertigo• basilar artery migraine• disturbed baseline vestibular function• more likely to develop BPPV
  27. 27. progressive disequilibrium of ageing• aged patient brought in by adult children• multi-system decline: • ear – vestibular presbyastasis • proprioception – arthritis in major joints • eyes – poor vision & cataracts • CNS – loss of Purkinje’s cells in cerebellum• gradual downward trajectory: gait instability & falls
  28. 28. progressive disequilibrium of ageingtreatment• stop vestibular suppressants & sedatives• correct vision & hearing• occupational therapist • hard sole-high top shoe • hand rails, lighting, loose carpets• physiotherapist • exercise gait training • stick or frame
  29. 29. cervical vertigo : risk factors• whiplash injury• cervical disc disease• degenerative arthritis• ergonomic/repetitive stress injury
  30. 30. cervical vertigo : clinical features• provoked by head-on-body movement• combination of floating dysequilibrium & brief episodes of vertigo• cervical trigger points may produce vertigo and/or nystagmus: fibromyalgia
  31. 31. summary• what is the ‘flavour’ of dizziness?• what is the ‘trajectory’?• exclude patient’s medication as a factor• if acute vertigo, does it fit ‘the matrix’?• if not, is it PDA, MAD or CV• if none of the above, consider neurological referral

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