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A Practical Approach to Assesment of Dizzy Patient
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A Practical Approach to Assesment of Dizzy Patient

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A Practical Approach to Assesment of Dizzy Patient A Practical Approach to Assesment of Dizzy Patient Presentation Transcript

  • a practical approach toassessment of the dizzy patient
  • practical assessment• easy – mainly based on the history• effective – diagnostic groups for investigation & treatment
  • ‘flavours’ of dizziness• near syncope• disequilibrium – ‘gait only’ or ‘global’• true vertigo• psychogenic
  • trajectory of dizziness over timeSYMPTOM SEVERITY TIME
  • 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
  • diagnostic matrix for acute vertigo VERTIGO EPISODIC PERSISTENT HEARING LOSS + Kentala & Rauch, 2003
  • diagnostic matrix for acute vertigo VERTIGO EPISODIC PERSISTENT HEARING LOSS + BPPV
  • 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
  • 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)
  • how do otoconia get into posterior SCC?
  • mechanisms cupulolithiasis • ‘heavy cupula’ theory • basophilic particles adherent to cupula canalithiasis • free floating particles in SCC
  • Dix-Hallpike test
  • Epley canalith repositioning procedure • first patient 1978 • presented 1980 • published 1992 • induced migration of canaliths by gravitation • otoconia dissolve in endolymph (Zucca, 1978)
  • CRP for left PSCC BPPV
  • Brandt-Daroff exercises (1980)
  • diagnostic matrix for acute vertigo VERTIGO EPISODIC PERSISTENT HEARING LOSS Meniere’s + disease BPPV
  • 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
  • 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%
  • Meniere’s disease : medical treatment• buccastem • salt restriction• stemetil <2000mg/day suppositories • life style changes • diuretics • betahistine • urea
  • 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
  • diagnostic matrix for acute vertigo VERTIGO EPISODIC PERSISTENT HEARING LOSS Meniere’s + disease labyrinthitis BPPV vestibular neuritis
  • 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
  • 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
  • vestibular neuritis : treatment• no effective treatment• stop vestibular suppressants early• early mobilization• vestibular rehabilitation : Cawthorne-Cooksey exercises
  • conditions that do not fit ‘the matrix’• migraine-associated dizziness• progressive disequilibrium of aging• cervical vertigo
  • 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
  • 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
  • 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
  • cervical vertigo : risk factors• whiplash injury• cervical disc disease• degenerative arthritis• ergonomic/repetitive stress injury
  • 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
  • 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