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Dizziness and vertigo


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Published in: Health & Medicine

Dizziness and vertigo

  1. 1. Nicole A. Walstein PA-C
  2. 2. Summary
  3. 3. Anatomy
  4. 4. Differential Diagnosis - Cochleovestibular system
  5. 5. Differential Diagnosis- Cochleovestibular system
  6. 6. Differential Diagnosis- Nervous system
  7. 7. Differential Diagnosis- Cardiovascular system <ul><li>Circulatory </li></ul><ul><ul><li>Hypovolemia </li></ul></ul><ul><ul><li>Anemia </li></ul></ul><ul><ul><li>Polycythemia </li></ul></ul><ul><ul><li>Orthostatic hypotension </li></ul></ul><ul><ul><li>Hypotension </li></ul></ul><ul><ul><li>Wallenburg lateral medullary syndrome </li></ul></ul><ul><li>Cardiac </li></ul><ul><ul><li>Arrhythmias </li></ul></ul><ul><ul><li>Valvular disease: AS/AI </li></ul></ul><ul><ul><li>Stokes-Adams attacks </li></ul></ul><ul><li>Great vessels </li></ul><ul><ul><li>Subclavian steal </li></ul></ul><ul><ul><li>Hypersensitive carotid sinus reflex </li></ul></ul>
  8. 8. Differential Diagnosis- Other Systems
  9. 9. Differential Diagnosis Duration of Vertigo Auditory Symptoms Present Auditory Symptoms Absent Seconds Perilymphatic Fistula BPPV, Vertebrobasilar insufficiency, Cervical vertigo Hours Endolymphatic hydrops (Meniere’s disease) Recurrent vestibulopathy, Vestibular migraine Days Labyrinthitis, Labyrinthine concussion Vestibular neuronitis Months Acoustic neuroma, Ototoxicity Multiple sclerosis, Cerebellar degeneration
  10. 10. History- HPI
  11. 11. History- HPI <ul><li>Vertigo </li></ul><ul><ul><li>A subtype of dizziness </li></ul></ul><ul><ul><li>The illusion of movement of either one's self or one's environment (it doesn’t matter which one!) </li></ul></ul><ul><ul><li>Cardinal symptom of vestibular disease </li></ul></ul>
  12. 12. History- HPI <ul><li>Onset and progression of symptoms- slow and insidious (CNS) or acute (vestibular)? </li></ul><ul><li>Continuous or episodic (ex. fleeting or prolonged)? </li></ul><ul><li>Associated symptoms? (ex. hearing loss, tinnitus, aural fullness, diaphoresis, nausea, or emesis) </li></ul><ul><ul><li>Does hearing fluctuate? (Meniere’s) </li></ul></ul><ul><li>Are the episodes associated with turning the head (BPPV), lying supine, or sitting upright? </li></ul>
  13. 13. History- HPI <ul><li>Ascertain the degree of impairment during an episode </li></ul><ul><li>Can the patient ambulate during an acute episode? (if not, think cerebellar) </li></ul><ul><li>Is there a sense of being pushed down or pushed to 1 side (pulsion)? </li></ul><ul><ul><li>Oscillopsia - A peculiar sense of movement of objects viewed when the patient moves </li></ul></ul><ul><li>Brainstem symptoms? (ex. diplopia, dysarthria, facial paresthesia, or extremity numbness or weakness) </li></ul>
  14. 14. History- HPI <ul><li>Headache? </li></ul><ul><li>Vertigo with nose blowing? (fistula) </li></ul><ul><li>Vertigo with pressure or noise (superior canal dehiscience) </li></ul><ul><li>Aura or warning before symptoms start? (migraine) </li></ul><ul><li>Visual symptoms? (ex. scintillating scotoma) </li></ul>
  15. 15. History- HPI <ul><li>Head trauma? (Post traumatic hydrops, fistula, basilar skull fx, labyrinthine concussion) </li></ul><ul><li>Vertigo with Neck movement? </li></ul><ul><li>Symptoms preceded by an upper respiratory infection or flu-like illness ? (Vestibular neuronitis) </li></ul><ul><li>Exposure to ototoxic medications? </li></ul><ul><li>Anxiety? </li></ul>
  16. 16. History Vestibular Not vestibular Sudden onset Gradual onset Spinning Ill defined symptoms Hearing loss Passing out Aural fullness Can’t ambulate Tinnitus Numbness/weakness
  17. 17. History- PMH <ul><li>Headaches (ex. migraines) </li></ul><ul><li>Ear disease (ex. chronic ear infections, cholesteatoma) </li></ul><ul><li>Anxiety or depression </li></ul><ul><li>Diabetes </li></ul><ul><li>Hypertension </li></ul><ul><li>Cardiovascular or cerebrovascular disease </li></ul><ul><li>Neurologic disease (ex. multiple sclerosis) </li></ul>
  18. 18. History- PSH <ul><li>Ear surgery </li></ul><ul><ul><li>Surgery for cholesteatoma may result in iatrogenic or acquired labyrinthine fistula </li></ul></ul><ul><ul><li>Stapes surgery for otosclerosis or tympanosclerosis may cause vestibular symptoms because of perilymphatic fistula, adhesions between the oval window and saccule, or an overly long prosthesis </li></ul></ul>
  19. 19. History <ul><li>FHx: cardiovascular disease, peripheral vascular disease, migraine, otosclerosis, Ménière disease </li></ul><ul><li>SH- recreational drugs, including ETOH and tobacco </li></ul><ul><li>Medications- prescription medicines, over-the-counter medications, herbal medicines; starting a new medication or a change in dose/frequency </li></ul>
  20. 20. Physical Exam- What is Equilibrium?
  21. 21. Physical Exam <ul><li>Vital signs - Orthostatic blood pressure and pulse </li></ul><ul><li>CV exam - Auscultate the heart and cervical vessels </li></ul><ul><li>Neurologic exam - CN, reflexes (upper/lower), EOM </li></ul><ul><li>Neck exam - for range of motion and flexibility </li></ul><ul><li>ENT exam </li></ul><ul><ul><li>Infection or inflammation of the external or middle ear? </li></ul></ul><ul><ul><li>Retracted/perforated TM or cholesteatoma? </li></ul></ul><ul><ul><li>Test hearing and discrimination </li></ul></ul>
  22. 22. Acute Otitis Media Cholesteatoma
  23. 23. Physical Exam- Nystagmus <ul><li>Defined as an involuntary, periodic, rhythmic ocular oscillation of the eyes </li></ul><ul><li>Unilateral or bilateral </li></ul><ul><li>May be spontaneous, gaze-induced, or positional </li></ul><ul><li>May be horizontal, vertical, or torsional (rotary) </li></ul><ul><ul><li>Peripheral nystagmus is usually rotatory </li></ul></ul><ul><ul><li>Pure vertical nystagmus usually is a sign of brainstem disease </li></ul></ul><ul><ul><li> </li></ul></ul>
  24. 24. Physical Exam- Office Tests <ul><li>Gait test </li></ul><ul><ul><li>Check for staggering or leaning to one side </li></ul></ul><ul><ul><li>Normal gait: erect posture, moderately sized steps, and walking in a straight line </li></ul></ul><ul><li>Romberg </li></ul><ul><ul><li>Stand heel to toe with one foot in front of the other with eyes closed </li></ul></ul><ul><li>Tandem Romberg </li></ul><ul><ul><li>Walk heal to toe with arms out for balance </li></ul></ul>
  25. 25. Physical Exam- Office Tests <ul><li>Dix-Hallpike maneuver </li></ul><ul><ul><li>Used to identify BPPV </li></ul></ul><ul><ul><li>Performed by guiding the patient rapidly from a sitting position with the head turned 45° to one side to a supine position. </li></ul></ul><ul><ul><li>Abnormal: patient reports vertigo and has a torsional (rotary) nystagmus that starts a few seconds after the patient lies back, lasts 40-60 seconds, reverses when the patient sits up, and fatigues with repetition. </li></ul></ul><ul><ul><li>DEMO </li></ul></ul>
  26. 26. Physical Exam- Office Tests <ul><li>Head-shake test </li></ul><ul><ul><li>The examiner vigorously shakes the patient's head from side to side for 10-15 seconds </li></ul></ul><ul><ul><li>Observe the eyes for nystagmus </li></ul></ul><ul><li>Head-thrust test </li></ul><ul><ul><li>The patient gazes steadily at a target in the room. </li></ul></ul><ul><ul><li>The examiner briskly thrusts the patient's head from one side to the other while observing eye position </li></ul></ul>
  27. 27. Physical Exam- Office Tests <ul><li>Fistula test </li></ul><ul><ul><li>Designed to elicit symptoms and signs of an abnormal connection (fistula) between the labyrinth and surrounding spaces </li></ul></ul><ul><ul><li>Apply pressure to the patient's ear canal (press on the tragus) and observes the eye movements </li></ul></ul><ul><li>Fukuda test </li></ul><ul><ul><li>High step in place for 20-30 seconds </li></ul></ul>
  28. 28. Physical Exam- Office Tests <ul><li>Oscillopsia test </li></ul><ul><ul><li>Before and during vigorous head shaking, the patient reads the smallest visible line on the Snellen eye chart </li></ul></ul><ul><ul><li>Normal- the ability to maintain acuity within 2 lines of the acuity at rest </li></ul></ul><ul><li>Heel to shin test </li></ul><ul><ul><li>Repeatedly run the heel of one foot from the top of the shin of the other leg down to the big toe </li></ul></ul>
  29. 29. Physical Exam- Vestibular Tests <ul><li>Electronystagmography (ENG) Testing (or VNG) </li></ul><ul><ul><li>Saccadic test </li></ul></ul><ul><ul><li>Gaze test </li></ul></ul><ul><ul><li>Pursuit eye movement test </li></ul></ul><ul><ul><li>Optokinetic nystagmus test (OKN) </li></ul></ul><ul><ul><li>Head-shake nystagmus test </li></ul></ul><ul><ul><li>Positional nystagmus test </li></ul></ul><ul><ul><li>Positioning nystagmus test (Dix Hallpike) </li></ul></ul><ul><ul><li>Bithermal caloric tests </li></ul></ul><ul><li>Rotating Chair Test (sinusoidal harmonic acceleration – SHA) </li></ul><ul><li>Computerized dynamic posturography (CDP) </li></ul>
  30. 30. Physical Exam- Vestibular Lab Tests <ul><li>Vestibular autorotation testing (VAT) </li></ul><ul><li>Computerized platform posturography </li></ul><ul><li>Electrocochleography (Ecog) </li></ul><ul><li>Auditory brainstem response (ABR) </li></ul><ul><li>Vestibular evoked myogenic potentials (VEMP) </li></ul>
  31. 31. Equipment in Neurotologic Clinic
  32. 32. Diagnostic Studies <ul><li>MRI of the brain and IAC (internal auditory canals) with and without gadolinium </li></ul><ul><ul><li>The yield in patients younger than 50 years is <1%. </li></ul></ul><ul><ul><li>The incidence of an acoustic tumor or other brainstem and posterior-fossa lesions also is low </li></ul></ul><ul><li>CT of the brain or temporal bones </li></ul><ul><li>Blood tests </li></ul>
  33. 33. Medical Management <ul><li>Antihistamine- vestibular suppressants </li></ul><ul><ul><li>Antivert (meclizine) </li></ul></ul><ul><ul><li>Dramamine </li></ul></ul><ul><li>Benzodiazepine- depresses CNS </li></ul><ul><ul><li>Valium (diazepam) </li></ul></ul><ul><li>Phenothiazine- treats emesis </li></ul><ul><ul><li>Promethazine (Phenergan) </li></ul></ul><ul><ul><li>Prochlorperazine (Compazine) </li></ul></ul><ul><li>Oral steroids </li></ul><ul><li>Vestibular Rehabilitation </li></ul><ul><li>At home exercises: Cawthorne Cooksey </li></ul>
  34. 34. Most Common
  35. 35. Benign paroxysmal positional vertigo (BPPV) <ul><li>Caused by otolith debris (canalith) floating in the semicircular canals (canalithiasis) or adhering to the cupula (cupulolithiasis) </li></ul><ul><li>Possible causes: vestibular neuronitis, Ménière’s disease, or head trauma, which dislodges particles (otoconia) </li></ul><ul><ul><li>Posterior canalithiasis ~90% of the time </li></ul></ul>
  36. 36. <ul><li> </li></ul>
  37. 37. BPPV <ul><li>Symptoms of acute vertigo with episodes lasting < 1 minute that occurs with changing head/body position </li></ul><ul><li>Residual sensation of disequilibrium between episodes </li></ul><ul><li>May spontaneously resolve </li></ul><ul><li>No medication </li></ul><ul><li>To diagnose- Dix Hallpike </li></ul><ul><li>Treatment- Epley manuever- Canalith repositioning technique- the particles are shifted out of the semicircular canal </li></ul>
  38. 38. Vestibular neuronitis <ul><li>Severe vertigo that begins acutely after an URI </li></ul><ul><li>Lasts 24-48 hours and gradually subsides with patients complaining of unsteadiness for weeks </li></ul><ul><li>Hearing is not effected </li></ul><ul><li>Patients cannot perform home or work activities </li></ul><ul><li>Medications- antiemetics, vestibular suppressants, corticosteroids </li></ul><ul><li>Vestibular rehabilitation </li></ul><ul><li>1/3 of patients develop BPPV </li></ul>
  39. 40. Labyrinthitis <ul><li>Acute onset of continuous, severe vertigo lasting several days to a week, accompanied by hearing loss and tinnitus </li></ul><ul><li>Unilateral or bilateral </li></ul><ul><li>Bacteria or viruses can cause acute inflammation of the labyrinth </li></ul><ul><li>Medications: antiemetic medications, vestibular suppressant, oral steriods </li></ul>
  40. 42. Ménière’s disease <ul><li>1) Fluctuating, low frequency hearing loss 2) tinnitus 3) aural fullness 4) episodes of vertigo that last for hours </li></ul><ul><li>Bilateral involvement in 25% of patients </li></ul><ul><li>Etiology- unknown </li></ul><ul><li>Patho- overproduction or underabsorption of endolymph </li></ul><ul><li>Test for syphilis with FTA </li></ul>
  41. 44. Ménière disease <ul><li>Treatment </li></ul><ul><ul><li>80% respond to salt restriction and diuretics </li></ul></ul><ul><ul><li>Vestibular suppressants </li></ul></ul><ul><ul><li>Corticosteroids orally or intratympanically </li></ul></ul><ul><ul><li>Intratympanic gentamicin (chemical labyrinthectomy) </li></ul></ul><ul><li>Surgical treatment: </li></ul><ul><ul><li>Endolymphatic sac decompression (ESD) </li></ul></ul><ul><ul><li>Cutting the vestibular division of CN VIII, sparing the auditory division </li></ul></ul><ul><ul><li>Labyrinthectomy– vertigo improves, but hearing is lost </li></ul></ul>
  42. 45. Central Vertigo <ul><li>Vestibular Schwannoma (Acoustic Neuroma) </li></ul><ul><ul><li>Uncommon, but don’t miss it! </li></ul></ul><ul><ul><li>Slowly progressive, unilateral hearing loss and tinnitus </li></ul></ul><ul><ul><li>Dizziness is not common </li></ul></ul><ul><ul><li>MRI of the brain and IAC’s with and without gadolinium IAC- Internal Auditory Canal </li></ul></ul>
  43. 50. Mini Case Study 1 <ul><li>“ I woke up and the bed was spinning” </li></ul><ul><li>“ I bent over (rolled over, turned quickly, laid down, sat up from bed, etc.) and everything started spinning around.” </li></ul><ul><li>“ Every time I tried to get up I fell back in to the bed.” </li></ul>
  44. 51. Mini Case Study 2 <ul><li>“ I had constant spinning and nausea for about 3 days.” </li></ul><ul><li>“ I was in the hospital for about 3 days, and they couldn’t find anything wrong with me.” </li></ul><ul><li>“ After the worst of it (vertigo and nausea) I was okay if I didn’t move. If I moved I was off balanced and would get nauseous if I moved too much.” </li></ul>
  45. 52. Mini Case Study 3 <ul><li>“ I have had several episodes of severe vertigo with nausea, lasting for hours at a time.” </li></ul><ul><li>“ It didn’t matter if I moved or not.” </li></ul><ul><li>“ I feel so much pressure in my head (ear).” </li></ul><ul><li>“ My ear was roaring.” </li></ul><ul><li>“ After an episode, I need to sleep for several hours.” </li></ul>
  46. 53. Mini Case Study 4 <ul><li>“ I have episodes of spinning and nausea that come on without warning, but had no ear symptoms.” </li></ul><ul><li>“ It felt like someone suddenly pulling the rug out from under me.” </li></ul><ul><li>“ I felt a sudden wave come over me.” </li></ul><ul><li>“ I can’t stand any type of motion. It never bothered me when I was a kid.” </li></ul>
  47. 54. Mini Case Study 5 <ul><li>“ I felt like my heart was pounding out of my chest.” </li></ul><ul><li>“ I felt like I was standing outside my body.” </li></ul><ul><li>“ I felt like I was dying.” </li></ul><ul><li>“ I couldn’t breathe.” </li></ul>
  48. 55. Mini Case Study 6 <ul><li>“ I get dizzy and off balance when I stand up.” </li></ul><ul><li>“ I get up and start to walk and feel like I am going to fall over.” </li></ul><ul><li>“ When I get up quickly, I feel like I could faint.” </li></ul>
  49. 56. PANCE review questions (from Appleton & Lange) <ul><li>A patient presents with a 3 month history of persistent dizziness. Quick movements of the head seem to increase the symptoms. Initial examination of the patient shows spontaneous vertical nystagmus. Which of the following is the most likely diagnosis? </li></ul><ul><ul><li>CNS lesion </li></ul></ul><ul><ul><li>Positional vertigo </li></ul></ul><ul><ul><li>Labyrinthitis </li></ul></ul><ul><ul><li>Meniere’s disease </li></ul></ul><ul><ul><li>Vestibular neuronitis </li></ul></ul>
  50. 57. PANCE review questions (from Appleton & Lange) <ul><li>A 33-year-old female presents with episodes of vertigo lasting about 20 minutes and associated with fluctuating hearing loss and a low-frequency nonpulsatile tinnitus in the affected ear. After these episodes of vertigo the patient states her hearing improves and the tinnitus resolves. Which of the following illnesses is suggested by there symptoms? </li></ul><ul><ul><li>Meniere’s disease </li></ul></ul><ul><ul><li>Perilymphatic fistula </li></ul></ul><ul><ul><li>Neural syphilis </li></ul></ul><ul><ul><li>Migraine Variant </li></ul></ul><ul><ul><li>All of the above </li></ul></ul>
  51. 58. <ul><li>“ Guess I got one o' the OTHER causes o' Dizziness” </li></ul>
  52. 59. Nicole A. Walstein M.S., PA-C [email_address] ENTACC 80 West Welsh Pool Rd. Suite 103 Exton, PA 19341 (610) 363-2532