Vertigo & Dizziness


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Vertigo is a subtype of dizziness in which a patient inappropriately experiences the perception of motion (usually a spinning motion) due to dysfunction of the vestibular system.

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  • Sudden attacks of vertigo are more commonly due to benign disorders of the inner ear, and while bothersome, they can be less worrisome.  Viral infections of the inner ear can interfere with normal signaling, causing a sudden attack of vertigo that can last for over 24 hours. Usually, patients will have a history of recent runny nose, cough or fever. On the other hand, short episodic attacks associated with changes in head position are suggestive of a condition called benign paroxysmal positional vertigo. While symptoms can be debilitating, the condition can be easily treated by a physician through series of specific physical maneuvers to reposition the components of the inner ear.Dizziness or lightheadedness, on the other hand, could be indicative of a heart or vascular problem. While stroke is a rare cause of dizziness, over 50 percent of patients diagnosed with stroke report dizziness.  Early diagnosis of stroke is vital in order to administer key medications that can prevent permanent damage.  In order to maximize the effectiveness of the medication, it should be administered within 90 minutes of symptom onset.  Additional stroke red flags include:- Trouble with speaking or understanding- Numbness or weakness on one side of your body or face- Blurred or double visionFurthermore, if a stroke occurs in the balance center of your brain, sudden vertigo can also occur.Read more:
  • Plasil(metoclopramide)
  • Vertigo & Dizziness

    1. 1. Dizziness &VertigoFrederick Mars Untalan
    2. 2. VertigoLatin word “vertere” means to turnsuffix “igo” is a condition of turning about
    3. 3. O Dizziness one of the most commoncomplaints in the primary care settingO 3rd most common complaint after chest painand fatigueO 20%, general population, aged 18-65yrs, reported dizziness within previousmonth*O Incidence increases with age***Yardley I,Owen N, Nazareth I, Luxon L. Br J Gen Prac. 1998;.**Kroenke K, Mangelsdorf D. Am J Med. 1989Epidemiology
    4. 4. EpidemiologyO Over one year 18% of 65+ complained toa physician or had loss of usual activitiesdue to dizzinessO 30% prevalence in community surveyO Most common complaint over age 75O Risk factor for functional
    5. 5. The number of patients presenting with dizzinessto primary care professionals increases with age0. 1 2 3 4 5 6 70–1415–2425–3435–4445–5455–6465–7475–8485+Ageofpatients% primary care visits with dizziness as a presenting complaintSloane PD. J Fam Pract 1989;29:33–8.US survey of 2879 physicians
    6. 6. Sloane PD.. J Fam Pract 1989Proportion Seen by Different DisciplinesGP / FM44%GeneralInternist23%Other Internal MedSpecialist6%Otolaryngologists6%Cardiologists6%Other4%General Surgeons4%Neurologists4%Surgical Sub-Specialists(OB/GYN)3%Physicians/Specialists
    7. 7. Sloane PD, dallara J, Roach C, Bailey KE, Mitchell M, McNUtt R.. J Am Board Fam Pract. 1994*Desmond AL.,20043 of 140( 2%) patients referred for otologic diagnosis*Treatment Strategies done by MDsTreatment Strategy0%Office Lab Test14%Advanced Testing(CT, MRI)5%Referral to Specialist4%Medication25%Observation29%Reassurance17%BehaviouralRecommendations6%Treatment Strategy
    8. 8.
    9. 9.
    10. 10. Vestibular
    11. 11.
    12. 12.
    13. 13.
    14. 14. Dizziness vs
    15. 15. DIZZINESS VERTIGOO LightheadednessO Heart/vascularproblemO strokeO Inner ear disorderO Viral infxO Changes in
    16. 16.
    17. 17. Types of
    18. 18. VertigoO Due to an imbalance in vestibularsystem, arising from inner or middleear, brainstem or cerebellumO Common causes include benignparoxysmal positionalvertigo, cerebrovascular dx, and acutelabyrinthitis and vestibular
    19. 19. Presyncopal lightheadednessO Due to diffuse cerebral ischemiatypically arising from vascular or cardiaccausesO Common causes include vasovagalepisodes, postural hypotension, cardiacdx (such as arrhythmia, CHF, lowoutput), and carotid sinus
    20. 20. DysequilibriumO Perceived as body rather than headsensation arising from motor controlsystem(vision, vestibulospinal, proprioceptive, sensory, cerebellar or motor function)O Common causes include stroke, sensorydeficits, severe vestibular loss, peripheralneuropathy, and cerebellar
    21. 21. Other causes of dizzinessO These are vaguely described and may beassociated with anxiety and otherpsychological disordersO Less common cause of dizziness in olderthan younger
    22. 22. Multiple CausesO Subtyping may be useful in only about halfthe casesO Older persons often describe severalsubtypesO Most have dysequilibrium along with someother type of dizziness - vertigo
    23. 23. Temporal Pattern ofSymptomsO Continuous -psychological, medications, permanentstructural damage (e.g. stroke, cerebellaratrophy, vestibular damage, peripheralneuropathy, deconditioning)O Episodic - BPPV, recurrentvestibulopathy, TIAs, Meniere’sdx,
    24. 24. Common Problems in AgingO Greater sway during platform studies withknown loss of hair in semicircularcanals, utricle, and saccule of vestibularsystemO Progressive decline in baroreflexsensitivityO Resting cerebral blood flow close tothreshold for cerebral
    25. 25. Key Dizziness SyndromesO Postural dizzinessO Positional vertigoO LabyrinthitisO Vestibular neuronitisO Meniere’s diseaseO Vertebrobasilar TIAsO StrokeO Cervical dizzinessO Physical deconditioningO Drug inducedO Multiple sensoryimpairmentsO
    26. 26. Approach to
    27. 27.
    28. 28. VESTIBULOOCULAR REFLEX(VOR)O Enables the preservation of visual acuityand stable visual environment duringlocomotionO Nystagmus can be the result of anydisorder causing a malfunction in the VOR
    29. 29.
    30. 30. Vertigo Made Easy 2011SpontaneousNYSTAGMUS
    31. 31. Frenzel glasses to evaluate nystagmus
    32. 32. ExaminationVestibular test : for BPPVPositional Test : Dix Hallpike test
    33. 33. Test for Coordination:CEREBELLAR TESTSCerebellar Cortical Disease Evaluation
    34. 34. Vestibulospinal Reflex (VSR)
    35. 35. Posture and Gait Test:A test of somatosensation andpropioception.Not a test of vestibular input.
    36. 36. Tandem RombergtestStanding onFoam, FTPassFail• AbN Vest• AbNSomatosensory(SS)• AbN visual• All 3 N20secEyesOpenEyesClosedPass• Vest N• SS NFail• One of two AbN30secStanding on foam, FTFallAbNVest
    37. 37. Tandem walk:
    38. 38. Other Vestibular Tests toConfirm Diagnosis after HistoryandOffice Exam:1. ENG/VNG2. Posturography3. CT scan4. MRI
    39. 39. VideoNystagmography
    40. 40. MRI with gadolinium1 cm, VestibularSchwannoma, R3 x 3 cm CPA tumor, RMeningioma
    41. 41. HRCT ( HIGH RESOLUTION CT SCAN)SuperiorCanalDehiscenceNormal
    42. 42. Dizzy
    43. 43.
    44. 44. Peripheral Symptoms in Inner Ear Disorder:Disorder Duration ofVertigoHearingLossTinnitus AuralFullnessMeniere’s D Minutes tohoursFluctuatingHL+ +BPPV seconds +/- +/- +/-VestibularNeuritisDays toweeks- - -Acousticneuroma“imbalance” +ProgressivePoor SDS+ -Patient feels fine in between spells.
    45. 45.
    47. 47.
    48. 48.
    49. 49. 1 Antihistamines- Anticholinergic effects- (dry mouth, blurring ofvision)1 Diphenhydramine2 Dimenhydrinate3 Meclizine4 Cinnarizine5 Flunarizine6 PrometazineII. AntiemeticsO- Centrally acting, majortranquilizer, extrapyramindalsymptoms1 Metoclopramide2 ProchlorperazineVestibular sedatives
    50. 50. VasodilatorsO Disturbed labyrinthine vascularityO Re-establishes blood flow in ischemicareas of inner eara. Nicotinic acidb. Histaminec. Betahistine
    51. 51. Acute versus Chronic Vertigo• Acute: With well-defined isolated spells of vertigo;with distinct onset and offset; resolves in twoweeks*• Chronic: persistent or chronic sensation;recurrentGoebel JA. Management options for acute versus chronic vertigo 2000*Kroenke K, Lucas CA, Rosenberg ML, Scherokman B, Herbers JE, WehrlePA, Boggi JO. Ann Intern Med 1992
    52. 52. Treatment for Acute Dizziness• Use centrally-acting vestibular suppressants toreduce vertigo and nausea• Suppress activity of both vestibular nucleus andreticular activating system(RAS)• Examples1. Meclizine 25 mg TID +/- Promethazine 25-50mg TID2. Diazepam 2-5mg TID; if severe, 5-10mg IM3. Droperidol 2.5mg IM4. Prochlorperazine 25 mg per rectum• Must be discontinued as soon as possible when theacute event subsides
    54. 54. Principle of Treatment of ChronicDizzinessVestibularrehabilitationPharmacotherapy
    55. 55. What is CentralCompensation?Loss or reduction in function of oneorgan/ systemOther sensory organsubstitutes for loss offunction(sensory substitution)Tonic rebalancing ofsensory inputsHabituation(motor learning)Through cerebellar/ brainstem neuralcircuits- adaptiveplasticity/reprogrammingSensory conflictDizziness
    56. 56. Medical Treatment of Chronic(persistent) Dizziness• Enhance central compensation : Betahistine- usedfor Meniere’s disease• Clinical use of most drugs began long before thedevelopment of neuroscience; clinical efficacy andtheir dosages have been established empirically*• Animal studies showed its role in facilitating centralcompensationBhansali SA. 2001
    57. 57. Mechanisms of Action:Betahistine hydrochlorideIncrease in cochlear blood flow (H3pre-synaptic heteroreceptorantagonism)Decrease resting discharge inlabyrinthine hair cells(H3 antagonist and H1 agonistaction)Inhibition of firing activity ofvestibular nuclei (H3 receptorantagonist)Vestibularcompensation
    58. 58. Pharmacologic Effects ofBetahistine:Peripheral endorgan• Increase cochlear bloodflow• Decrease in restingelectrical dischargethrough presynaptic H3receptor antagonismCentral organs• HA release in VN resultsin excitation of neuronalactivity• Effect adaptivereprogramming of VOR tostabilize gaze, and VSR tocontrol posture
    59. 59. Recent Placebo and Active ControlTrials of BetahistineReference Method Diagnosis TreatmentanddurationResultAlbers et. al2003N=52Double-blind,randomized,multi-centerRecurrentVestibularvertigoBetahistineFlunnarizine8wksBetahistine significantly better inDHI, physical and functionalscoresMira,multicenter,randomized,parallelMeniere’sdisease orparoxysmalpositionalvertigo ofpossiblevascular originBetahistine16 tidPlacebo3 mosBetahistine significantly reducedfrequency, intensity and durationof vertigoDella RCT,-n=367)Vertiginoussyndromee-BPPV,vascularBetahisitnePlacebo3-8wksBetahistine relieved vertigo 3xversus placebo
    60. 60. Adverse EffectsO Generally rareO HeadacheO Skin reactionsO Heart burn/ nauseaLacour M, Van de Heyning PH, Novotny M,Tighilet b. Betahistine in the treatment of Meniere’sdisease. Neuropsychiatry disease and treatment. 2007;3(4):429-440Mira E, Guidetti G, Fattori GB,Malaninno M, MaialinoL,MoraR, Ottobonis S, in the treatment of peripheral vestibula vertigo. Euro ArchOtorhinolaryngol2003;260;73-77
    61. 61. Dizziness &VertigoFrederick Mars Untalan