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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.

Published in: Health & Medicine
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Vertigo & Dizziness

  1. 1. Dizziness &VertigoFrederick Mars Untalan MDwww.entmdclinic.webs.com
  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 declinewww.entmdclinic.webs.com
  5. 5. The number of patients presenting with dizzinessto primary care professionals increases with age0.20.71.81.82.423.446.70 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. www.entmdclinic.webs.com
  9. 9. www.entmdclinic.webs.com
  10. 10. Vestibular Systemwww.entmdclinic.webs.com
  11. 11. www.entmdclinic.webs.com
  12. 12. www.entmdclinic.webs.com
  13. 13. www.entmdclinic.webs.com
  14. 14. Dizziness vs Vertigowww.entmdclinic.webs.com
  15. 15. DIZZINESS VERTIGOO LightheadednessO Heart/vascularproblemO strokeO Inner ear disorderO Viral infxO Changes in headpositionwww.entmdclinic.webs.com
  16. 16. www.entmdclinic.webs.com
  17. 17. Types of Dizzinesswww.entmdclinic.webs.com
  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 neuronitiswww.entmdclinic.webs.com
  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 sensitivitywww.entmdclinic.webs.com
  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 diseasewww.entmdclinic.webs.com
  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 personswww.entmdclinic.webs.com
  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 orpresyncopewww.entmdclinic.webs.com
  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, migrainewww.entmdclinic.webs.com
  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 ischemiawww.entmdclinic.webs.com
  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 Psychologicalwww.entmdclinic.webs.com
  26. 26. Approach to vertigowww.entmdclinic.webs.com
  27. 27. www.entmdclinic.webs.com
  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. www.entmdclinic.webs.com
  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 Matrixwww.entmdclinic.webs.com
  43. 43. www.entmdclinic.webs.com
  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. Treatmentwww.entmdclinic.webs.com
  46. 46. TREATMENT OF DIZZINESSSPECIFIC MANAGEMENT DEPENDSON THE DIAGNOSIS THAT ISCAUSING THE VERTIGO.GENERAL MANAGEMENT OFDIZZINESS INCLUDESPHARMACOTHERAPY.
  47. 47. www.entmdclinic.webs.com
  48. 48. www.entmdclinic.webs.com
  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
  53. 53. START BETAHISTINE AS SOON AS POSSIBLETO FACILITATE CENTRAL COMPENSATIONTreatment for Acute Dizziness
  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 e.al.2003N=144Double-blind,multicenter,randomized,parallelMeniere’sdisease orparoxysmalpositionalvertigo ofpossiblevascular originBetahistine16 tidPlacebo3 mosBetahistine significantly reducedfrequency, intensity and durationof vertigoDella PepaC.et.al.Meta-analysis(7 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, et.al.Betahistinehydrochloride in the treatment of peripheral vestibula vertigo. Euro ArchOtorhinolaryngol2003;260;73-77
  61. 61. Dizziness &VertigoFrederick Mars Untalan MDwww.entmdclinic.webs.com

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