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“VERTIGO”November 12, 2011
Kansas Association of Osteopathic Medicine Primary Care Update
G. Marcus Stephens, D.O.
A 67 year-old man rolled over in bed early in the morning and suddenly developed severe nausea as well as the unpleasant sensation that the room was spinning around him. The spinning resolved within 30 seconds but recurred again in the opposite direction when he rolled back to his original position. This had never happened to him before. The patient denied tinnitus, hearing loss, recent viral illness, or head trauma.
Illustrative Case
The patient's past medical history was remarkable only for hypertension for which he took atenolol. Surgical history was unremarkable. He did not smoke, drank only occasionally, and denied illicit drug use. Family history was non-contributory. He had no known drug allergies.
Case continues
VS: 37.2, 70, 140/85, 12, 98%. The head, eyes, ears, neck, and cardiac examinations were unremarkable. A detailed neurological examination, including mental status, cranial nerves, motor function, sensory function, and cerebellar function, was normal. A Dix-Hallpike (aka Nylan-Barany) test was performed and showed torsional nystagmus in the right head-hanging position, along with reproduction of the patient's symptoms.
Case continues
What are the 4 major categories of dizziness?
How is it worked up?
How is it treated? What is vertigo? How is it worked
up?
Review Inner Ear anatomy and physiology
Understand BPPV. Learn the Dix-
Hallpike Maneuver Learn Canalith
Repositioning technique
Objectives
Common and Treatable Dx by history The physical exam is just confirmational. The dx does not yield to technology, some
tests may lead astray.
“Dizziness”
NEVER suggest any symptom, especially with dizziness, or any other sensorineurologic condition, e.g. headache, numbness, etc.
You are interviewing the affected organ Family docs are usually the first to work up The first 30 seconds in the life of a dizzy
complaint are the most important
Rules for taking a history.
The psychiatrists approach: “Feeling dizzy lately?”
Then WAIT! Average time a doctor waits for an answer
is 8 seconds. No questionnaires!
More rules
‘Dizzy’ is a lay term Synonyms include woozy, lightheaded,
drunk-feeling, unstable. Vertigo is becoming a lay term Listen for localizing symptoms, e.g.. Hearing
loss, tinnitis, double vision, dysarthria, ataxia, 4-limb weakness (points to CNS rather than peripheral lesion)
Still more rules
A landmark study done several years ago at Northwestern University on hundreds of patients complaining of dizziness found that the complaints could be categorized into 4 main types:
The four types of dizziness
Vertigo: an illusion or hallucination of motion
Dysequilibrium: a gait disorder Near-syncope: a sensation of impending
faint Ill-defined lightheadedness: a metaphor for
anxiety
The Four Types
An illusion or hallucination of motion The most common of the 4 types We’ve all experienced it, e.g. spinning on a
stool Illusion: a misperception of a stimulus,
accounts form most forms of vertigo Hallucination: a perception without a
stimulus, e.g. vertiginous migraine, temporal lobe seizure
Vertigo
A sensation of impending faint. We’ve all experienced this, e.g.
hyperventillating, standing up to fast after squatting, etc.
Only about 50% do faint. Workup same as for syncope German study on medical students with EEG
and Video monitoring: “looks like a seizure”
Near-syncope
A gait disorder “I stagger” “I feel like I’m drunk” “I feel
like I’m going to fall” “I feel unbalanced” About 50% do fall
Dysequilibrium
Aka Type IV Dizziness A metaphor for anxiety “What do you mean, dizzy?” “I’m just dizzy. I’m dizzy all the time.
Nothing really helps.” Try to use another word to describe how you
feel… “Dizzy!”
Ill-defined lightheadedness
There is more dizziness than there are dizzy people
There are roughly 1.5 dizzy complaints per dizzy person.
About half of all dizziness is vertigo, the other half is about a third each of the other 3 types.
Some may have a mixture of types…try to ascribe percentages, e.g. 75% vertigo, 25% type IV.
Prevalence of Dizziness
Always look in the ear Test hearing Look for nystagmus Positional exam Neuro exam
Physical Exam
Inner Ear
Is there hearing loss? (Finger rubs) Is it sensorineural or conductive (Rinne test) If it’s sensorineural, is it cochlear or
retrocochlear (speech discrimination) If it’s retrocochlear, do MRI If you can’t rember all this, do audiogram
Hearing Test
Dix Hallpike Test Aka Barany’s test Start seated Supine with neck
extended 20 degrees Head rotated 45
degrees Watch for nystagmus
and ask about vertigo Repeat on other side
Actual photo of Dix Hallpike
cranial nerve findings
Hemiparesis Facial weakness Diplopia Hypesthesia Horner’s sign Gait ataxia-may
have no limb ataxia
hearing loss (AICA exception)
Able to walk Nystagmus
◦ horizonto-rotary◦ Gaze-independent◦ Reduced with visual
fixation Dix-Hallpike
differences
Central Peripheral
Dix Hallpike Peripheral Central
Latency 2-40 seconds None
Severity of Vertigo Severe Mild
Duration <1 minute >1 minute
Fatigability Yes No
Habituation Yes No
Postural Instability Can walk Falls, very unstable
Hearing loss May be present Usually absent
Other neuro sxs Absent Usually present
Nystagmus Only one position In all positions
Benign paroxysmal positional vertigo Usually in elderly Self-limited Responds poorly to antivertigo drugs Due to canaliths
BPPV
Canaliths
Epley Manuever
1. Seated2. Supine with head
rotated 45 degrees toward the involved side
3. Rotate to opposite side4. Roll to lateral
recumbent5. Nose down6. Sit up
Post-Epley Instructions Sleep upright 2 nights Cervical collar?? Avoid head back position No dentist, hair dresser Don’t drive home 2 pillows at night for a wk Watch eye drops, shaving Avoid BPPV position
Perilymphatic fistula Vestibular neuronitis Labyrinthitis Meniere’s Disease Traumatic Vertigo Acoustic Neuroma
Other causes of Vertigo
Acoustic Neuroma
Near-syncope◦ Usually due to impaired ability to vasoconstrict in
the upright posture, e.g. hypovolemia, high ambient temperature, hyperventilation, alpha-blockers, ACEi, bp meds.
◦ Overactive baroreceptor response in elderly (treat w betablocker-blocks beta receptor and allows unopposed alpha action)
Non-vertiginous dizziness
Dysequilibrium◦ Gait disorders, e.g. Parkinsonism, ◦ Cervical spondylosis◦ Myelopathy, e.g. B12 deficiency
Non-vertiginous dizziness
Type IV: Ill-defined lightheadedness◦ “dizzy all the time” a metaphor for anxiety◦ Replace the word dizzy with the word anxious◦ Hyperventillation
Non-vertiginous dizziness
For BPPV if Epley fails For motion sickness (physiologic vertigo) Use anticholinergic drugs that cross the
blood-brain barrier Works better prophylactically NASA experience Antihistamines (sedating) Benzodiazepines (Type IV)
DRUGS
Nystagmus due to peripheral causes has all of the following featuresexcept:a. Diminishes with fixationb. Unidirectional fast componentc. Can be horizontal, rotary or verticald. Nystagmus increases with gaze in
direction of fast componente. Can be accentuated by head movement
Nystagmus due to peripheral causes has all of the following featuresexcept:a. Diminishes with fixationb. Unidirectional fast componentc. Can be horizontal, rotary or verticald. Nystagmus increases with gaze in
direction of fast componente. Can be accentuated by head movement
a. Does not change with gaze fixation b. Can be unidirectional or bidirectional c. Can be horizontal, rotary or vertical d. Nystagmus increases with gaze in
direction of fast component e. Can be dramatically accentuated by
head movement
Nystagmus due to central causes has all of the following featuresexcept:
a. Does not change with gaze fixation b. Can be unidirectional or bidirectional c. Can be horizontal, rotary or vertical d. Nystagmus increases with gaze in
direction of fast component e. Can be dramatically accentuated
by head movement
Nystagmus due to central causes has all of the following featuresexcept:
Epley Maneuver Demonstration
Montani Semper Liberi
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