a practical approach to assessment of the dizzy patient

1
a practical approach to assessment of the dizzy
patient

• Peter Valentine
• Consultant Otologist ENT SurgeonRoyal Surrey
  County Hospital and Ashford St. Peters
  Hospitals NHS Trusts

2
practical assessment

• easy mainly based on the history
• effective diagnostic groups for investigation
  treatment

3
flavours of dizziness

• near syncope
• disequilibrium gait only or global
• true vertigo
• psychogenic

4
trajectory of dizziness over time
SYMPTOM SEVERITY
TIME
5
dizziness associated with commonly used drugs
6
diagnostic matrix for acute vertigo
VERTIGO
EPISODIC
PERSISTENT

HEARING LOSS
Kentala Rauch, 2003
7
diagnostic matrix for acute vertigo
VERTIGO
EPISODIC
PERSISTENT

HEARING LOSS
BPPV
8
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

9
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)

10
(No Transcript)
11
(No Transcript)
12
how do otoconia get into posterior SCC?
13
mechanisms

• cupulolithiasis
• heavy cupula theory
• basophilic particles adherent to cupula

• canalithiasis
• free floating particles in SCC

14
Dix-Hallpike test
15
Epley canalith repositioning procedure

• first patient 1978
• presented 1980
• published 1992
• induced migration of canaliths by gravitation
• otoconia dissolve in endolymph (Zucca, 1978)

16
CRP for left PSCC BPPV
17
(No Transcript)
18
(No Transcript)
19
Brandt-Daroff exercises (1980)
20
diagnostic matrix for acute vertigo
VERTIGO
EPISODIC
PERSISTENT
Menieres disease

HEARING LOSS
BPPV
21
Menieres disease

• repeated attacks of spontaneous vertigo (hours)
  with nausea vomiting
• unilateral hearing loss, tinnitus aural
  fullness
• occurs in clusters
• otolithic crises of Tumarkin

22
Menieres disease natural history

• variable
• single bout for a few months
• relentless course
• permanent loss of auditory vestibular function
  as disease progresses
• burnt-out Menieres disease
• becomes bilateral in about 40-50

23
Menieres disease medical treatment

• salt restriction lt2000mg/day
• life style changes
• diuretics
• betahistine
• urea

• buccastem
• stemetil suppositories

24
Menieres disease surgical treatment

• aimed at destroying inner ear balance function
• intra-tympanic gentamicin injections
• labyrinthectomy
• vestibular nerve section
• conservative surgery
• endolymphatic sac surgery

25
diagnostic matrix for acute vertigo
VERTIGO
EPISODIC
PERSISTENT

Menieres disease
labyrinthitis
HEARING LOSS
vestibular neuritis
BPPV
26
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

27
vestibular neuritis natural history

• only 50 recover peripheral vestibular function
• 20 experience persistent subjective imbalance
• 20 develop BPPV
• bilateral sequential vestibular neuritis
• Menieres disease

28
vestibular neuritis treatment

• no effective treatment
• stop vestibular suppressants early
• early mobilization
• vestibular rehabilitation Cawthorne-Cooksey
  exercises

29
conditions that do not fit the matrix

• migraine-associated dizziness
• progressive disequilibrium of aging
• cervical vertigo

30
migraine-associated dizziness patterns of
vestibular dysfunction

• vertigo aura with hemi-cranial headache
• migraine equivalent vertigo
• basilar artery migraine
• disturbed baseline vestibular function
• more likely to develop BPPV

31
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 Purkinjes cells in cerebellum
• gradual downward trajectory gait instability
  falls

32
progressive disequilibrium of ageing treatment

• 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

33
cervical vertigo risk factors

• whiplash injury
• cervical disc disease
• degenerative arthritis
• ergonomic/repetitive stress injury

34
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

35
summary

• what is the flavour of dizziness?
• what is the trajectory?
• exclude patients 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