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“VERTIGO”

“VERTIGO”. November 12, 2011 Kansas Association of Osteopathic Medicine Primary Care Update G. Marcus Stephens, D.O. Illustrative Case.

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“VERTIGO”

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  1. “VERTIGO” November 12, 2011 Kansas Association of Osteopathic Medicine Primary Care Update G. Marcus Stephens, D.O.

  2. Illustrative Case • 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.

  3. Case continues • 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.

  4. 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 torsionalnystagmus in the right head-hanging position, along with reproduction of the patient's symptoms.

  5. Objectives • Review Inner Ear anatomy and physiology • Understand BPPV. • Learn the Dix-Hallpike Maneuver • Learn Canalith Repositioning technique • 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?

  6. “Dizziness” • Common and Treatable • Dx by history • The physical exam is just confirmational. • The dx does not yield to technology, some tests may lead astray.

  7. Rules for taking a history. • 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

  8. More rules • The psychiatrists approach: “Feeling dizzy lately?” • Then WAIT! • Average time a doctor waits for an answer is 8 seconds. • No questionnaires!

  9. Still 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)

  10. The four types of dizziness • 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:

  11. The Four Types • 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

  12. Vertigo • 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

  13. Near-syncope • 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”

  14. Dysequilibrium • 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

  15. Ill-defined lightheadedness • 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!”

  16. Prevalence of Dizziness • 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.

  17. Physical Exam • Always look in the ear • Test hearing • Look for nystagmus • Positional exam • Neuro exam

  18. Inner Ear

  19. Hearing Test • 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

  20. 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

  21. Actual photo of Dix Hallpike

  22. Central Peripheral • hearing loss (AICA exception) • Able to walk • Nystagmus • horizonto-rotary • Gaze-independent • Reduced with visual fixation • Dix-Hallpike differences • cranial nerve findings • Hemiparesis • Facial weakness • Diplopia • Hypesthesia • Horner’s sign • Gait ataxia-may have no limb ataxia

  23. BPPV • Benign paroxysmal positional vertigo • Usually in elderly • Self-limited • Responds poorly to antivertigo drugs • Due to canaliths

  24. Canaliths

  25. Epley Manuever • Seated • Supine with head rotated 45 degrees toward the involved side • Rotate to opposite side • Roll to lateral recumbent • Nose down • Sit up

  26. 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

  27. Other causes of Vertigo • Perilymphatic fistula • Vestibular neuronitis • Labyrinthitis • Meniere’s Disease • Traumatic Vertigo • Acoustic Neuroma

  28. Acoustic Neuroma

  29. Non-vertiginous dizziness • 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)

  30. Non-vertiginous dizziness • Dysequilibrium • Gait disorders, e.g. Parkinsonism, • Cervical spondylosis • Myelopathy, e.g. B12 deficiency

  31. 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

  32. DRUGS • 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)

  33. Nystagmus due to peripheral causes has all of the following featuresexcept: a.    Diminishes with fixation b.   Unidirectional fast component c.    Can be horizontal, rotary or vertical d.   Nystagmus increases with gaze in direction of fast component e.    Can be accentuated by head movement

  34. Nystagmus due to peripheral causes has all of the following featuresexcept: a.    Diminishes with fixation b.   Unidirectional fast component c.    Can be horizontal, rotary or vertical d.   Nystagmus increases with gaze in direction of fast component e.    Can be accentuated by head movement

  35. 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

  36. 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

  37. Epley Maneuver Demonstration MontaniSemperLiberi

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