DIZZINESS - Doctor 2018• Severe “dizziness” for 2 days • Nauseas and vomiting • Whenever...
Transcript of DIZZINESS - Doctor 2018• Severe “dizziness” for 2 days • Nauseas and vomiting • Whenever...
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DIZZINESS:PBL approach
DR. LUBNA KHREESHA
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INTRODUCTION
VERTIGO
CAUSE OF VERTIGO CENTRAL VS PERIEPHRAL
HISTORY, FOCUSED
PHYSICAL EXAMINATION
CLINICAL CASES
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Balance
constant process of position detection, feedback and adjustment using
communication between the inner ear, eyes, muscles, joints and the brain.
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dizziness
Describe “Dizziness”
• Wait for it… let the
patient describe
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Causes of Vertigo
Peripheral “Benign”
• BPPV
• Vestibular neuritis
• Meniere’s disease
• Perilymphatic fistula
• Herpes zoster oticus
• Acoustic neuroma
• Ototoxicity
• Otitis media
• Vestibular hypofunction
• Semicircular canal dehiscence
syndrome
Central “Serious”
• Migrainous vertigo
• Intracranial mass
• Stroke – Cerebellar/brainstem
• Vertebrobasilar insufficiency
• Chiari malformation
• Multiple sclerosis
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Historical Clues
• Timing – Episodic vs
Constant
• Duration – Seconds
vs hours vs days
• Recurrence
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Historical Clues
• Triggers – position changes, head movement, pressure changes
• Associated symptoms – neurologic, hearing loss, tinnitus,
headache
• PMH – diabetes, CVD, HTN, head trauma
• FH – stroke, migraine, Meniere’s, BPPV
• Medications – antihypertensives, anticonvulsants 1
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Physical Exam
• Ear: cerumen, vesicles on TM, middle ear effusion,
hearing
• Eye: nystagmus, ocular movements, vision
• CV: carotid bruits, murmur, arrhythmia, signs of PAD
• Neurologic: RHomberg, cerebellar signs
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History and examination
will lead you to next
step…to target the
problem
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Case 1: 67 years lady with vertigo
• “I feel like the room is spinning”
• “Comes and goes”
• Lasts only seconds
• Brought on by rolling over to get out of bed in the morning, looking
up to a shelf
• No hearing loss or tinnitus
• Feels fine between these “spells”
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Case 1: 67 years lady with vertigo
• Vitals: NORMAL
• ENT: NORMAL
• Neck: No carotid bruits
• CV: no murmurs
• Neurological: normal, no nystagmus
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What should you do next?
DIX-HALLPIKE
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Benign Paroxysmal Positional Vertigo
BPPV
• Most common cause of vertigo – Increasing incidence with age
• Brief episodes lasting < 1 minute
• Triggered by head position changes – No vertigo between attacks
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CASE 1 : BPPV TREATMENT
Most spontaneously improve in 4-6
weeks
• Best: Epley maneuver
• Physical Therapy (vestibular
rehabilitation) in resistant cases
• Avoid symptomatic medications –
Meclizine, antiemetics,
benzodiazepines
• Counsel about recurrence,
evaluate fall risK
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CASE 2: 45 Taxi driver who can’t drive
• Severe “dizziness” for 2 days
• Nauseas and vomiting
• Whenever he opens his eyes, feels like everything is moving
• Prefers to lie still with eyes closed
• Recent Upper respiratory tract infection
• No hearing loss or tinnitus
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Case 2
• ENT: normal
• CV: normal, no murmurs
• Neuro: – spontaneous unilateral nystagmus to right
– Rhomberg normal
– gait – veers towards the left but can walk
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Case 2
What tests might help differentiate vestibular neuritis
from a CVA?
HEAD THRUST TEST
VISUAL FIXATION
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Head thrust
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Visual fixation
• Have a patient focus on a visual target
in peripheral– Nystagmus stops
• Central lesions will not be suppressed by visual fixation
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Case 2: Vestibular neuritis
• Second most common cause of vertigo
– 50% have had recent URI – Hypothesized to be a viral infection
• Sudden, constant severe vertigo
• spontaneous nystagmus
• May veer towards affected side
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Case 2: Vestibular neuritis treatment
• Rest, gradually improves in a few weeks
• Vestibular suppressants for first few days ONLY
– antiemetics, antihistamines, benzodiazepines
-Corticosteroids controversial –Studies show earlier return of vestibular function
testing but mixed evidence for earlier recovery of symptoms – Prednisone burst
for 10 days
• BEST – vestibular rehabilitation
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Vestibular rehabilitation
• Facilitates “vestibular
adaptation” – brain compensates
for vestibular dysfunction
• Quicker recovery and decreased
long-term sequel
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Case 3: 13 year old who is missing school
from “dizzy spells”
• Describes as spinning sensation, often triggered by movement
• Lasts hours, sometimes days.
• Associated with nausea and vomiting and photophobia
• Often seems to occur around time of menstruation
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Case 3: 13 year old who is missing school
from “dizzy spells”
• PMH: chronic headaches
• Meds: NSAIDs as needed
• FH: Migraines in mother, CVA in grandmother
• PE: no abnormal findings including neurologic exam and
gait
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Case 3: Vestibular migraine
• Common, unrecognized cause of vertigo
• Migraine variant
• Often a history of migraine
• Vertigo may occur with headache
• Duration and triggers similar to migraine
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Case 3: Vestibular migraine
Exam usually normal
• Clinical diagnosis of exclusion
– Obtain audiometry and vestibular function testing to exclude other
etiologies
– Consider MRI brain, esp. if red flags/stroke risk factors
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Case 3: Vestibular Migraine Treatment
• Same as for migraine
– Improvement of vertigo with triptans can be both therapeutic and
diagnostic
– Trigger avoidance
– Prophylaxis if frequent or debilitating
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Case 4: A dizzy 37 female with an earful
of ocean
• Last week, had vertigo, nausea, and vomiting
– Lasted 3-4 hours
– Spontaneously resolved
• Recurred this morning
• Difficulty walking
• “Sounds like the ocean is in my left ear”
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Case 4
PMH: Hypertension
• Meds: HCTZ, OCP
• FH: Grandfather with a “dizziness problem”
• SH: Occasional ETOH, former smoker
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Case 4
Vitals: BP 132/85, HR 77, RR 18
• General: Lying supine, uncomfortable appearing
• HEENT: Horizontal nystagmus with left gaze; decreased hearing in left ear
• CV: RRR, no murmurs, no bruits
• Neuro: + Rhomberg, mild gait ataxia
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Meniere’s Disease
• Classic triad of vertigo, hearing
loss, and tinnitus/aural fullness
– HL is fluctuating, occurs with
vertigo, initially low frequency
Meniere’s Disease
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Case 4:Meniere’s Disease
Overtime, can lead to permanent disability
– Permanent hearing loss
– Vestibular function loss leads to chronic imbalance and positional vertigo
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Case 4: Meniere’s Disease Diagnosis
• Clinical diagnosis
• Audiometry
• MRI/MRA – only to rule out other
causes
• +/- Vestibular function testing
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Treatment
• Goals: decrease frequency/severity of vertigo, improve balance,
preserve hearing and QOL
• Acute: Symptomatic meds, steroid
• Prophylaxis: – Diet: Decrease salt, caffeine, alcohol, nicotine
– Diurectics: e.g. triamterene-hydrochlorothiazide (Dyazide) 37.5-25
mg
• Educate: No “cure” but most can get good improvement of vertigo
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Other treatment modalities
• Vestibular rehabilitation
• Intratympanic gentamicin
• Endolymphatic sac procedures
• Vestibular neurectomy
• Labyrinthectomy
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Case 5: 72 years female who gets dizzy
when putting the dishes away
• Feels like things are spinning
• Noticed that it occurs whenever she looks up to put dishes away on high
shelves
• Lasts about a minute, resolves if she “holds still”
• Normal between episodes
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Case 5: history
• Medications: Lisinopril-HCTZ, ibuprofen
• PMH: HTN
• FH: Father died of MI age 62
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Case 5: Examination
Orthostatics: BP → 145/76,↑ 113/68
– Stopped diuretic – symptoms unchanged
• Dix-Hallpike: +vertigo on right, ? nystagmus
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CASE 5: INVESTIGATIONS
• Carotid doppler
– Right ICA 50-69% stenosis
– Reversal of flow in left vertebral artery: Subclavian Steal Syndrome
• Symptoms resolve with stenting of left subclavian artery (90% stenosis)
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syndrome Vertebrobasilar insufficiency
(TIAs) UNDERLYING PATHOLOGIES ARE
• Brainstem ischemia
– Embolic, atherosclerotic occlusions of vertebrobasilar arterial system
– Subclavian steal syndrome
– Rotational vertebral artery
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Vertebrobasilar insufficiency
• Recurrent, abrupt episodes lasting min - hours
• +/- diplopia, ataxia, weakness, drop attacks, dysarthria
– Isolated vertigo if ischemia is in the distribution of the vertebral artery
• Crescendo pattern
• KEY: Risk factors for cardiovascular disease
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References
1. Bope ET, Kellerman RD: Conn's Current Therapy 2013. Philadelphia, Saunders, 2012, p 301
2. Bhattacharyya N, Baugh RF, Orvida L, et al: Clinical practice guideline: Benign paroxysmal positional vertigo, Otolaryngol Head Neck Surg 139:S47-S81, 2008.
3. Committee on Hearing and Equilibrium guidelines for the diagnosis and evaluation of therapy in Meniere's disease. American Academy of Otolaryngology-Head and Neck Foundation, Inc. Otolaryngol Head Neck Surg . Sep 1995;113(3):181-185.
4. Fishman JM, Burgess C, Waddell A. Corticosteroids for the treatment of idiopathic acute vestibular dysfunction (vestibular neuritis). Cochrane Database Syst Rev. 2011(5):CD008607.
5. Lempert T, Olesen J, Furman J, et al. Vestibular migraine: diagnostic criteria. Journal of vestibular research : equilibrium & orientation. 2012;22(4):167-172.
6. Wipperman J. Dizziness and vertigo. Primary care. Mar 2014;41(1):115-131. 7. Dix-Hallpikevideo. YouTube. https://www.youtube.com/watch?v=kEM9p4EX1jk Accessed 11/22/14 8. Epley video. YouTube. https://www.youtube.com/watch?v=ZqokxZRbJfw Accessed 11/22/14