Dizzy Patient

8/18/2019 Dizzy Patient

1/19

T H E D I Z Z Y

P A T

I E N T

O t o l o g i c

e v a

l u a t i o n


2/19

LEARNING OBJECTIVES

After reviewing this module, the student will have the

ability to:

Develop a broad working diagnosis of the dizzypatient

Evaluate the dizzy patient by physical exam and

know when to refer for advanced testing Gain a basic understanding of inner ear anatomy and

physiology

nderstand when the dizzy patient warrantsconsultation to !tolaryngology


3/19

CASE PRESENTATION

!" #ea$ ol% &e'ale (it) )#*e$ten+ion i+ $e&e$$e% to t)e ENT clinic &o$%i,,ine++- Patient $e*o$t+ t)at +)e get+ %i,,# +*ell+ +eve$al ti'e+ *e$(ee.-

T)e+e +*ell+ la+t +econ%+/ an% +)e %e+c$i0e+ t)e e*i+o%e+ a+ &eeling li.et)e $oo' i+ +*inning a$oun% )e$- T)e %i,,ine++ +ee'+ to 0e 0$oug)t on0# c)ange+ in *o+ition/ +*eci1call# tu$ning )e$ )ea% to t)e $ig)t o$$olling ove$ in 0e% to )e$ $ig)t +i%e- T)e %i,,# +*ell+ +ee' to $e+olve ont)ei$ o(n a&te$ +eve$al +econ%+-

No a++ociate% neu$ologic +#'*to'+-Patient %enie+ )ea$ing lo++/ otalgia/ oto$$)ea/ au$al &ullne++/ tinnitu+-

Denie+ noi+e e2*o+u$e/ ea$ t$au'a/ *$io$ ea$ +u$ge$#/ o$ &a'il# )i+to$# o&)ea$ing lo++-

"hat is your di#erential diagnosis$


4/19

DI33ERENTIAL DIAGNOSIS%here is a very broad di#erential for Dizziness: 4VITA5IN C6'ne'onic

&ascular

O$t)o+tatic )#*oten+ion Ca$%iac a$$)#t)'ia+/ valve +teno+i+

B$ain+te' ce$e0$ova+cula$ %i+ea+e

5ig$aine

'nfectious

La0#$int)iti+ 7 *o+tvi$al

5eningiti+

%raumatic

Autoimmune

(etabolic)(edications:

Dia0ete+

T)#$oi% %i+ea+e

Aging

'diopathic)'atrogenic

P+#c)iat$ic8)#*e$ventilation Va+ovagal

*eoplastic

Ce$e0ello*ontine Angle Tu'o$+

9Ve+ti0ula$ +c)(anno'a:

+ongential

!ther: 5e%ication+

5e%ication +i%e e;ect+

Ototo2icit#

!tologic &estibular- causes

Benign Pa$o2#+'al Po+itionalVe$tigo 9BPPV:

5enie$e


5/19

ETIOLOGIES O3 DIZZINESS Dizziness is most common presenting complaint in patients

./ years or older

0ostural stability)balance involves integration of input fromvarious systems:

Vi+ual = P$o*$ioce*tive = So'ato+en+o$# = Ve+ti0ula$ 9Inne$ ea$:

(a1ority 2345- of dizziness can be attributed to one of thefollowing categories:

Pe$i*)e$al Ve+ti0ula$ %i+o$%e$+

Ca$%iova+cula$ %i+o$%e$+

5ulti+en+o$# %i+o$%e$+

B$ain+te' ce$e0$ova+cula$ %i+ea+e

Neu$ologic %i+o$%e$+

P+#c)iat$ic %i+ea+e

H#*e$ventilation +#n%$o'e


6/19

CHARACTERIZING DIZZINESS

%ypes of Dizziness

P$e+#nco*e> i'*en%ing &aint/ o&ten %e+c$i0e ?+*ot+< in vi+ion

D#+e@uili0$iu'> i'*ai$e% 0alance an% ga,e

Non+*eci1c> Lig)t)ea%e%ne++/ &oggine++/ con&u+ion

&ertigo: *e$ce*tion o& 'otion 9eit)e$ linea$ o$ $otating: in a0+ence o&'ove'ent

%iming

Le++ t)an 'inute

Due to *e$i*)e$al ve+ti0ula$ +#+te'8BPPV 5inute+ to )ou$+

5enie$e %i+ea+e/ t$an+ient ce$e0$al )#*o*e$&u+ion/ 'ig$aine/ *+#c)iat$ic%i+o$%e$+/ otic +#*)ili+

Hou$+ to %a#+

5ig$aine/ 5enie$e/ la0#$int)iti+


7/19

ESTION

'n our patient, after completing full history and physical, what

physical exam or test will help point to an inner ear etiologyin diagnosing this patient6s dizziness$

A7 Audiogram)hearing test

87 %uning fork exam

+7 0neumatic otoscopyD7 +hanging patient6s posture)positioning on the exam table

E7 *eurologic exam, especially focusing on cranial nerves

97 ('


8/19

ESTION

'n our patient, after completing full history and physical, what physicalexam or test will help point to an inner ear etiology in diagnosing this

patient6s dizziness$

A7 Audiogram)hearing test

87 %uning fork exam

+7 0neumatic otoscopy

D7 +hanging patient6s posture)positioning on the exam tableE7 *eurologic exam, especially focusing on cranial nerves

97 ('

All of the above are potentially important components of the workup of adizzy patient, however postural testing will give the examiner an ideaof vestibular function as it relates to this patient6s dizziness


9/19

PHYSICAL EA5

9ull neurologic exam

Te+t +en+o$#/ *$o*$ioce*tive/ c$anial ne$ve+/ 'u+cle +t$engt)/ gait +ardiovascular

A+cultate/ *al*ate *ul+e+/ o$t)o+tatic+

!toscopy under microscope if possible-

Rule out 'i%%le ea$ %i+ea+e/ c)ole+teato'a

%uning fork exam ;ead < *eck exam

Eye exam)baseline visual exam

Dix=;allpike (aneuver


10/19

ORF P O3 VERTIGO

+omprehensive ;earing evaluation: Audiogram

A++ociate% Hea$ing lo++ o$ anato'ic le+ion $elate% tove+ti0ulococ)lea$ ne$ve

&estibular testing

3o$'al ve+ti0ula$ te+ting )el*+ locali,e%e&ect an% )el*+ to %i;e$entiate

ve+ti0ula$ *at)olog# &$o' ocula$ o$

*$o*$ioce*tive %e1cit+ ('

Neu$ologic %e1cit

Ce$e0ello*ontine Angle tu'o$


11/19

VESTIBLAR SYSTE5 ANATO5Y PHYSIOLOGY

C$anial Ne$ve VIII Ve+ti0ulocococ)lea$ ne$ve

Co'*onent+> +e'ici$cula$ canal+ = " otolit)+ O$ient+ )ea% in +*ace/ %etect+ 'otion to allo( &o$

*o+itional a%u+t'ent+ o& e#e+/ )ea%/ an% *o+tu$eto 'aintain vi+ion an% 0alance

Se'ici$cula$ canal+ %etect angula$ accele$ation9)ea% $otation:

t$icle = Saccule +en+itive to linea$ accele$ation+9g$avit#/ ve)icle 'otion:

5ove'ent o& en%ol#'*) (it) 'ove'ent/ +)i&tingo& otoconia in t)e+e o$gan+ +ti'ulate )ai$ cell+t)at t$an+'it in&o$'ation 0ac. to t)e 0$ain


12/19

DIHALLPIFE

Te+ting &o$ $e*$o%uction o& ve$tigo/ a+ evi%ence% 0# n#+tag'u+/ (it)

c)ange+ in *o+ition8)ea% 'ove'ent+

Rotation o& )ea% in *lane o& +e'ici$cula$ canal +)i&t+ canalit)+/()ic) cau+e+ ove$+ti'ulation o& ne$ve+ (it) ove$co$$ection o& e#e*o+ition in o**o+ite %i$ection/ *$o%ucing n#+tag'u+

Po+itive Di2Hall*i.e $e*$o%uce+ ve$tigo

Diagno+tic o& BPPV

Ou$ *atient )a+ a = Di2Hall*i.e


13/19

BENIGN PAROYS5AL POSITIONALVERTIGO (ost common peripheral vestibular disorder: T#*icall# *$e+ent+ in

t)!t) %eca%e/ "> &e'ale *$e%o'inance

+ause: Otolit)+ accu'ulate in 9'o+t co''onl# *o+te$io$: +e'ici$cula$canal canalit)ia+i+

>igns)symptoms:

Ve$tigo +*ell+ a++ociate% (it) n#+tag'u+ la+ting +econ%+ t)at a$e*$eci*itate% 0# )ea% 'ov'ent+ +uc) a+ $olling ove$ in 0e%-

N#+tag'u+ $e+olve+ (it) u*$ig)t *o+ition-

Diagnosis

Di2Hall*i.e 'aneuve$

Re+*on+e to te+ting i+ &atiga0le/ t)at i+ it %ec$ea+e+ (it) $e*eate%te+ting a+ t)e 0$ain a%u+t+

"orkup: 3ull Hi+to$# P)#+ical/ ve+ti0ula$ te+ting/ Au%iog$a'


14/19

TREAT5ENT O3 BPPV

Epley (aneuver: +annalith repositioning

Cannalit) t$avel+ t)$oug) +e'ici$cula$ canal t)$oug) +e$ie+ o&$otational 'ove'ent+ in t)e *lane o& canal to $eac) ve+ti0ule


15/19

5ENIERE Pea. age t)

!t)

%eca%e+/ 'o$e *$evalent inCauca+ian+/ > 'ale to &e'ale $atio/ 'a# 0e &a'ilial co'*onent

+ause: overaccumulation of endolymph within vestibularsystem

>igns)symptoms

S*ontaneou+ e*i+o%ic attac.+ o& ve$tigo

Sen+o$ineu$al )ea$ing lo++ t)at Kuctuate+

Tinnitu+ =8 Au$al &ullne++

Diagnosis

Clinical )i+to$#> T$ia% o& Ve$tigo = Hea$ing lo++ = Tinnitu+

Ve+ti0ula$ te+ting )el*&ul


16/19

TREAT5ENT O3 5ENIERE Re+t$iction o& Ca;eine/ Alco)ol/ To0acco/ an% Salt 9CATS:

Diu$etic+> %ec$ea+e en%ol#'*) volu'e

S#'*to'atic t$eat'ent>

Antive$tigo 'e%ication+ 9e2- 'ecli,ine:

Antie'etic+ 9e2- P$o'et)a,ine/ on%an+et$on:

Se%ative+ 9e2- Ben,o%ia,e*ine+:

Anti%e*$e++ant+

>urgical treatment: !nly after failure of medical management Int$at#'*anic inection o& +te$oi%+ o$ ototo2ic agent+> 4c)e'ical

la0#$int)ecto'#6

En%ol#'*)atic +ac %eco'*$e++ion

Ne$ve +ection

La0#$int)ecto'# > %e+t$uction o& )ea$ing an% ve+ti0ula$ &unction


17/19

TAFE HO5E POINTS

%here is an extremely broad di#erential diagnosis for

Dizziness

ule out non=otologic causes of dizziness ?rst

0atients with vertigo should get comprehensive evaluation

to include vestibular testing

@now how to perform Dix=;allpike (aneuver


18/19

RESORCES

8ailey 8, ohnson %7 !tolaryngology B ;ead < *eck >urgery7

Cth

ed7 ippincott "illiams 44F79lint: +ummings !tolaryngology: ;ead < *eck >urgery, /th ed7

44 (osby, especially ch FC=FF

*etter 97 Atlas of ;uman Anatomy7 Accessed via %he *etterpresenter : human anatomy collection7 edited by ohn %7;ansen7 Elsevier 447

'mages from *etter and +ummings citations above-


19/19

ACFNOLEDGE5ENTS

%hank you to +hristian >tallworth, (D for overseeing

this pro1ect and providing advisory support7

0hoto credits= %hank you to (egan (7 Ga#ey, (D andauren %homas for providing physical exam photos

Editing and input:

+hristopher %hompson, (D

Dizzy Patient

Documents

Transcript of Dizzy Patient