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Referred for severe « dizzy spells »
PRESENT ILLNESS:
• First episode March 1997 (1h) and June 1997 (2h45)
• Daily DIZZY SPELLS, completely incapacitating,
since fall 97
• Stopped working 3 1/2 years ago
• 2 operations on the left ear in 1998
Male 40 years old, OttawaCase 1" Linesman " (Hydro Ontario)
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Past history: Negative Rx: None
Functional inquiry: Negative
- No neurological symptoms
- Anxiety ++: fear of MS
Physical: BP 130/84 HR 72
- ENT: Decreased hearing left ear
- Lungs: Normal
- Heart: S1-S2 normal; no murmur
- Neuro: Normal
Male 40 years old, OttawaCase 1
Diagnosis: ???
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Type I: Vertigo (Vestibular - Central Nervous System)
Type II: Presyncope (Cardiovascular)
Type III: Walking disequilibrium (Neuromuscular)
Type IV: Light headedness (Plus non specific symptoms)
(Hyperventilation)
" DIZZINESS " evaluation
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History
Type 1: VERTIGO
(temporary disequilibrium, rotating movement)
(Vestibular – Central nervous system)
“Dizziness”
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VESTIBULAR
Nystagmus
CENTRAL NERVOUSSYSTEM
Symptoms - Signs:
Diplopia - Dysarthria
Bilateral Loss of vision
Hemiparesis - Hypoesthesia – Ataxia – Cranial nerves
Vertigo
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Duration
2 days-2 weeks
10 min - 20 hrs.
10 min – 20 hrs.
< 1 minute
Syndrome
Labyrinthitis (Vest.N.)
Recurrent neuronitis
Meniere’s disease
Positional vertigo
Periodicity
0
+ recurrent
++ recurrent
+++ recurrent
Other
0
0
Tinnitus Hearing ∆ Position
Peripherical vestibular vertigo
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Dix Hallpike
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Dix Hallpike
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" Objective ": confirms the diagnosis
" Subjective ": suggests the diagnosis
Positive
Does not rule out the diagnosis!
Négative
Dix Hallpike
NEGATIVE
POSITIVE
History
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Epley’s manoeuver
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Inform the Patient
Day 1: vertical position - sleeping, head elevatedNormal activities afterward
Recurrence rate: 15% (Mobile otoliths)
Provoke vertigo in left -right decubitus (Identifies involved ear)
Recurrence
Repeat posterior canal manoeuvre (Patient himself)
Horizontal canal?: specific manoeuvre
Positional vertigo:Inform the Patient
Recurrence
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1) Wrong diagnosis
2) Wrong ear: cervical arthrosis
3) Wrong position: position “C”
4) Wrong “timing”: >1 1/2 min in each position
5) Wrong canal: horizontal canal? (other manoeuvre)
“Yes we can!” President Obama
Epley’s manoeuvre: FAILURE?
““YES WE CAN…!YES WE CAN…! President Obama
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“Clinical practice guideline: Benign paroxysmal positional vertigo”RECOMMANDATIONS:
Otolaryngology-Head and neck Surgery; November 2008: 139: S47-S81
1) BPV diagnoses is certain: BPV clinical history + Dix-Hall Pike (+)
2) “Clinicians should not obtain radiographic imaging, vestibular testing, or either in a patient diagnosed with BPV.”
3) “Clinicians should not routinely treat BPV with vestibular suppressant medications such as antihistamines or benzodiazepines.” (no Serc)
4) “Clinicians should treat patients with posterior canal BPV with particle repositioning maneuver.” (Epley)
5) Clinicians should revaluate the patient one month after repositioning maneuver.
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ER 14/09/02: Presented 2 “dizzy spells” in the morning while attending a conference
Presents with episodes of sudden “fatigue” or “weakness” lasting 5 minutes for 10 years. Frequency 4 to 6 a year.Has been treated for “hypoglycemia”.
Does not drive his car outside Montreal, fearing a spell while driving! PAST HISTORY: Bilroth II 0 Rx 0 Alcohol
FUNCTIONAL INQUIRY: NEGATIVE (Neuro.- Cardio - Vascular)
PHYSICAL: BP 140/82 HR 72 reg. OTHERWISE: NORMAL (Cardiovascular)
Male 51 years oldCase 4
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System
• Cardiovascular
(90%)
•Neuro (epilepsy)
•Metabolic
Presyncope = cardiovascular syncope
Onset
Sudden
Sudden
Slow
Recovery
Sudden
Slow
Slow
Presyncope
Syncope
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Mechanical: Aortic Stenosis - Left atrium Myxoma
Electric: Bradycardia, tachycadia (supra. or ventricular)
AV block, prolonged sinus pauses...
Reflex: Vagal - " cardiac reflex " - micturition - etc.
Presyncope
« MER »
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• History (sens. 95% - spec. 45%)
• Physical
• ECG
OpinionOpinion Specific diagnosis
Normal heart/Sick heart
Presyncope
Initial evaluation
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• Electric: > 70%LV Dysfonction: ventricular tachycardia
• Reflex: 70%
SickHeart
NormalHeart
Presyncope
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• Past History - Medication
• Onset: Advanced age
• Position: Lying down
• Concomitant Symptoms:
– Chest pains
– Palpitations
• Past history
• Onset: Young age
• Position: Standing
• Activity: Micturition - cough - etc.
• Stimulus: Pain - Discomfort
• Concomitant Symptoms:
– Nausea - Vomiting
– Yawning - Fatigue +++
CardiacSick Heart
ReflexNormal Heart
History
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• BP Lying - Standing: orthostatic hypotention
• BP < 90 mmHg or ∆ BP systolic: > 20 mmHg standing position
• Carotid sinus massage
• Aortic murmur
• Heart failure signs:• jugular veins - pulmonary rales
• S3(+) - Legs oedema
Physical
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• Sinus bradycardia (diagnostic if < 40) - sinus pause > 3
seconds
• Bifascicular bundle branch block
• Second degree AV block (Mobitz I)
• Prolonged QT (> 500 milliseconds)
• WPW
• Brugada’s syndrome
• Supraventricular or ventricular tachycardia
• Myocardial infarction (old or new)
Electrocardiogram
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• Hospit - Ambul. Monitoring
• Echo - Treadmill• Loop Recorder
• EPS
• Ambulatory Monitoring
• Carotid Sinus Massage
• Loop Recorder
• Tilt Table Test
SickHeart
NormalHeart
Specific Evaluation
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First evaluation: 21-08-2001
“Dizzy spells”: 2 types •Vertigo < 1 min changing position, with nausea - vomiting
• (Left lateral decubitus) - recurrent since a car accident in 1993
Dix Hallpike (+) left: Epley left ear
•Presyncope - syncope (Sudden onset - recovery). Began at
age 16 always in standing position, more often with stimulus
(dysmenorrhea and sometimes with nausea induced by BPV)
Woman 48 years oldCase 3
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Woman 48 years old (continued)
Case 3
Diagnosis: ???
Second evaluation: 12-12-2001
Severe disabling “dizzy spells”
• Weakness – Light headedness - " spins in the head "• Concentration difficulty
• Palpitations - Shortness of breath - " Lasts all day " followed by intense fatigue feeling
• Since 08/ 01 no “vertigo” while changing position - no syncope
Past history - Functional inquiry - Physical : NORMAL
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• Identification by the patient of the cause of his symptoms
• Explanation of “respiratory alcalosis”
• Recognition of stopping the symptoms by breath holding
• Elaboration of strategies for stress management
“Break vicious circle”
Provoke patient’s hyperventilation
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History
« Dizziness, Syncope »« Dizziness, Syncope »
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