CNS/ HN - Dizziness Flashcards
Differential Diagnosis of Dizziness
Dizziness/vertigo
- Vestibular Neuritis
- Menieres
- BPPV
- PICA
- Atrial Fibrillation
- Hypoglycemia
Vertigo: Central Vertigo: • Stroke • Brain Stem Disease (PICA) • Cerebellar cause • Infection • Trauma • Tumour • Complex Migraine • Multiple Sclerosis
Peripheral causes: (Most common causes) • Vestibular Neuritis • Labyrinthitis • Benign Paroxysmal Vertigo • Meniere’s Disease • Acoustic Neuroma • Cervical Spondylosis • Chronic Otitis Media • Ototoxic Drugs
Dizziness - Key History
Key history
vertigo or pseudovertigo (giddiness, faintness or disequilibrium).
Check for neurological symptoms, aural symptoms and visual symptoms.
Recent history of respiratory infection or head injury.
Drug history including illicit drugs and alcohol (?acute intoxication).
Dizziness - Key PE
Key examination •General examination including gait •Cardiovascular, auditory and neurological examinations •Hallpike manoeuvre and Epley test •Forced hyperventilation test
Dizziness - Key Investigation
Key investigations
•FBE
•b glucose
•audiometry
•ECG, ?Holter monitor
•Other tests according to history and examination
•Consider MRI, especially if acoustic neuroma or other tumour suspected
Dizziness - Key Diagnostic
Diagnostic tips
•A sudden attack of vertigo in a young person after a recent URTI suggests vestibular neuronitis.
•Dizziness is often multifactorial, especially in the elderly.
•Commonly prescribed drugs, especially antihypertensives, antidepressants, aspirin and salicylates, glyceryl trinitrate, benzodiazipines, major tranquilisers, antiepileptics and antibiotics, can cause dizziness
Dizziness History approach
From notes I can see you have noticed some vertigo can you describe me what you mean by it: Spinning sensation of room
• Dizziness/light-headedness: usually said as funny turn
• Intensity: how bad is it?
• Quality how is affecting your life or can you explain what you mean by vertigo?
• Onset: Can you explain me how it started and what were you doing when it started?
• Duration for how long the episode lasted?
• Frequency: any similar episodes in past?
• Course: if yes are the symptoms worsening?
• Anything you noticed that brings the episode or relieves symptoms?
Associated symptoms:
• HEENT approach:
• Head: headache
• Higher functions: any LoC, do you feel drowsy/confused/forgetful?
• Motor function: any weakness in any part of your body?
• Sensory: any pins and needle sensation?
• Coordination: any changes noticed way you walk?
• Any tremors or uncontrolled movements noticed?
- Ear:
- any pain in ear? Chronic Otitis Media
- Any loss of hearing? if yes rules out vestibular neuritis (very rare)
- Any sensation of ear fullness? Meniere’s, Acoustic neuroma and Ch. Otitis Media
- or any ringing sensation?, also absent in Vestibular neuritis
- Any recent flu like symptoms: if yes DD: can be labyrinthitis or vestibular neuritis
- Eyes:
- Any blurring of vision?
- Any difficulty negotiating turns or do you bump into things quite often?
- Any coloured halos or double visions?
- Neck:
- do you feel any stiffness/pain in neck? Meningoencephalitis or cervical spondylosis
- Throat:
- any difficulty speaking or swallowing or tasting indicates stroke or brainstem involvement
Other Ddx
• Any fever, nausea or vomiting? - Infection
• Have you recently had any injury to head - Trauma
• Any unintentional weight loss - Malignancy
• Do you feel thirsty quite often and need to go to loo repeatedly? DM
-PMH Hypertension, DM, Migraine or Epilepsy
-FH of Migraine
-SADMA - Alcohol, Medication
Vestibular neuritis - Management
Treatment: • Conservative: • Bed rest • Avoid driving • Avoid seeing in the direction in which you have vertigo
• Specific treatment:
• We will start you n special medication which act as vestibular sedatives:
○ Prochlorperazine (Stemetil)
○ Diazepam
○ Dimenhydrinate
○ Oral Steroids also help in reduction of swelling in the nerve (short course)
• Ensure Regular follow up
• Reading material
• Red flag signs: if symptom worsen, associated with neck stiffness, fever present please present to ER
Vestibular Neuritis - Diagnosis
- Condition: it is inflammation of vestibular nerve which is part of inner ear and helps us in balancing ourselves. It is a transient condition and will settle down over few days.
- Cause: it happened to you because of the recent flu like infection you had
- Commonality: not uncommon
- Complication: disturbing symptoms
Meniere’s Disease - Diagnosis
- Condition: our ear has 3 parts outer, middle and inner ear. In the inner most ear there is a balancing and sound perceiving centre. It contains special fluid called as endolymph if it is produced more than body can normally absorb back causes symptoms as in your case
- Cause: not clear may be autoimmune that is for unknown reasons body defence mechanism gets confused and attacks own our own body.
- Commonality: not uncommon
- Complication: progressive if untreated very discomforting, permanent hearing loss
Meniere’s Disease - Management
• Investigation: Audiogram critical error
Treatment • Conservative: • Bed rest in acute attacks • Avoid coffee, tea, alcohol • Reduce salt intake • Stop smoking • Avoid driving
- Specific:
- Referral to ENT
- Special medication:
- Vestibular sedation
- Water pills
- Closure with 4
BPPV - Diagnosis
- Condition: our inner ear has a special centre function of which is to help us maintain body balancing. It contains special component which is called otolith which help us maintain balance whenever we move our head. For some reason these otoliths have been displaced causing vertigo
- Common
- Cause: already said unknown
- Complication: repeated attack unless replaced to original position.
BPPV - Management
• Avoid positions which aggravates attacks
• Vestibular sedatives
• Referral to physiotherapist trained in vestibular exercise
○ Epley’s Manoeuvre
Hawthorn-Cooksey manoeuvre
PICA - Diagnosis
In our hind brain there is a blood vessel called PICA either there is bleeding or blockage of this vessel causing the symptoms.
• It is a form of stroke
Common
Cause
Clinical feature
• Complication: if left untreated there can be serious or life threatening consequences.
Medical emergency
PICA - Management
- Conservative Mx:
- Admit to stroke unit
- Call Registrar
- Specific:
- Investigation:
- Blood: CBC, LFT, KFT, S. Elec, Lipid profile, BSL, Coagulation profile
- Urine R/E
- Imaging’s: ECG and MRI brain and will be managed by MDT: neurologist, neurosurgeon, physiotherapist, dietician.
Atrial fibrillation - Diagnosis
Condition -
Atrial fibrillation (AF) is a specific irregular rhythm of the heartbeat. Fibrillation means an uncoordinated quivering movement of muscle fibres. Heart function involves the contraction of two chambers: the smaller atrium, which connects to the larger ventricle. The heart’s electrical conduction system runs from the atrium to the ventricle with the ‘firing’ beginning in the atrium. In atrial fibrillation the atrium beats too fast and the ventricle cannot keep pace and beats at a slower and more irregular rate than the atrium. The heart still pumps out blood, usually faster but not as efficiently as normal.
Common
It is very common especially with increasing age but it can occur at any age. It affects about 1 in 10 people over 70 years of age.
Cause The main causes are: s coronary artery disease with or without a previous heart attack s overactive thyroid (thyrotoxicosis) s hypertension s rheumatic heart disease, especially mitral stenosis s cardiomyopathy, S including excess alcohol.
Risk factors for AF include: s increasing age s drugs including some prescribed drugs s excessive alcohol including binge drinking s smoking
Clinical feature
Often there are no symptoms. The most common complaint is palpitations, which is an awareness of faster (racing) or more powerful heartbeats. AF is the most likely diagnosis if a person describes a rapid and irregular heartbeat. Other symptoms include weakness, chest pain (angina), shortness of breath, dizziness or faintness.
Complication
The main danger is the risk of small blood clots forming in the atria from abnormal blood flow. The clots can travel through the circulation and block a smaller artery—this is called embolism. The main concern is an embolus to the brain causing a stroke. This risk is higher in older people.
A common complication is heart failure, which usually causes shortness of breath.
It is important to realise that AF can come and go, with periods of normal heart function between attacks.
