The Dizzy Patient Flashcards
what is the most common cause of GP presentation in 75+ year olds?
dizziness
dizziness can be related to what 8 things?
cardio haematological and metabolic anxiety neurological drugs migrane ontological trauma
dizziness vs vertigo?
non-specific - can cover vertigo, pre-syncope, disequilibrium
vertigo = sensation of movement, usually spinning
what can affect cardio system to cause dizziness?
arrhythmias
postural hypotension
what can affect vestibular system to cause dizziness?
BPPV
Menieres
vestibular neuronitis
what can affect proprioceptive system to cause dizziness?
diabetes
arthritis
neurology
what can affect visual system to cause dizziness?
cataracts
diabetes
how can central pathways be affected to cause dizziness?
stress
migraine
MS
space occupying lesion
features of cardiac dizziness?
lightheaded, syncope, palpitations
features of neurological dizziness?
blackouts visual disturbance paraesthesia weakness speech and swallow problems
features of vertigo dizziness?
spinning, falling, being pushed sensation
how can duration of episodes aid diagnosis?
seconda = BPPV hours = menieres days = vestibular neuritis variable = migraine associated vertigo
what symptoms may be associated with dizziness?
hearing loss tinnitus aural pressure migraines or sensory sensitivity sound or pressure induced symptoms
top questions for quick diagnosis?
do you get dizzy rolling over in bed? = BPPV
was your first attack severe, lasting hours with nausea and vomiting = vestibular neuritis
do you ever get light sensitive during the dizzy spells? = vestibular migrane
does one ear ever feel full or do you get hearing loss before or during the dizzy spell? = menieres
components of examination of dizziness?
otoscopy neurological BP (lying and standing) balance system audiometry
what are the vestibular end organs?
ampullae of lateral posterior and superior semi-circular canals
maculae of utricle and saccule
how can direction of nystagmus indicate which ear is affected?
usually away from lesion
bilateral nystagmus?
central lesion
excitement of left and right sides of vestibule when head is static/moving
how is this different in normal and right vestibular neuritis?
normal
- equal left and right excitement when static
- more left excitement when turning left
- more right side excitement when turning right
right vestibular neuritis
- no excitement in the right when static so left seems more by comparison and brain therefore thinks head is moving?
vertical nystagmus?
e.g stroke
central lesion
head impulse test?
quick movements of head while focusing on a spot
tests V.O.R
eyes will slip if V.O.R is abnormal
name 3 common causes of ???
postural dizziness
side effects of medication
psychogenic and interaction with imbalance
what causes BPPV
crystals (otoliths) break off membrane of the utricle and float around the ear
can enter the semi-circular canal which can trick the semi-circular canal into thinking youre spinning
what can initially cause BPPV?
head trauma
ear surgery
idiopathic
what can BPPV be confused with and how can they be differentiated?
vertebrobasilar insufficiency (VBI) VBI diagnosis requires other symptoms of impaired circulation in posterior brain associated with the vertigo - visual disturbance - numbness - weakness
when does vertigo occur in BPPV?
looking up turning in bed first lying down in bed at night first getting out of bed in the morning bending forwards rising from bending moving head quickly (often only in one direction)
how is BPPV diagnosed?
Dix hallpike test
turn head 45 degrees to the left or right and
lay down flat with eyes open
hold for 10 seconds
will produce symptoms of characteristic nystagmus in this 10 seconds
- vertical/torsional nystagmus
how is BPPV managed?
Epley manoeuvre (most common)
semont manoeuvre
brandt-daroff exercises
how does the Epley manoeuvre work?
moves the displaced crystals back into the utricle and out of the semi-circular canal
how successful is Epley manoeuvre?
70-75% success with 1 manoeuvre
90% are symptoms free with 2 manouvres
prolonged vertigo and no hearing loss?
probably vestibular neuritis
features of vestibular neuritis?
prolonged vertigo (days)
no associated tinnitus or hearing loss
may be viral prodromal symptoms
common cause of vestibular neuritis?
usually viral
features of labrynthitis?
prolonged vertigo (days)
may be associated with tinnitus or hearing loss
probably viral
may have viral prodromal symptoms
how is vestibular neuritis/labrynthitis managed?
supportive with vestibular sedatives (diazepam etc)
generally self limiting
rule of 3s
- in bed for 3 days
- 3 weeks off work
- off balance for 3 months
further investigation needed if prolonged or atypical
how common in menieres?
very rare
endolymphatic hydlops?/hydrops?
- pressure builds and can rupture and endolymph and perilymph can mix causing severe attacks of vertigo and tinnitus etc
how does menieres disease present?
history of recurrent spontaneous rotational vertigo with at least 2 episodes lasting >20 mins (often last hours)
occurrence of or worsening of tinnitus on affected side
occurrence of aural fullness on affected side
documented sensorineural hearing loss on at least one occasion
other causes excluded
what type of hearing loss in menieres?
low frequency, sensorineural hearing loss
sensorineural vs conductive hearing loss?
sensorineural = cause lies in inner ear, cochlea or vestibulocochlear nerve conductive = due to a blockage, usually temporary
how is menieres disease managed?
supportive during attacks tinnitus therapy hearing aids prevention (low salt/betahistine/caffeine/alcohol/stress) grommet insertion/meniette intratympanic steroids/gentamicin surgery
why does gentamicin work in menieres?
gentamicin is vestibulotoxic (damages vestibular apparatus)
what surgery can be used for menieres?
vestibular nerve section (separate vestibular and cochlear nerves and then cut the vestibular nerve)
what symptoms can accompany migrane?
photophobia
phonophobia
25% have spontaneous vertigo and ataxia (doesn’t have to come with headache, can occur in the absence of a headache)
motion sensitivity with bouts of motion sickness
how does vestibular schwannoma present?
progressive imbalance and hearing loss with tinnitus
