The Dizzy Patient Flashcards
What is dizziness?
non-specific term
may cover vertigo, pre-syncope, disequilibrium etc
What is vertigo?
a sensation of movement - usually spinning
What are the symptoms of cardiac dizziness?
light-headedness
syncope
palpitations
What are the symptoms of neurological dizziness?
blackouts visual disturbance paraesthesia weakness speech and swallow problems
What is the most common cause of vertigo?
benign positional paroxysmal vertigo
What causes benign positional paroxysmal vertigo?
head trauma
ear surgery
idiopathic
What is the pathophysiology of benign paroxysmal vertigo?
otoliths displaced into semi-circular canals - most commonly posterior SSC
What is the differential diagnosis for benign positional paroxysmal vertigo?
vertebrobasilar insufficiency
How is vertebrobasilar insufficiency differentiated from benign paroxysmal vertigo?
for diagnosis of VBI need other symptoms of impaired circulation in the posterior brain associated with vertigo - e.g. visual disturbance, weakness, numbness
What are the symptoms of benign paroxysmal vertigo?
vertigo on: looking up turning in bed (often worse to one side) first lying down in bed at night first getting out of bed in the morning bending forward rising from bending moving head quickly (often only in one direction)
How is benign paroxysmal vertigo diagnosed?
Dix-Hallpike test
How is the Dix-Hallpike test done?
- ask patient to keep their eyes open and look straight ahead at all times
- place the patient sitting on the couch in such a way that when they lie back their head will be over the edge of the couch
- turn the patient’s head 45° towards the test ear maximal stimulation of the posterior semi-circular canal on lying
- continue to hold the patient’s head between your hands and ask them to lie back on the couch, then quickly lower their head 30° below the level of the couch
- ask the patient if they feel dizzy and look for nystagmus
What happens in a positive Dix-Hallpike test?
vertigo and rotatory nystagmus towards the bottom ear after a latent period of 5-10 seconds which lasts <30 seconds
one sitting there is vertigo +/- nystagmus
Nystagmus should be towards affected ear
What is the treatment for benign paroxysmal vertigo?
Epley manoeuvre
What is the purpose of the Epley manoeuvre?
reposition otolith
How is the Epley manoeuvre performed
- start with patient sitting on the couch, turn patient’s head towards effected side and pause in this position for 30 seconds
- slowly lie the patient flat whilst supporting head, head remains turned to affected side and is hanging off the end of the couch, pause for 30 seconds
- turn the patients head towards the good ear, pause for 30 seconds
- keeping head in the same direction ask the patient to gently move to lie on the hip and shoulder of the good side, then turn head towards good ear (will now be looking at the ground with chin close to the shoulder), pause for 30 seconds
- bring patient to sitting position, ensure head does not change relative to the trunk (chin still on shoulder of good side), pause for 30 seconds
- turn head to centre and flex to put chin on chest in one movement, pause for 30 seconds
What conditions are classed as acute vestibular failure?
vestibular neuronitis
labyrinthitis
What are the symptoms of acute vestibular failure?
vertigo +/- vomiting lasting one to two days
What are the signs of acute vestibular failure?
nystagmus away from affected side
What is the aetiology of acute vestibular failure?
probable viral aetiology - often follows viral urti
How are vestibular neuronitis and labyrinthitis differentiated?
vestibular neuronitits - no associated tinnitus or hearing loss
labyrinthitis - tinnitus and hearing loss
What is the management of acute vestibular failure?
supportive management with vestibular sedatives - generally self limiting
rule of 3s - in bed 3 days, off work 3 weeks, off balance 3 months
prolonged or atypical - further investigation
What is Meniere’s disease?
dilation of the endolymphatic spaces of the membranous labyrinth
What causes Meniere’s disease?
unknown
The incidence of Meniere’s disease is high. TRUE/FALSE
false - its low
What are the symptoms of Meniere’s disease?
recurrent, spontaneous, rotational vertigo with at least two episodes >20 minutes (often last hrs)
tinnitus on affected side
aural fullness on affected sides
documented sensorineural hearing loss on at least one occasion
other causes excluded
What is the management of Meniere’s disease?
betahistamine - reduces frequency and severity of attacks of hearing loss, vertigo and tinnitus
hearing aids
grommet insertion - intratympanic steroids or gentamicin
surgery
What are the surgery options for Meniere’s disease?
labyrinthectomy - 95% effective in controlling vertigo but ipsilateral deafness
vestibular neurectomy - 90% effective, 5% risk of hearing loss
What are the symptoms of a vestibular migraine?
phonophobia (most common auditory symptom)
fluctuating hearing loss and acute permanent hearing loss (rare)
motion sickness
tinnitus
vertigo
What is the natural history of Meniere’s disease?
symptoms resolve in the majority of patients after 5-10 years
majority of patients will be left with a degree of hearing loss
psychological distress
What can be given during acute attacks of Meniere’s disease?
buccal or IM prochlorperazine
How is the acute phase of vestibular neuronitis treated?
prochlorperazine - stopped after a few days as it delays recovery by interfering with central compensatory mechanisms
What type of drug is prochlorperazine?
anti-emetic
What is the management of chronic vestibular neuronitis?
vestibular rehabilitation exercises
betahistine - less effective
What can cause non-vestibular vertigo?
trauma
multiple sclerosis
ototoxicity e.g. gentamicin
What is the most likely diagnosis in an elderly patient dizzy on extending their neck?
vertebrobasilar ischaemia
