The dizzy patient Flashcards
what is the prevalence of dizziness?
it is the most common cause of presentation to the primary care physician in people over 74 years old
what is the percentage of people in the community that suffer from dizziness?
17%
>25% of 50-64 year olds state that they currently suffer dizziness
how many people in the UK consult their GP with vertigo?
5/1000
by the age of 80…
2/3 women and 1/3 men will have experienced episodes of vertigo
what is etiology of dizziness?
Cardiovascular system Haematological and metabolic Anxiety Neurological conditions Drug side-effects / interactions Migraine Otological Trauma
what is the definition of dizziness?
non-specific term, which may cover vertigo, pre-syncope, disequilibrium, etc.
what is the definition of vertigo?
a sensation of movement, usually spinning
what are the central pathways of the balance systems of the body?
visual cardiovascular vestibular vestibule-ocular reflex vestibulospinal tract proprioceptive
what are the conditions that affect the vestibular balance system?
BPPV
menieres
vestibular
neuronitis
what are the conditions that affect the vestibulospinal tract and vestibule-ocular reflex?
stress
migraine
SOL
MS
what are the conditions that affect the proprioceptive balance systems?
DM
arthritis
neurology
what are conditions that affect the visual balance system?
cataracts
DM
what are the conditions that affect the cardiovascular balance systems?
arrthymias
postural hypotension
how can we use history the differentiate between cardiac, neurological & vestibular?
Lightheadedness, syncope, palpitations
Blackouts, visual disturbance, paraesthesia, weakness, speech & swallow problems
Vertigo is a sensation of motion: spinning, falling, being pushed
things to ask in the history?
Triggers? Time Course? Associated symptoms? Precipitators? Alleviating factors? Medication?
vertigo episodes…
duration of episodes is the key
which condition has vertigo episodes that last seconds?
BPPV
which condition has vertigo episodes that last hours?
Menieres
which condition has vertigo episodes that last variable?
migraine associated vertigo
vertigo history:
Associates symptoms also important:
Hearing loss , tinnitus, aural pressure
Migraines or sensory sensitivity
Sound or pressure induced symptoms
Do you get dizzy rolling over in bed?
BPPV
Was your first attack severe, lasting hours with nausea & vomiting?
Vestibular neuritis
Do you get light-sensitive during the dizzy spells?
Vestibular Migraine
Does one ear feel full or do you get hearing loss before or during the dizzy spell?
Meniere’s
Examination of dizzy patient:
Otoscopy Neurological Blood pressure including lying/standing Balance system Audiometry
what are vestibular end organs?
Ampullae of lateral, posterior & superior semicircular canals
Maculae of the utricle & saccule
Different functions
what is the vestibule-ocular reflex?
head movement to the right causes right side excitation and left Side inhibition
what are the common causes of dizziness?
Postural dizziness History, Hb, Na, BP lying/standing Side effect of medication History Psychogenic & interaction with imbalance
what is the commonest cause of vertigo on looking up?
BPPV
what are the causes of BPPV?
it is very common,
head trauma, ear surgery, idiopathic
what is the pathophysiology of BPPV?
otolith material from article displaced into semicircular canals
most commonly in posterior SCC
what is BPPV confused with?
vertebrobasilar insufficiency
what is required for a diagnosis of VBI?
other symptoms of impaired circulation in posterior brain associated with the vertigo such as visual disturbance, weakness, numbness
BPPV causes vertigo on:
looking up
turning in bed - often worse to one side
first lying down in bed at night
on first getting out of bed in the morning
bending forward
rising from bending
moving head quickly – often only in one direction
what is the Dix hall pike test?
Sit up, enough room to lay down on couch Eyes open! Short latency Symptomatic or nystagmus Vertical/torsional geotropic They will be dizzy & maybe sick!
what are tests used to confirm BPPV?
Hallpike’s Test
Epley Manoeuvre
Semont Manoeuvre
Brandt-Daroff Exercises
employ manoeuvre:
70-75% successfully treated with single manoeuvre.
90% symptom free after two manoeuvres
Most easily & successfully treated ‘dizzy patient’
vestibular neuronitis:
prolonged vertigo (days)
with no associated tinnitus or hearing loss
probable viral etiology
may be viral prodromal symptoms
labyrinthitis:
prolonged vertigo (days)
may be associated with tinnitus or hearing loss
probable viral etiology may be vial prodromal symptoms
management of vestibular neuritis/labyrinthitis
Supportive management with vestibular sedatives
Generally self-limiting
If prolonged or atypical may require further investigation
May be helped by rehabilitation exercises if prolonged
Rule of 3s: In bed 3 days, off work 3 weeks, off balance 3 months
Menieres disease:
cause unknown
pathophysiology
incidence - 50-200/100,000
how to diagnose menieres disease?
History of recurrent, spontaneous, rotational vertigo with at least two episodes >20mins (often lasting hours)
Occurrence of or worsening of tinnitus on the affected side
Occurrence of aural fullness on the affected side
Documented SNHL on at least one occasion
Other causes excluded
what is the management of Menieres disease?
Supportive treatment during episodes Tinnitus therapy Hearing Aids Prevention Salt restriction / Betahistine / caffeine / alcohol / stress
Grommet insertion / Meniette
Intratympanic Steroids / Gentamicin
Surgery
what is the incidence of migraines?
15-20%
what is the estimated percentage of migraine sufferers that have spontaneous attacks of vertigo and ataxia?
25%
what is the most common auditory symptom?
photophobia
Fluctuating hearing loss and acute permanent hearing loss occur in a small percentage.
Migraine and Vertigo
migraine and vertigo:
Motion sensitivity with bouts of motion sickness occurs in about 2/3 of patients with migraine.
Episodes of vertigo occur in about one quarter of patients
