week 10- dizziness Flashcards
4 subtypes of dizziness
- vertigo
- presyncope
- dysequilbirum
- light headed (undifferentiated/ nonspecific)
vertigo
Illusion or hallucination of movement (usually rotation) either of oneself or the environment
pre syncope
Feeling that one is about to faint or lose consciousness (syncope is
the sudden, transient loss of consciousness)
dysequilbiriuum
Impaired walking due to balance difficulties
light headedness/ undiffernetiated/ nonspecific dizziness
Dizziness that is not vertigo, presyncope/syncope or dysequilibrium
vertigo is caused by
most often: dysfunction in the vestibular system from a peripheral or central lesion
Other causes: medications (anticonvulsants, salicylates, antibiotics), psychologic disorders (mood disorders, anxiety, somatization)
peripheral vs central causes of vertigo
peripheral: Menderes disease, vestibular neuritis, benign paroxysmal positional vertigo (BPPV)
central: vestibular migraine, cerebrovascular disease (ischemic or hemorrhagic stroke, VBI)
TiTrATE for diagnosis of dizzinesss
- Timing of the symptom
- Triggers that provoke the symptom
- ** A**nd a Targeted Examination
** FLOW CHART ON SLIDE 9
differences and similarities when doing a flow chart for benign paroxysmal position vertigo (BPPV) and orthostatic hypotension
both episodic and triggered by something
BPPV: positive dix hall pike maneuver
OH: negative dix hallpiek maneuver
Benign Paroxysmal Positional Vertigo (BPPV)
Episodic vertigo (lasting a few minutes or less) triggered by head motion or change in body position
cause of Benign Paroxysmal Positional Vertigo (BPPV)
displaced inner ear otoliths (calcium crystals) into posterior semicircular canal
most common age for Benign Paroxysmal Positional Vertigo (BPPV)
50-70yoa
or head trauma if younger
assessment for Benign Paroxysmal Positional Vertigo (BPPV)
dix-hallpike test
treat Benign Paroxysmal Positional Vertigo (BPPV)
physical therapy with vestibular rehabilitation exercise:
* Epley maneuver (canalith repositioning procedure – repositions canalith from semicircular canal into vestibule)
what to avoid in treatment of Benign Paroxysmal Positional Vertigo (BPPV)
Avoid pharmacological treatment with vestibular suppressant medications such as antihistamines and/or benzodiazepines
orthostatic hypotension is what type of dizziness and usually due to what
Dizziness (usually presyncope) occurs with movement to upright position from sitting or lying down (due to decreased cerebral perfusion)
diagnostic criteria for orthostatic hypotension
systolic BP drops by at least 20 mmHg or diastolic BP drops by at least 10 mmHg within 3 minutes of standing from a sitting or supine position
causes of orthostatic hypotension
hypovolemia (due to dehydration, hemorrhage, overdialysis, hot environments), medications, autonomic insufficiency (neurologic disorders, prolonged bed rest)
similarities and differences between meunière disease, vestibular migraine and panic attack/psychaitric condition
all dizziness or vertigo that is episodic and spontaneous
meunière: hearing loss
vestibular: migraine headache
panic/psych: psychiatric sx
meniere disease is caused by
endolymphatic hydrops (increased volume of endolymph in the semicircular canals); excess fluid pressure causing inner ear dysfunction
sx of meniere disease
Unilateral sensorineural hearing loss with episodic attacks of vertigo (lasting several minutes to hours)
- Severe vertigo may cause nausea, vomiting, loss of balance, and necessitate bed rest
- May also have tinnitus and aural fullness
- Unidirectional, horizontal-torsional nystagmus during episodes of vertigo
treatment of Menderes disease
salt restriction (limit dietary salt intake to <2000 mg/day), reduce caffeine and alcohol intake, diuretics, vestibular suppressant medications for acute attacks, vestibular rehabilitation exercises, intratympanic corticosteroid injections, surgery
vestibular migraines sx
episodic vertigo + unilateral throbbing/pulsatile headaches
nauseas, vomit, photophobia, photophobia, visual auras
diagnostic criteria of vestibular migraines
- At least 5 episodes of vestibular symptoms of moderate or severe intensity lasting 5 min to 72 hours
- Current or previous history of migraine headache
- One or more migraine features (unilateral headache, photophobia, phonophobia, aura) and at least 50% with vestibular symptoms
- No other cause of vestibular symptoms
management of vestibular migraines
identify and avoid migraine triggers, stress management, encourage adequate sleep and exercise, vestibular suppressant medications, preventative medications (anticonvulsants, beta adrenergic blockers, calcium channel blockers, tricyclic antidepressants, butterbur extract, magnesium)
psychogenic dizziness
light headed/nonspecific/ undiffernetntiated dizziness
secondary to psychiatric disorder (i.e. panic, depression, anxiety)
type of dizziness that is likely psychogenic
Continuous vertigo lasting longer than 1-2 weeks without daily variation is likely psychogenic
associated sx and physical findings in psychogenic dizziness
chest pain, shortness of breath, impending sense of doom, palpitations, perioral paresthesias, tingling in hands/feet
physicals:
* Moment-to-moment fluctuations in impairment
* Excessive slowness or hesitation
* Exaggerated sway on Romberg, improved by distraction
* Sudden buckling of knee, typically without falling
* A cautious “walking on ice” pattern
what do barotrauma and medications have in common for dizziness
they are both continuous and causes by trauma or toxin
barotrauma
vertigo from changes in ambient pressure
increases pressure: scuba diving, explosion
decreased: flying, altitude chamber
medication induced dizziness
who’s most susceptible
poly pharmacy + elders
medications that can cause dizziness
-ones with cardiac effects (alcohol, antihistamines, narcotics, antihypertensives)
- anticholinergic
-hypoglycemics
-ototoxicty
-bone marrow suppression and bleeds (anticoagulant)
-cerebellar toxicity (lithium)
etccccc
vestibular neuritis vs stroke or transient ischemic attack
both are continuous and spontaneous and need the HINTS examination (dif findings)
vestibular neuritis: peripheral aetiology; saccade present, unidirectional horizontal nystagmus, normal test of skew
stroke or TIA: central aetiology, no saccade, nystagmus dominantly vertical, torsional or gaze-evoked bidirectional, abnormal test of skew
HINTS exam acronym
Head Impulse-Nystagmus-Test for Skew
- Combines:
- Head impulse test
- Examination of nystagmus
- Test of skew
head impulse test (thrust technique)
how? normal and abnormal findings?
seated and eyes fixed on distant target
turn head quickly to left or right by 15 degrees
normal: eyes remain on target
abnormaL; eyes move off target, followed by saccade (rapid eye movement) back to target) –> peripheral lesion causing deficient vestibuloocular reflex
nystagmus assessment
normal vs central vs peripheral pathology
normal: (functional vestibular system) can maintain gaze during rotation through vestibular ocular reflexes
peripheral pathology (i.e. vestibular neuritis): spontaneous unidirectional horizontal nystagmus
central pathology (i.e. stroke, TIA): spontaneous vertical or torsional nystagmus, or changes direction with gaze
test for skew
normal vs abnormal
pt seated and looks straight ahead, cover 1 eye and see if vertical shift in the uncovered eye
- Normal response: no vertical deviation of the covered eye after uncovering
- Abnormal response: central lesions (brainstem involvement) → slight skew deviation
HINTS exam; how to know if peripheral and central lesion
Abnormal head impulse test with unidirectional nystagmus and
absent skew→suggests peripheral lesion
- Normal head impulse on both sides with direction-changing nystagmus or skew deviation→suggests central lesion
skew test is for what type of lesion
central
second most common cause of vertigo
vestibular neuritis/neuronitis
cause of vestibular neuritis/neuronitis
inflammation of the vestibular nerve most often caused by viral infection
type of vertigo and sx in vestibular neuritis/ neuronitisi
- Severe episodic vertigo not associated with any trigger
- Accompanied by nausea/vomiting, oscillopsia (apparent movement of objects in visual field), unsteady gait (tendency to fall to affected side)
- Spontaneous horizontal (and torsional) nystagmus
- Hearing is not impaired
what is the ddx for vestibular neuritis/neuronitis but is different because it also has hearing loss
labryinthitis
direction of nystagmus in vestibular neuritis
go toward healthy/ unaffected ear
prognosis of vestibular neuritis
great; will go away in a day or so
15% develop benign paroxysmal positional vertigo (BPPV) *
50% have nerve damage that may take 2 months to resolve
treatment for vestibular neuritis
symptomatic treatment with vestibular suppressant medications (antiemetics, antihistamines, benzodiazepines) for first few days, vestibular rehabilitation
Vertebrobasilar Insufficiency (VBI) or
Vertebrobasilar Ischemia
Caused by inadequate blood flow through the posterior circulation of the brain (vertebrobasilar system) which supplies blood to brainstem, cerebellum and inner ear – any major branch occlusion can cause vertigo
RED FLAG
findings in Vertebrobasilar Insufficiency (VBI) or Vertebrobasilar Ischemia
vertigo as initial sx 50%
<50% have neurological findings: cranial nerve dysfunction (e.g., diplopia, dysphonia, dysarthria, dysphagia), cerebellar dysfunction (e.g., ataxia), numbness or weakness
Vertebrobasilar Insufficiency (VBI) or
Vertebrobasilar Ischemia can lead to
transient ischemic attack (TIA) or stroke
Vertebrobasilar Insufficiency (VBI) or
Vertebrobasilar Ischemia treatment
antiplatelet therapy, reduction of risk factors for cerebrovascular disease
acute labyrinthitis cause
Inflammation most often caused by viral infection such as otitis media or meningitis
acute labyrinthitis presentation
Similar presentation to vestibular neuritis but includes hearing loss
- Acute onset of severe vertigo lasting several days with hearing loss and tinnitus
treat acute labryinthtisi
antibiotics, oral corticosteriods, supportive care
Herpes Zoster Oticus (Ramsay Hunt Syndrome)
can cause vertigo how
inflammation of the vestibulocochlear nerve due to reactivation of latent Varicella-zoster virus in the geniculate ganglion
facial nerve too –> facial paralysis
cholesteatoma
in middle ear and mastoid: Proliferation of keratinized stratified squamous epithelium → formation of cyst-like lesion filled with keratin debris
otosclerosis
type of hearing loss? if effects ____ than causes tinnitus and vertigo
- Abnormal growth of bone in middle ear→conductive hearing loss
- May affect cochlea→tinnitus and vertigo
perilymphatic fistula is caused by
leakage of perilymphatic fluid from inner ear into tympanic cavity via the round or oval window
- Mostly results from physical trauma (e.g., head injury, hand slap to ear), extreme barotrauma, vigorous Valsalva maneuvers
perilymphatic fistula is what type of hearing loss
Episodes of vertigo lasting seconds with sensorineural hearing loss
Tumours Arising from the Cerebellopontine Angle
Examples: brainstem glioma, medulloblastoma, vestibular schwannoma
vestibular schwannoma (Tumor)
type of hearing loss
most common lesion in the cerebellopontine angle; meningioma – 2nd most common lesion in the cerebellopontine angle and most common extra-axial tumour in adults
sensorineural hearing loss and vertigo
multiple sclerosis can cause both central and peripheral vertigo; how?
entral: causes demyelinating plaques in the vestibular pathways
- Peripheral: associated with BPPV
red flag cases of vertigo; central lesions
- Cerebrovascular accidents (VBI, TIA, stroke)
- Neoplasms/tumours
sx for red flag central causes of vertigo
neurological deficits
* Diplopia, dysarthria, dysphagia, dysphonia
* Sensory or motor impairment
* Cerebellar dysfunction (e.g., ataxia, dysequilibrium)
physical exam to differentiate btwn central and peripheral vertigo
- Dix-Hallpike maneuver
- HINTS examination
- Gait and Romberg test
- Otoscopic exam, hearing tests (Weber and Rinne)
- Cranial nerve testing
- Blood pressure, orthostatic hypotension
when to do neuroimaging in vertigo
and what type of imaging
- Central lesion is suspected
- Risk factors for stroke, associated focal neurological deficits, a new headache, physical exam is not entirely consistent with peripheral lesion
MRI or MRA
