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Dizziness. A Patient Complaint That Can Make the Doctor’s Head Spin. What Is Dizziness ? . A non-specific term used to describe a number of signs and symptoms Unsteadiness Giddiness Light-headed Disequilibrium Vertigo. Focus of Diagnostic Workup. Vertigo – auditory and Vestibular system
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Dizziness A Patient Complaint That Can Make the Doctor’s Head Spin.
What Is Dizziness ? • A non-specific term used to describe a number of signs and symptoms • Unsteadiness • Giddiness • Light-headed • Disequilibrium • Vertigo
Focus of Diagnostic Workup • Vertigo – auditory and Vestibular system • Near-faint dizziness– cardiovascular system • Psychophysiological dizziness - psychiatric • Hypoglycemic dizziness- metabolic assessment • Disequilibrium – peripheral nerves, spinal cord, inner ear, vision, CNS Dizziness, Hearing Loss, and Tinnitus/ Baloh,R.W 1998,F.A.Davis Co
Vertigo • An illusion of movement in space • Rotation (most common) • Linear • Tilt
History of the Dizzy Patient • Detailed description of dizziness • Differentiate vertigo from non-vertigo • Determine onset, length, and if recurrent • Associated neurological or systemic signs • Any hearing loss? • Current medications • Differentiate Peripheral vs. Central cause
Peripheral Labyrinth or vestibular nerve dysfunction Recurrent Nystagmus-horizontal Position change Moderate to severe vertigo Central Cerebellum or brain stem dysfunction Continuous Nystagmus-vertical Mild vertigo Non-positional Peripheral or Central Cause? Differential Diagnosis and Management for the Chiropractor, Aspen Publishers, Inc 2001
BPPV Labrynthitis Meniere’s disease Acoustic Neuroma Motion sickness Cervicogenic Perilymphatic fistula Vestibular neuronitis Semicircular canal infection Semicircular canal water penetration Peripheral Vestibular Disorders Assessment of the dizzy patient, Australian Family Physician Vol. 31, No. 8, August 2002
Brain stem lesion Basilar artery migraine TIA Stroke MS Cerebellar lesions Metastatic Tumor Meningioma Central Vestibular Disorders Assessment of the dizzy patient, Australian Family Physician Vol. 31, No. 8, August 2002
Anatomic and Physiologic Components of Balance • Vestibular – labyrinth, vestibular nuclei • Visual – CN III, IV, VI • Proprioceptive – upper cervical ms and joints
Subjective vertigo The patient feels that they are spinning Objective vertigo The patient feels still but objects appear to be moving around them Types of Vertigo
Causes of Vertigo • Ear disease • Toxic conditions (alcohol, food poisonings) • Postural hypotension • Infectious disease • Cervicogenic • Disease of the eye or brain • Psychological
Schimp D. A diagnostic algorithm for the dizzy patient Chiropractic Technique, vol 6(4) Nov 1994
Benign Paroxysmal Positional Vertigo (BPPV) 20% • Brief episodes – recurrent • Moderate to severe • Associated with head position • Gradually diminishes over a month or two • No hearing loss • Latency or delayed onset of S/S • Positive Nylen-Barany maneuver • Caused by otoconia (debris) floating in PSC
Nylen-Barany AKA Dix-Hallpike • Patient seated, head turned 45 degrees • Patient quickly lays supine • Latency period, then horizontal or rotational nystagmus • Nystagmus decreases after 10-20 seconds • Affected ear is the side head is turned toward when nystagmus and vertigo occurs
Nylen-Barany Maneuver Dizziness, Hearing Loss, and Tinnitus R.W. Baloh, F.A. Davis Company 1998
Treatment Options for BPPV • Epley’s • Sermont’s • Habituation exercises (Brandt-Daroff) • Cervical adjusting
Modified Epley’s Maneuver • Patient placed supine with head turned 45 degrees toward the affected ear (30 sec.) • Dr. turns head 90 degrees so affected ear is up. (30 sec.) • Patient rolls on to side, head looking toward the floor (30 sec.) • Patient is lifted into sitting position • Procedure is repeated until no nystagmus
Modified Epley Maneuver Dizziness,Hearing Loss, and Tinnitis R.W. Baloh, F.A. Davis Company 1998
Sermont’s Maneuver • Patient can be instructed to do this at home. • Patient turns head 45 degrees away from the affected side • Quickly lays down maintaining head position (4 minutes) • Brought up and placed on other side with same head position. (4 min) Sit up normal
Sermont’s Maneuver Archives Otolaryngol Head Neck Surgery, Vol 119, p452, 1993
Post Maneuver Instructions • Patient waits 10 min. before leaving office. • Other person drives them home. • Sleep half-reclined 2-3 days. • Avoid laying on bad side. • Avoid extreme head extension for 2-3 days
Cervicogenic Vertigo • Hx of neck trauma, muscle spasm • Limited cervical ROM • Positive chair rotation test (Fitz-Ritson) • Patients may complain of dysequilibrium (tilt) more than rotational vertigo • Overstimulation of upper cervical proprioceptors • May overlap BPPV or Meniere’s disease
Vertebrobasilar Insufficiency TIA’s • Vertigo with associated Neurological signs • Diplopia • Ataxia • Drop attacks • Dysarthria • Paralysis/weakness/Numbness • Headache • Risk factors (HTN, Diabetes, Coronary Disease)
Meniere’s Disease • Sudden and recurrent (paroxysmal) attack of severe vertigo (4th leading cause) • Low-tone hearing loss • Low-tone tinnitis • Sense of fullness in the ear • Vertigo lasts for hours to a day then burn out • Hearing loss may progress
Cause of Meniere’s • Overproduction or retention of endolymph • Possible autoimmune etiology • Head trauma • Previous infection • Pregnant females are more prone
Management of Meniere’s • Salt-restriction diet • Diuretic therapy • Cervical adjusting (overlaps with cervicogenic vertigo
Perilymphatic Fistula • Hx of barometric pressure changes (airplane or weight lifting) • Opening develops between middle and inner ear (oval window rupture) • Rare cause of vertigo • Bearing down reproduces s/s • Tx - surgical
Labyrinthitis • Sudden severe vertigo that last days to weeks • Maybe nausea and vomiting • Viral infection - no hearing loss • Bacterial infection hearing loss
Acoustic Neuroma • Mild but constant hearing loss • Dizziness with possible tinnitis • Gradual onset • Benign schwannoma of 8th CN • Other CN findings as tumor grows • Surgical excision
Cerebral Hemorrhage • Sudden vertigo and nausea • Vomiting associated with a headache • Inability to stand • Nystagmus, nuchal rigidity, facial paralysis, ataxia, dysrythmia, small reactive pupils • Hx of HTN in 2/3 of patients
When to refer to a specialist • Serious vertigo that is disabling • Ataxia out of proportion to vertigo • Vertigo longer than 4 weeks • Changes in hearing • Vertical nystagmus • Focal neurological signs • Systemic disease or psychological origin Australian Family Physician Vol. 31, No 8, August 2002