Dizziness and Vertigo

1. By Meighan O’Connor, POPPF Dizziness and Vertigo

2. Dizziness includes lightheadedness, motion intolerance, imbalance, floating or vertigo. Vertigo is a type of dizziness defined as the illusion of the environment or oneself spinning. Approximately 40 % of dizzy patients have peripheral vestibular dysfunction; 10 % have a central brainstem vestibular lesion; 15 % have a psychiatric disorder; and 25 % have other problems, such as presyncope and disequilibrium. Dizzinessand Vertigo

3. HPI: 52 y/o female with h/o Ehlers Danlos type IV and migraines complains of “dizziness.” She states that earlier today she was walking into her living room and suddenly started stumbling to the right and fell into the floor. While she was lying on the floor she could not focus on objects and the room would not stop spinning. She denies nausea, vomiting, sweating, syncope, numbness, tingling, weakness, other vision or hearing changes, trouble speaking, new or severe h/a, or chest pain. After two minutes the sensation went away and she was left with 2/10 pain on the left side of her neck and head that is still present. She said this has never happened before. CC: “Dizziness”

4. Meds: Imitrexprn, PMHx: Ehlers Danlos Type IV diagnosed three years ago, migraines for past 25 years. SHx: Sigmoid colon perforation repair 30 years ago. SocHx: Denies using tobacco products or ETOH

5. Vitals: BP 134/87 standing, 138/88 supine Pulse 80; RR 14 HEENT: PERRLA, EOM intact BL; Tympanic membrane grey and reflective BL, Weber and Rinne hearing test negative BL; Nasal turbinates non-inflamed, pink and moist BL; Throat pink and moist, no ulcers. Cardio: No carotid bruits or murmurs auscultated BL, normal rate Neuro: CN II-XII intact BL, sensation was intact BL and DTR were 2/4 BL, heel-toe walking was normal. MSK: Full ROM of cervical spine BL, C2-C5FRLSL with associated hypertonic paraspinals BL Cranial: CRI at 16 cycles/minute PE

6. TIA CVA Vertebral Artery Dissection Brain Tumor BPPV Vestibular Neuronitis (mcc acute vertigo) DDX

7. Dizziness not including vertigo is more likely due to central nervous system (CNS) such as MS, cardiovascular such as CVA and orthostatic hypotension, or systemic diseases such as anemia where the symptoms are often gradual and ill-defined. Cardiovascular disease is important to rule out in the elderly, although dizziness at a late age may have multiple etiologies. Common Causes of Dizziness:

8. Inner Ear Pathology: • Vestibular Neuronitisis the most common cause of acute vertigo and may result from a reactivation of HSV that affects the vestibular ganglion nerves. Vertigo is without auditory or other CNS symptoms and lasts for several days • Benign Paroxysmal Positional Vertigo is the second most common cause of vertigo. Typically patients experience brief vertigo upon changing head or body position. The mechanism of BPPV can be due to canalithiasis (otoconia floating in the endolymph) or cupulolithiasis (otoconia adherent to cupula). • MénièreDisease presents with symptoms of episodic vertigo, tinnitus, and hearing loss. Untreated, severe hearing loss and unilateral vestibular paresis are inevitable. The common pathophysiology is disordered fluid homeostasis in the inner ear. • Other Pathology: TIA or Stroke, MS, post-traumatic as with concussion, medicatons, migraines Common Causes of Vertigo

9. Modified Epley Maneuver

10. Epley Maneuver

11. In order to r/o vertebral artery dissection, an MRA was performed. The test showed a diminutive left vertebral artery with a focal area of absent/decreased flow and abnormal signal hyperintensity from the C1-2 through the C5-6 levels. These findings likely represent dissection of a short segment of vertebral artery. Patient was given intravenous heparin and then switched to warfarin anticoagulation CC: “Dizziness”

12. Medications: • An antihistamine, such as the prescription medicine meclizine, or non-prescription medicines like dimenhydrinate, or diphenhydramine. • Prescription anti-nausea medicines, such as promethazine, metoclopramide, or ondansetron. • Prescription sedative medicines, such as diazepam, lorazepam, or clonazepam • Canalith repositioning: • Maneuvers such as Epley Maneuver is a treatment that may be recommended for people with benign paroxysmal positional vertigo (BPPV). The purpose is to reposition any otoliths in the vestibular canals. • Balance rehabilitation: • Most patients with vertigo prefer to keep their head still. However, staying still and not moving the head can make it harder to cope with vertigo. Rehabilitation can help people with vertigo that is caused by injury to the vestibular system. The vestibular system includes parts of the inner ear and nervous system, which controls balance. • The rehabilitation works by helping your brain adjust its response to changes in the vestibular system. The therapy can also help train your eyes and other senses to "learn" how to compensate. This therapy is most helpful when it is started as soon as possible after you develop vertigo. TX

13. Dizziness can be caused by a temporal bone dysfuncion -specifically the bone becomes internally rotated, compressing the vestibulochoclear nerve (CN VIII) which can also cause tinnitis. SCM hypertonicityespecially when chronic can pull the temporal bone and cause local tissue inflammation, blocking the lymphatic flow. i.e. meniere's syndrome. Otitis media can give vestibular symptoms that can be treated using the raking the face maneuver. Many case studies have been reported where treating the cervical soft tissue and joints gave significant or complete relief of dizziness. Somatic dysfunctions of the cervical spine including OA, upper thoracicsand cranium should be treated. OMT

14. Dizziness, Vertigo, and Imbalance Author: Hesham M Samy, MD, PhD; Chief Editor: Robert A Egan, MD http://emedicine.medscape.com/article/1159385-overview#a30; Patient information: Dizziness and vertigo; Author Joseph M Furman, MD, PhD; Section Editor Michael J Aminoff, MD, DSc; Deputy Editor Janet L Wilterdink, MD http://www.uptodate.com.ezproxylocal.library.nova.edu/contents/patient-information-dizziness-and-vertigo?source=search_result&search=epley+maneuver&selectedTitle=2%7E4 A Case of Dizziness , http://www.ferne.org/Lectures/dizziness1001.htm#AB Osteopathic Approach to Vertigo, Developed for OU-COM CORE by: Derek Stone, DO. 2006. http://www.ohiocore.org/gfx/media/contribute/Session9CranialPPT_000.pdf Dizziness and Vertigo, Attorney & Physician Advisory Board, American Medical Forensic Specialists, Inc. http://www.bailey-law.com/docs/dizziness-and-vertigo.htm References