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Referred for severe « dizzy spells » PRESENT ILLNESS:

Case 1. Male 40 years old, Ottawa. "  Linesman  " (Hydro Ontario). Referred for severe « dizzy spells » PRESENT ILLNESS: First episode March 1997 (1h) and June 1997 (2h45) Daily DIZZY SPELLS, completely incapacitating, since fall 97 Stopped working 3 1/2 years ago

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Referred for severe « dizzy spells » PRESENT ILLNESS:

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  1. Case 1 Male 40 years old,Ottawa " Linesman " (Hydro Ontario) • Referred for severe « dizzy spells » • PRESENT ILLNESS: • First episode March 1997 (1h) and June 1997 (2h45) • Daily DIZZY SPELLS, completely incapacitating, • since fall 97 • Stopped working 3 1/2 years ago • 2 operations on the left ear in 1998

  2. Diagnosis: ??? Case 1 Male 40 years old,Ottawa Past history: Negative Rx: None Functional inquiry: Negative - No neurological symptoms - Anxiety ++: fear of MS Physical: BP 130/84 HR 72 - ENT: Decreased hearing left ear - Lungs: Normal - Heart: S1-S2 normal; no murmur - Neuro: Normal

  3. " DIZZINESS " evaluation Type I: Vertigo (Vestibular - Central Nervous System) Type II: Presyncope (Cardiovascular) Type III: Walking disequilibrium (Neuromuscular) Type IV: Light headedness (Plus non specific symptoms) (Hyperventilation)

  4. “Dizziness” Type 1: VERTIGO (temporary disequilibrium, rotating movement) (Vestibular – Central nervous system) History

  5. Symptoms - Signs: Diplopia - Dysarthria Bilateral Loss of vision Hemiparesis - Hypoesthesia – Ataxia – Cranial nerves Nystagmus Vertigo VESTIBULAR CENTRAL NERVOUS SYSTEM

  6. Peripherical vestibular vertigo Other 0 0 Tinnitus Hearing ∆ Position Syndrome Labyrinthitis (Vest.N.) Recurrent neuronitis Meniere’s disease Positional vertigo Duration 2 days-2 weeks 10 min - 20 hrs. 10 min – 20 hrs. < 1 minute Periodicity 0 + recurrent ++ recurrent +++ recurrent

  7. Dix Hallpike

  8. Dix Hallpike

  9. Positive POSITIVE Négative NEGATIVE Dix Hallpike "Objective ": confirms the diagnosis "Subjective ": suggests the diagnosis Does not rule out the diagnosis! History

  10. Epley’s manoeuver

  11. Inform the Patient Inform the Patient Recurrence Recurrence Positional vertigo: Day 1: vertical position - sleeping, head elevated Normal activities afterward Recurrence rate: 15% (Mobile otoliths) Provoke vertigo in left -right decubitus (Identifies involved ear) Repeat posterior canal manoeuvre (Patient himself) Horizontal canal?: specific manoeuvre

  12. 1) Wrong diagnosis 2) Wrong ear: cervical arthrosis 3) Wrong position: position “C” 4) Wrong “timing”: >1 1/2 min in each position 5) Wrong canal: horizontal canal? (other manoeuvre) “Yes we can!” President Obama Epley’s manoeuvre: FAILURE? “YES WE CAN…! President Obama

  13. “Clinical practice guideline: Benign paroxysmal positional vertigo” RECOMMANDATIONS: Otolaryngology-Head and neck Surgery; November 2008: 139: S47-S81 1) BPV diagnoses is certain: BPV clinical history + Dix-Hall Pike (+) 2) “Clinicians should not obtain radiographic imaging, vestibular testing, or either in a patient diagnosed with BPV.” 3) “Clinicians should not routinely treat BPV with vestibular suppressant medications such as antihistamines or benzodiazepines.” (no Serc) 4) “Clinicians should treat patients with posterior canal BPV with particle repositioning maneuver.” (Epley) 5) Clinicians should revaluate the patient one month after repositioning maneuver.

  14. Case 4 Male 51 years old ER 14/09/02: Presented 2 “dizzy spells” in the morning while attending a conference Presents with episodes of sudden “fatigue” or “weakness” lasting 5 minutes for 10 years. Frequency 4 to 6 a year. Has been treated for “hypoglycemia”. Does not drive his car outside Montreal, fearing a spell while driving! PAST HISTORY: Bilroth II 0 Rx 0 Alcohol FUNCTIONAL INQUIRY: NEGATIVE (Neuro.- Cardio - Vascular) PHYSICAL: BP 140/82 HR 72 reg. OTHERWISE: NORMAL (Cardiovascular)

  15. System • Cardiovascular (90%) • Neuro (epilepsy) • Metabolic Onset Sudden Sudden Slow Recovery Sudden Slow Slow Presyncope Presyncope = cardiovascular syncope Syncope

  16. Presyncope « MER » Mechanical: Aortic Stenosis - Left atrium Myxoma Electric: Bradycardia, tachycadia (supra. or ventricular) AV block, prolonged sinus pauses... Reflex: Vagal - " cardiac reflex " - micturition - etc.

  17. Specific diagnosis Opinion Normal heart/Sick heart Presyncope • History (sens. 95% - spec. 45%) • Physical • ECG Initial evaluation

  18. Normal Heart Sick Heart Presyncope • Reflex: 70% • Electric: > 70% • LV Dysfonction: ventricular tachycardia

  19. Reflex Normal Heart Cardiac Sick Heart History • Past history • Onset: Young age • Position: Standing • Activity: Micturition - cough - etc. • Stimulus: Pain - Discomfort • Concomitant Symptoms: • Nausea - Vomiting • Yawning - Fatigue +++ • Past History - Medication • Onset: Advanced age • Position: Lying down • Concomitant Symptoms: • Chest pains • Palpitations

  20. Physical • BP Lying - Standing: orthostatic hypotention • BP < 90 mmHg or ∆ BP systolic: > 20 mmHg standing position • Carotid sinus massage • Aortic murmur • Heart failure signs: • jugular veins - pulmonary rales • S3(+) - Legs oedema

  21. Electrocardiogram • Sinus bradycardia (diagnostic if < 40) - sinus pause > 3 seconds • Bifascicular bundle branch block • Second degree AV block (Mobitz I) • Prolonged QT (> 500 milliseconds) • WPW • Brugada’s syndrome • Supraventricular or ventricular tachycardia • Myocardial infarction (old or new)

  22. Normal Heart Sick Heart Specific Evaluation • Ambulatory Monitoring • Carotid Sinus Massage • Loop Recorder • Tilt Table Test • Hospit - Ambul. Monitoring • Echo - Treadmill • Loop Recorder • EPS

  23. Case 3 Woman 48 years old • First evaluation: 21-08-2001 • “Dizzy spells”: 2 types • Vertigo < 1 min changing position, with nausea - vomiting • (Left lateral decubitus) - recurrent since a car accident in 1993 • Dix Hallpike (+) left: Epley left ear • Presyncope - syncope (Sudden onset - recovery). Began at age 16 always in standing position, more often with stimulus (dysmenorrhea and sometimes with nausea induced by BPV)

  24. Diagnosis: ??? Case 3 Woman 48 years old (continued) • Second evaluation: 12-12-2001 • Severe disabling “dizzy spells” • Weakness – Light headedness - " spins in the head " • Concentration difficulty • Palpitations - Shortness of breath - " Lasts all day " followed by intense fatigue feeling • Since 08/ 01 no “vertigo” while changing position - no syncope • Past history - Functional inquiry - Physical : NORMAL

  25. Provoke patient’s hyperventilation • Identification by the patient of the cause of his symptoms • Explanation of “respiratory alcalosis” • Recognition of stopping the symptoms by breath holding • Elaboration of strategies for stress management “Break vicious circle”

  26. « Dizziness, Syncope » • WWW.LEMIEUXBEDARD.COM/EMC History

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