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Vertigo Clearing confusion for patients and doctors

Vertigo Clearing confusion for patients and doctors. Dr SK Ng Specialist in Otorhinolaryngology Division of ENT NT East cluster The Chinese University of Hong Kong. Dizziness and vertigo are common. Dizziness and Vertigo. Ear dysfunction Vascular insufficiency Neurological dysfunction

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Vertigo Clearing confusion for patients and doctors

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  1. VertigoClearing confusion for patients and doctors Dr SK Ng Specialist in Otorhinolaryngology Division of ENT NT East cluster The Chinese University of Hong Kong

  2. Dizziness and vertigo are common

  3. Dizziness and Vertigo • Ear dysfunction • Vascular insufficiency • Neurological dysfunction • Psychological problems

  4. Radiological and Laboratory Tests: • Rarely helpful

  5. Systematic Approach • Arrive at diagnosis • Recognize potentially dangerous condition • Specialist attention

  6. Diagnostic Approach • History • Physical examination • Investigations

  7. The First Question: • What does the patient mean by dizziness? • Giddiness vs Vertigo

  8. Giddiness • Most common form: non-specific light-headedness • Vague and Subjective • Never actual fall or veer

  9. Nonspecific light-headedness • Psychogenic • Hyperventilation • Hypoglycemia • Anemia

  10. Near-syncope • Light-headedness • Generalised weakness • Faintness • Rise from lying or sitting

  11. Typically worse in the morning • When supine: No symptoms • Causes: • 1. Autonomic dysfunction • DM • Drugs: anti-HT, anti-arrhythmic • Cardiovascular disease

  12. Dysequilibrium • Feeling of unsteadiness • No actual illusion of movement • No sensation of faintness

  13. Cause • Dysequilibrium of ageing • multi-sensory deficits • vestibular sedatives not useful • vestibular rehabilitation program • a walking stick

  14. Refer for neurological evaluation • Dysequilibrium + poor gait

  15. Vertigo • Hallucination of movement • Typically but not necessarily rotatory • Lesion in the vestibular system

  16. The Second Question • Is it Benign Paroxysmal Positional Vertigo? • (BPPV)

  17. BPPV • Common • Very characteristic • Highly treatable

  18. Benign Paroxysmal Positional Vertigo(BPPV) • Rotatory vertigo last for seconds • Positional: looking up rapidly • rolling over in bed • Nausea, no vomiting • No tinnitus/ hearing loss

  19. Diagnosis confirmed by Dix Hallpike maneuver

  20. Pathophysiology

  21. Benign Paroxysmal Positional Vertigo(BPPV) • Drugs: USELESS • Treatment of choice: Epley maneuver

  22. 30 Seconds each step

  23. 90% chance of success • What if the maneuver fails?

  24. Try again!

  25. If still fails, • Refer to ENT

  26. The Third Question • Is the vertigo central in origin?

  27. Central Vertigo • Uncommon • Potentially fatal • Refer

  28. Central Vertigo • Associate neurological symptoms • Risk factors for CVA • Severe imbalance • Vertical nystagmus

  29. Peripheral Vertigo

  30. Peripheral Vestibular Disorders • Meniere’s disease • Vestibular neuronitis

  31. Meniere’s disease • rotatory vertigo lasting for hours • Classic triad hearing loss • tinnitus • to 60 years of age • nausea and vomiting

  32. Meniere’s disease Pathogenesis: over-accumulation of fluid within the inner ear Meniere’s disease Normal

  33. Meniere’s disease • Treatment: • Vestibular sedatives • Prophylactic treatment: ? • Ablative surgery

  34. Vestibular neuronitis • Rotatory vertigo last for days • Nausea and vomiting • No otological symptoms • Commonly follow a flu

  35. Vestibular neuronitis • Natural course: • Vertigo followed by a period of unsteadiness • Treatment • Vestibular sedatives • Vestibular rehabilitation

  36. Rarer Peripheral Disorders • Acute suppurative labyrinthitis • Perilymph fistula

  37. Acute suppurative labyrinthitis • Bacterial infection of inner ear • Severe vertigo + hearing loss + ear discharge • Refer ENT

  38. Perilymph fistula • Violation of barrier between middle and inner ear • Vertigo onset after trauma • Refer ENT

  39. To Sum Up ….

  40. Approach to Dizziness • Vertigo vs Giddiness • ? BPPV • ?Central vertigo • Peripheral vertigo: duration of attack • associated otological symtoms

  41. Duration of Vertiginous Attacks • Seconds: BPPV • Minutes: vertebrobasilar insufficiency/ TIA • Hours: Meniere’s disease, migraine

  42. Days: vestibular neuronitis • acute labyrinthitis • cerebellar stroke • Constant: neurological disorder • incomplete recovery of vestibular failure • psychogenic

  43. Physical examination

  44. Dix Hallpike Maneuver • Confirm BPPV

  45. Treatment of Peripheral Vertigo • BPPV • Epley maneuver • 2. Acute sustained vertigo • Vestibular sedatives e.g. stemetil, stugeron

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