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The Dizzy patient

The Dizzy patient. Vertigo Presyncopal dizziness hypoglycaemic dizziness feeling drunk sense of dysequilibrium unsteadiness loss of balance light headedness. Duration of symptoms Onset -?sudden Length of episode(s) Other neurology? ?Fever, headache, trauma Precipitating factors

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The Dizzy patient

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  1. The Dizzy patient • Vertigo • Presyncopal dizziness • hypoglycaemic dizziness • feeling drunk • sense of dysequilibrium • unsteadiness • loss of balance • light headedness

  2. Duration of symptoms Onset -?sudden Length of episode(s) Other neurology? ?Fever, headache, trauma Precipitating factors Previous episodes ? neck trauma ? ototoxic drugs Dizziness - History

  3. Dizziness - examination • eye movements • hearing • Weber’s test • neck • Hallpike manoeuvre • finger-nose • heel-toe walking • Romberg’s

  4. The semicircular canals - 1 • Posterior vertical canal is transverse and causes most BPV • Ampulla at end of each canal contains crista or cupola: hair cells (each with kinocilium and stereocilia) • Endolymph in canals detects angular acceleration by movement of kinocilium towards stereocilia • vertical canals stimulated by movement away from ampulla

  5. Causes of vertigo • Benign positional vertigo • Migraine • Viral labyrinthitis • traumatic vestibular damage • Chronic vestibulopathy • Meniere’s diesase • Ischaemia • Vertebrobasilar insufficiency

  6. Benign Positional Vertigo • Many causes • Positional • Usually brief • Often turning in bed • Hallpike manoeuvre - fatiguable torsional vertical nystagmus

  7. Aim to keep image on fovea by saccadic eye movements (Saquer = to pull as in the tug of a horses reins to turn head or the flicking of a sail in a gust of wind) Prolonged head rotations use Smooth pursuit movements, which in man needs VOR suppression Precise relationship between individual semicircular canals and pulling direction of extraocular muscles VORs keep eyes stationary Vestibulo-ocular reflex

  8. Fluid in left horizontal canal moves towards cupola Excitation in medial vestibular nucleus Opposite VI and up ipsilateral MLF to III Eyes move to right, maintaining image on fovea Extra information from cerebellum and proprioceptive stretch receptors in neck muscles via vestibulospinal tract VOR, turning head to left

  9. There is no rational basis for using specific drugs based on understanding of receptors and neurotransmitters Glutamate, GABA and ACh (Hist, 5HT, peptides, DA, NA) Prochlorperazine(Stemetil) Betahistine (Serc) Cinnarazine (Stugeron) Cyclizine Hyoscine promethazine (Phenergan) Drug treatment of dizziness

  10. Positional Manoeuvre for BPV (Epley’s) BMJ 311: 489 (1995) Drugs vestibular rehabilitation Other Treatment of Vertigo

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