1. “VERTIGO” November 12, 2011 Kansas Association of Osteopathic Medicine
Primary Care Update
G. Marcus Stephens, D.O.

2. Illustrative Case
A 67 year-old man rolled over in bed early in the morning and suddenly developed severe nausea as well as the unpleasant sensation that the room was spinning around him. The spinning resolved within 30 seconds but recurred again in the opposite direction when he rolled back to his original position. This had never happened to him before. The patient denied tinnitus, hearing loss, recent viral illness, or head trauma.

3. Case continues
The patient's past medical history was remarkable only for hypertension for which he took atenolol. Surgical history was unremarkable. He did not smoke, drank only occasionally, and denied illicit drug use. Family history was non-contributory. He had no known drug allergies.

4. Case continues
VS: 37.2, 70, 140/85, 12, 98%. The head, eyes, ears, neck, and cardiac examinations were unremarkable. A detailed neurological examination, including mental status, cranial nerves, motor function, sensory function, and cerebellar function, was normal. A Dix- Hallpike (aka Nylan-Barany) test was performed and showed torsional nystagmus in the right head-hanging position, along with reproduction of the patient's symptoms.

5. Objectives What are the 4 major categories of dizziness?
How is it worked up?
How is it treated?
What is vertigo?
Review Inner Ear anatomy and physiology
Understand BPPV.
Learn the Dix- Hallpike Maneuver
Learn Canalith Repositioning technique

7. “Dizziness” Common and Treatable Dx by history
The physical exam is just confirmational.
The dx does not yield to technology, some tests may lead astray.
38% of elderly have this complaint at any given time.
As with many conditions, if you don’t know the dx at the end of the history, you will probably never know the dx.
It does not lend itself well to technology, in fact some tests may lead you astray.
The physical exam is just confirmatory.

8. Rules for taking a history.
NEVER suggest any symptom, especially with dizziness, or any other sensorineurologic condition, e.g. headache, numbness, etc.
You are interviewing the affected organ
Family docs are usually the first to work up
The first 30 seconds in the life of a dizzy complaint are the most important
You say, “does the room spin”
Pt says, “why yes, doctor, the room does spin.
You, “Do you get double vision?”
Pt, “Yes, I see double.”
You, “Triple?”
Pt Yes, triple
You “ever been blind”
Pt “Yes, I’ve been blind.”
Paralyzed…yes, paralyzed.
You “Does your stool glow in the dark?”
Pt…”Yes, doctor, my stool does glow in the dark.
You have created a neurologic monster…this will affect all subsequent interviews.

9. More rules The psychiatrists approach: “Feeling dizzy lately?”
Then WAIT!
Average time a doctor waits for an answer is 8 seconds.
No questionnaires!
I’m busy, how long should I wait…..til hell freezes over. It will save time in the long run.

10. Still more rules ‘Dizzy’ is a lay term
Synonyms include woozy, lightheaded, drunk-feeling, unstable.
Vertigo is becoming a lay term
Listen for localizing symptoms, e.g.. Hearing loss, tinnitis, double vision, dysarthria, ataxia, 4-limb weakness (points to CNS rather than peripheral lesion)
It turns out that there is no increased incidence of vertigo among patients who present complaining of vertigo. They get it from the Hitchcock movie Vertigo, or from internet sites, eg. “Doctor, I have a perilymphatic fistula.”

11. The four types of dizziness
A landmark study done several years ago at Northwestern University on hundreds of patients complaining of dizziness found that the complaints could be categorized into 4 main types:

12. The Four Types Vertigo: an illusion or hallucination of motion
Dysequilibrium: a gait disorder
Near-syncope: a sensation of impending faint
Ill-defined lightheadedness: a metaphor for anxiety

13. Vertigo An illusion or hallucination of motion
The most common of the 4 types
We’ve all experienced it, e.g. spinning on a stool
Illusion: a misperception of a stimulus, accounts form most forms of vertigo
Hallucination: a perception without a stimulus, e.g. vertiginous migraine, temporal lobe seizure

14. Near-syncope A sensation of impending faint.
We’ve all experienced this, e.g. hyperventillating, standing up to fast after squatting, etc.
Only about 50% do faint.
Workup same as for syncope
German study on medical students with EEG and Video monitoring: “looks like a seizure”
Hyperventillating decreases CO2, causing cerebral vasoconstriction (generalized, not focal like a TIA). Worse with crouching and hyperventillating, then stand up and Valsalva, decreases venous return, decreases cardiac output with cerebral vasconstriction, lead to syncope

15. Dysequilibrium A gait disorder
“I stagger” “I feel like I’m drunk” “I feel like I’m going to fall” “I feel unbalanced”
About 50% do fall

16. Ill-defined lightheadedness
Aka Type IV Dizziness
A metaphor for anxiety
“What do you mean, dizzy?”
“I’m just dizzy. I’m dizzy all the time. Nothing really helps.”
Try to use another word to describe how you feel…
“Dizzy!”

17. Prevalence of Dizziness
There is more dizziness than there are dizzy people
There are roughly 1.5 dizzy complaints per dizzy person.
About half of all dizziness is vertigo, the other half is about a third each of the other 3 types.
Some may have a mixture of types…try to ascribe percentages, e.g. 75% vertigo, 25% type IV.

18. Physical Exam Always look in the ear Test hearing Look for nystagmus
Positional exam
Neuro exam
Ear exam: just because patients expect it, everyone knows it must be an inner ear problem.
Nystagmus: don’t do extremes of gaze
Dix Hallpike: 2 slides later
Neuro exam: look for dysarthria, aphasia, hemiparesis, hemianopsia, do reflexes and Babinski, and assess gait and visual fields

19. Inner Ear
Let’s review the anatomy before we discuss the hearing tests and physical exam

20. Hearing Test Is there hearing loss? (Finger rubs)
Is it sensorineural or conductive (Rinne test)
If it’s sensorineural, is it cochlear or retrocochlear (speech discrimination)
If it’s retrocochlear, do MRI
If you can’t rember all this, do audiogram
Rinne: 256 Hz tuning fork on mastoid and by ear, which is louder no. 1 or no. 2, should be no.2, air should be better than bone, if not, then hearing loss is sensorineural
Don’t do Weber (Vay-burr) test, tuning fork in forehead, where do you hear it, they either point to the forehead, or to one ear, at which point you can’t remember what that means.
Phone conversation assesses speech discrimination, which if reduced indicates a retrocochlear problem, probably an acoustic neuroma, so do an MRI of posterior fossa and acoustic canal

21. Dix Hallpike Test Aka Barany’s test Start seated
Supine with neck extended 20 degrees
Head rotated 45 degrees
Watch for nystagmus and ask about vertigo
Repeat on other side

22. Actual photo of Dix Hallpike

23. Central Peripheral cranial nerve findings Hemiparesis Facial weakness
Diplopia
Hypesthesia
Horner’s sign
Gait ataxia-may have no limb ataxia
hearing loss (AICA exception)
Able to walk
Nystagmus
horizonto-rotary
Gaze-independent
Reduced with visual fixation
Dix-Hallpike differences

24. Dix Hallpike Peripheral Central Latency 2-40 seconds None
Severity of Vertigo
Severe
Mild
Duration
<1 minute
>1 minute
Fatigability
Yes No
Habituation
Postural Instability
Can walk
Falls, very unstable
Hearing loss
May be present
Usually absent
Other neuro sxs
Absent
Usually present
Nystagmus
Only one position
In all positions
Fatiguability meanse response remits spontaneously as position is maintained
Habituation means attenuation of response as position is assumed repeatedly

25. BPPV Benign paroxysmal positional vertigo Usually in elderly
Self-limited
Responds poorly to antivertigo drugs
Due to canaliths

26. Canaliths
Canaliths are calcium carbonate debris that gets in the semicircular canals, usually the posterior canal

27. Epley Manuever
Seated
Supine with head rotated 45 degrees toward the involved side
Rotate to opposite side
Roll to lateral recumbent
Nose down
Sit up

28. Post-Epley Instructions
Sleep upright 2 nights
Cervical collar??
Avoid head back position
No dentist, hair dresser
Don’t drive home
2 pillows at night for a wk
Watch eye drops, shaving
Avoid BPPV position

29. Other causes of Vertigo
Perilymphatic fistula
Vestibular neuronitis
Labyrinthitis
Meniere’s Disease
Traumatic Vertigo
Acoustic Neuroma
Crack in the oval window, often due to trauma, may be remote, eg woman fell off horse as a child, vertiginous for 6 weeks, years later got bronchitis, opened again, usually goes away, can be fixed with surgery
Vn usually viral or postviral, like Bell palsy of 8th nerve, if hearing component labyrinthitis, tx w steroid boost, no evidence that antiviral helps, resolves in 6 wks.
Meniere: probably autoimmune, can do antibody test, treat with steroids, antivertigo drugs, valium, lasix, hctz, decrease salt
Trauma: contusion of inner ear, dx w MRI, takes 6-8 wks to go away, don’t confuse w post-concussion syndrome which is more type IV dizziness, usually w work comp or lawsuit
Neuroma: retrocochlear hearing loss, mild tinnitus and mild vertigo, dx w MRI

30. Acoustic Neuroma

31. Non-vertiginous dizziness
Near-syncope
Usually due to impaired ability to vasoconstrict in the upright posture, e.g. hypovolemia, high ambient temperature, hyperventilation, alpha- blockers, ACEi, bp meds.
Overactive baroreceptor response in elderly (treat w betablocker-blocks beta receptor and allows unopposed alpha action)

32. Non-vertiginous dizziness
Dysequilibrium
Gait disorders, e.g. Parkinsonism,
Cervical spondylosis
Myelopathy, e.g. B12 deficiency
Always assess gait.
Parkinson’s dz or syndrome
Spondylosis: stiff neck and bad proprioception, worse in the shower, the Rhomberg machine, slippery, close eyes
Myelopathy: poor proprioception

33. Non-vertiginous dizziness
Type IV: Ill-defined lightheadedness
“dizzy all the time” a metaphor for anxiety
Replace the word dizzy with the word anxious
Hyperventillation

34. DRUGS For BPPV if Epley fails
For motion sickness (physiologic vertigo)
Use anticholinergic drugs that cross the blood-brain barrier
Works better prophylactically
NASA experience
Antihistamines (sedating)
Benzodiazepines (Type IV)
Astronauts were continuously vertiginous in early years, now use meclizine 25 mgq6h and ritalin 10mg q6h to combat soporiphic effect
Phenergan: very anticholinergic phenothiazine, parenteral
Scopolamine strong, but old people get delirious
Treat 3 days before and during and 3 days aftermotion sickness

35. Nystagmus due to peripheral causes has all of the following featuresexcept:
a.    Diminishes with fixation
b.   Unidirectional fast component
c.    Can be horizontal, rotary or vertical
d.   Nystagmus increases with gaze in direction of fast component
e.    Can be accentuated by head movement

36. Nystagmus due to peripheral causes has all of the following featuresexcept:
a.    Diminishes with fixation
b.   Unidirectional fast component
c.    Can be horizontal, rotary or vertical
d.   Nystagmus increases with gaze in direction of fast component
e.    Can be accentuated by head movement

37. Nystagmus due to central causes has all of the following featuresexcept:
a.    Does not change with gaze fixation
b.   Can be unidirectional or bidirectional
c.    Can be horizontal, rotary or vertical
d.   Nystagmus increases with gaze in direction of fast component
e.    Can be dramatically accentuated by head movement

38. Nystagmus due to central causes has all of the following featuresexcept:
a.    Does not change with gaze fixation
b.   Can be unidirectional or bidirectional
c.    Can be horizontal, rotary or vertical
d.   Nystagmus increases with gaze in direction of fast component
e.    Can be dramatically accentuated by head movement

39. Epley Maneuver Demonstration
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