Presentation on theme: "“VERTIGO” November 12, 2011 Kansas Association of Osteopathic Medicine"— Presentation transcript:
1 “VERTIGO” November 12, 2011 Kansas Association of Osteopathic Medicine Primary Care UpdateG. Marcus Stephens, D.O.
2 Illustrative CaseA 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 continuesThe 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 continuesVS: 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 physiologyUnderstand BPPV.Learn the Dix- Hallpike ManeuverLearn 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 organFamily docs are usually the first to work upThe first 30 seconds in the life of a dizzy complaint are the most importantYou 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, tripleYou “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 termListen 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 disorderNear-syncope: a sensation of impending faintIll-defined lightheadedness: a metaphor for anxiety
13 Vertigo An illusion or hallucination of motion The most common of the 4 typesWe’ve all experienced it, e.g. spinning on a stoolIllusion: a misperception of a stimulus, accounts form most forms of vertigoHallucination: 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 syncopeGerman 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 DizzinessA 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 peopleThere 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 examNeuro examEar exam: just because patients expect it, everyone knows it must be an inner ear problem.Nystagmus: don’t do extremes of gazeDix Hallpike: 2 slides laterNeuro exam: look for dysarthria, aphasia, hemiparesis, hemianopsia, do reflexes and Babinski, and assess gait and visual fields
19 Inner EarLet’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 MRIIf you can’t rember all this, do audiogramRinne: 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 sensorineuralDon’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 degreesHead rotated 45 degreesWatch for nystagmus and ask about vertigoRepeat on other side
23 Central Peripheral cranial nerve findings Hemiparesis Facial weakness DiplopiaHypesthesiaHorner’s signGait ataxia-may have no limb ataxiahearing loss (AICA exception)Able to walkNystagmushorizonto-rotaryGaze-independentReduced with visual fixationDix-Hallpike differences
24 Dix Hallpike Peripheral Central Latency 2-40 seconds None Severity of VertigoSevereMildDuration<1 minute>1 minuteFatigabilityYesNoHabituationPostural InstabilityCan walkFalls, very unstableHearing lossMay be presentUsually absentOther neuro sxsAbsentUsually presentNystagmusOnly one positionIn all positionsFatiguability meanse response remits spontaneously as position is maintainedHabituation means attenuation of response as position is assumed repeatedly
25 BPPV Benign paroxysmal positional vertigo Usually in elderly Self-limitedResponds poorly to antivertigo drugsDue to canaliths
26 CanalithsCanaliths are calcium carbonate debris that gets in the semicircular canals, usually the posterior canal
27 Epley ManueverSeatedSupine with head rotated 45 degrees toward the involved sideRotate to opposite sideRoll to lateral recumbentNose downSit up
28 Post-Epley Instructions Sleep upright 2 nightsCervical collar??Avoid head back positionNo dentist, hair dresserDon’t drive home2 pillows at night for a wkWatch eye drops, shavingAvoid BPPV position
29 Other causes of Vertigo Perilymphatic fistulaVestibular neuronitisLabyrinthitisMeniere’s DiseaseTraumatic VertigoAcoustic NeuromaCrack 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 surgeryVn 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 saltTrauma: 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 lawsuitNeuroma: retrocochlear hearing loss, mild tinnitus and mild vertigo, dx w MRI
31 Non-vertiginous dizziness Near-syncopeUsually 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 DysequilibriumGait disorders, e.g. Parkinsonism,Cervical spondylosisMyelopathy, e.g. B12 deficiencyAlways assess gait.Parkinson’s dz or syndromeSpondylosis: stiff neck and bad proprioception, worse in the shower, the Rhomberg machine, slippery, close eyesMyelopathy: poor proprioception
33 Non-vertiginous dizziness Type IV: Ill-defined lightheadedness“dizzy all the time” a metaphor for anxietyReplace the word dizzy with the word anxiousHyperventillation
34 DRUGS For BPPV if Epley fails For motion sickness (physiologic vertigo)Use anticholinergic drugs that cross the blood-brain barrierWorks better prophylacticallyNASA experienceAntihistamines (sedating)Benzodiazepines (Type IV)Astronauts were continuously vertiginous in early years, now use meclizine 25 mgq6h and ritalin 10mg q6h to combat soporiphic effectPhenergan: very anticholinergic phenothiazine, parenteralScopolamine strong, but old people get deliriousTreat 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 fixationb. Unidirectional fast componentc. Can be horizontal, rotary or verticald. Nystagmus increases with gaze in direction of fast componente. Can be accentuated by head movement
36 Nystagmus due to peripheral causes has all of the following featuresexcept: a. Diminishes with fixationb. Unidirectional fast componentc. Can be horizontal, rotary or verticald. Nystagmus increases with gaze in direction of fast componente. Can be accentuated by head movement
37 Nystagmus due to central causes has all of the following featuresexcept: a. Does not change with gaze fixationb. Can be unidirectional or bidirectionalc. Can be horizontal, rotary or verticald. Nystagmus increases with gaze in direction of fast componente. 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 fixationb. Can be unidirectional or bidirectionalc. Can be horizontal, rotary or verticald. Nystagmus increases with gaze in direction of fast componente. Can be dramatically accentuated by head movement
39 Epley Maneuver Demonstration Montani Semper Liberi