Dizziness PBL ST1 session Jo Swallow May 2009

DIZZY dizziness is a non-specific term used to describe a sensation of altered orientation in space vertigo is the hallucination of rotation or movement of one's self or one's surroundings. Dizziness is of little diagnostic value without trying to elaborate further information. However, when vertigo, postural hypotension or other types of unsteadiness are less severe or chronic, it may be impossible to describe the sensation more accurately than "dizziness". If there is loss of consciousness then this defines the term syncope

vertigo more than 50 percent of cases of dizziness in primary care it is frequently horizontal and rotatory may be associated with nausea, emesis, and diaphoresis

cause may be central or peripheral when associated with nausea and vomiting, should look for a peripheral rather than central cause Central-due to a disorder of the brainstem or the cerebellum Peripheral-due to a disorder in the inner ear or the VIIIth cranial nerve

lightheadedness this is non-specific sometimes difficult to diagnose may be associated with panic attacks

presyncope is due to cardiovascular conditions that reduce cerebral blood flow

dysequilibrium feeling of unsteadiness and instability peripheral neuropathy eye disease peripheral vestibular disorders

Or any of below psychiatric disorders, seizure disorders, motion sickness, otitis media, cerumen impaction

Ramsay Hunt The Ramsay Hunt Syndrome is characterised by sensorineural deafness, vertigo and facial paralysis following Herpes Zoster infection. The patient is usually elderly. Herpes zoster infects the geniculate ganglion, more rarely the IXth and Xth nerves and, very occasionally, nerves V, VI or XII. Recovery of facial nerve function is less likely than in Bell's palsy. The prognosis may be improved by treatment with acyclovir.

Ramsay hunt sensorineural deafness, vertigo facial paralysis following Herpes Zoster infection. The patient is usually elderly

Jo’s 5 minute dizzy examination History dependant Neuro Cardio Entry to the room (gait) Blood pressure + Pulse (standing if low/hx suggestive) Cranial nerves – fundoscopy, perla?eye movements ?nystagmus, fields by confrontation, Can they hear me? Any hearing complaints?

Dizzy 2 Otoscopy ? Lymph nodes ?cervical spine tenderness Finger nose test Rombergs Dicks hallpike +/- rebook for epley Listen to heart sounds and ?bruits when on the bed

Who to refer recurrent separate episodes neurological symptoms eg dysphasia, paraesthesiae, or weakness associated sensorineural deafness abnormality of the eardrum (especially cholesteatoma) or inadequate visualisation atypical nystagmus eg non-horizontal, persisting for weeks, changing in direction or differing in each eye If the patient has hearing problems in addition to vertigo then referral should be made to an ENT specialist. Other cases should be referred to a neurologist.

My 2 minute explanation of labyrinthitis This is a very common VIRAL ailment therefore…… It often follows an URTI and may occur repeatedly Unfortunately if you are prone to it you may get it again It causes vertigo, nausea and sometimes vomiting It is self limiting but can be helped symptomatically by prochlorperazine or domperidone. Buccal/suppository if vomiting. Usually settles in 7-14 days. If it perseveres do come back. There is unlikely to be any serious cause for this, it certainly doesn’t sound like a developing stroke or a brain tumour at all

My 2 minute explanation of BPPV This condition causes brief episodes of recurring vertigo on turning the head We all have crystals in our inner ear which are floating they control our balance, miniscule position changes create the illusion of movement. When the position is disrupted it can cause dizziness. There is a manouvere which attempts to redistribute these crystals Epley manouvere Vomit bowl handy We can teach patients to do this themselves

Epley manouvere http://www.youtube.com/watch?v=ZqokxZRbJfw Science fiction? Placebo ?crystal repositioning