1. Dizziness PBL ST1 session
Jo Swallow
May 2009

2. 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

3. 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

4. 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

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

6. presyncope
is due to cardiovascular conditions that reduce cerebral blood flow

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

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

9. 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.

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

11. 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?

12. 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

13. 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.

14. 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

15. 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

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