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A Practical Approach to Assesment of Dizzy Patient

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Dr.Mahmoud Abbas
Dr.Mahmoud Abbas

This document provides a summary of approaches to assessing dizzy patients. It describes classifying dizziness by "flavor" such as vertigo or disequilibrium. It outlines assessing the trajectory of symptoms over time and considering medication side effects. For acute vertigo, a diagnostic matrix is provided to classify it as BPPV, Meniere's disease, vestibular neuritis or labyrinthitis based on persistence and hearing loss. Conditions not fitting the matrix include migraine-associated dizziness, progressive disequilibrium of aging, and cervical vertigo.

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a practical approach to assessment of the dizzy patient
practical assessment • easy – mainly based on the history • effective – diagnostic groups for investigation & treatment
‘flavours’ of dizziness • near syncope • disequilibrium – ‘gait only’ or ‘global’ • true vertigo • psychogenic
trajectory of dizziness over time SYMPTOM SEVERITY TIME
dizziness associated with commonly used drugs Drug Type of dizziness Mechanism Aminoglycosides Vertigo & dyseqm. VHC damage Antiepileptics Dysequilibrium Cerebellar toxicity Tranquilizers Intoxication CNS depression Antihypertensives Near-syncope CBF, Postural & diuretics hypotension Amiodarone Dysequilibrium ? Alcohol Intoxic. & Position. CNS depression & cupula specific gravity Methotrexate Dysequilibrium Cerebellar toxicity Anticoagulants Vertigo Inner ear bleed
diagnostic matrix for acute vertigo VERTIGO EPISODIC PERSISTENT HEARING LOSS + Kentala & Rauch, 2003
diagnostic matrix for acute vertigo VERTIGO EPISODIC PERSISTENT HEARING LOSS + BPPV
benign paroxysmal positional vertigo • most common type of vertigo seen • causes: • closed head injury • vestibular neuritis – 20% will develop BPPV • ear surgery • prolonged bed rest
history : key features • vertigo • sudden attacks triggered by movement • last less than 30 seconds • occur in spells • time of day, sleeping habits • avoidance behaviour • disequilibrium • poor balance, light-headedness, nausea • abnormal postural stability (Herdman, 1995)
A Practical Approach to Assesment of Dizzy Patient
A Practical Approach to Assesment of Dizzy Patient
how do otoconia get into posterior SCC?
mechanisms cupulolithiasis • ‘heavy cupula’ theory • basophilic particles adherent to cupula canalithiasis • free floating particles in SCC
Dix-Hallpike test
Epley canalith repositioning procedure • first patient 1978 • presented 1980 • published 1992 • induced migration of canaliths by gravitation • otoconia dissolve in endolymph (Zucca, 1978)
CRP for left PSCC BPPV
A Practical Approach to Assesment of Dizzy Patient
A Practical Approach to Assesment of Dizzy Patient
Brandt-Daroff exercises (1980)
diagnostic matrix for acute vertigo VERTIGO EPISODIC PERSISTENT HEARING LOSS Meniere’s + disease BPPV
Meniere’s disease • repeated attacks of spontaneous vertigo (hours) with nausea & vomiting • unilateral hearing loss, tinnitus & aural fullness • occurs in clusters • otolithic crises of Tumarkin
Meniere’s disease : natural history • variable • single bout for a few months • relentless course • permanent loss of auditory & vestibular function as disease progresses • burnt-out Meniere’s disease • becomes bilateral in about 40-50%
Meniere’s disease : medical treatment • buccastem • salt restriction • stemetil <2000mg/day suppositories • life style changes • diuretics • betahistine • urea
Meniere’s disease : surgical treatment • aimed at destroying inner ear balance function • intra-tympanic gentamicin injections • labyrinthectomy • vestibular nerve section • ‘conservative’ surgery • endolymphatic sac surgery
diagnostic matrix for acute vertigo VERTIGO EPISODIC PERSISTENT HEARING LOSS Meniere’s + disease labyrinthitis BPPV vestibular neuritis
vestibular neuritis • sudden onset of intense vertigo, lasting several days with vomiting • spontaneous nystagmus away from affected ear • usually able to stand without support • disequilibrium may last for months • “labyrinthitis” – labyrinthine infarction with severe or total acute unilateral hearing loss
vestibular neuritis : natural history • only 50% recover peripheral vestibular function • 20% experience persistent subjective imbalance • 20% develop BPPV • bilateral sequential vestibular neuritis • Meniere’s disease
vestibular neuritis : treatment • no effective treatment • stop vestibular suppressants early • early mobilization • vestibular rehabilitation : Cawthorne-Cooksey exercises
conditions that do not fit ‘the matrix’ • migraine-associated dizziness • progressive disequilibrium of aging • cervical vertigo
migraine-associated dizziness patterns of vestibular dysfunction • vertigo aura with hemi-cranial headache • migraine equivalent vertigo • basilar artery migraine • disturbed baseline vestibular function • more likely to develop BPPV
progressive disequilibrium of ageing • aged patient brought in by adult children • multi-system decline: • ear – vestibular presbyastasis • proprioception – arthritis in major joints • eyes – poor vision & cataracts • CNS – loss of Purkinje’s cells in cerebellum • gradual downward trajectory: gait instability & falls
progressive disequilibrium of ageing treatment • stop vestibular suppressants & sedatives • correct vision & hearing • occupational therapist • hard sole-high top shoe • hand rails, lighting, loose carpets • physiotherapist • exercise gait training • stick or frame
cervical vertigo : risk factors • whiplash injury • cervical disc disease • degenerative arthritis • ergonomic/repetitive stress injury
cervical vertigo : clinical features • provoked by head-on-body movement • combination of floating dysequilibrium & brief episodes of vertigo • cervical trigger points may produce vertigo and/or nystagmus: fibromyalgia
summary • what is the ‘flavour’ of dizziness? • what is the ‘trajectory’? • exclude patient’s medication as a factor • if acute vertigo, does it fit ‘the matrix’? • if not, is it PDA, MAD or CV • if none of the above, consider neurological referral

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A Practical Approach to Assesment of Dizzy Patient

  • 1. a practical approach to assessment of the dizzy patient
  • 2. practical assessment • easy – mainly based on the history • effective – diagnostic groups for investigation & treatment
  • 3. ‘flavours’ of dizziness • near syncope • disequilibrium – ‘gait only’ or ‘global’ • true vertigo • psychogenic
  • 4. trajectory of dizziness over time SYMPTOM SEVERITY TIME
  • 5. dizziness associated with commonly used drugs Drug Type of dizziness Mechanism Aminoglycosides Vertigo & dyseqm. VHC damage Antiepileptics Dysequilibrium Cerebellar toxicity Tranquilizers Intoxication CNS depression Antihypertensives Near-syncope CBF, Postural & diuretics hypotension Amiodarone Dysequilibrium ? Alcohol Intoxic. & Position. CNS depression & cupula specific gravity Methotrexate Dysequilibrium Cerebellar toxicity Anticoagulants Vertigo Inner ear bleed
  • 6. diagnostic matrix for acute vertigo VERTIGO EPISODIC PERSISTENT HEARING LOSS + Kentala & Rauch, 2003
  • 7. diagnostic matrix for acute vertigo VERTIGO EPISODIC PERSISTENT HEARING LOSS + BPPV
  • 8. benign paroxysmal positional vertigo • most common type of vertigo seen • causes: • closed head injury • vestibular neuritis – 20% will develop BPPV • ear surgery • prolonged bed rest
  • 9. history : key features • vertigo • sudden attacks triggered by movement • last less than 30 seconds • occur in spells • time of day, sleeping habits • avoidance behaviour • disequilibrium • poor balance, light-headedness, nausea • abnormal postural stability (Herdman, 1995)
  • 12. how do otoconia get into posterior SCC?
  • 13. mechanisms cupulolithiasis • ‘heavy cupula’ theory • basophilic particles adherent to cupula canalithiasis • free floating particles in SCC
  • 15. Epley canalith repositioning procedure • first patient 1978 • presented 1980 • published 1992 • induced migration of canaliths by gravitation • otoconia dissolve in endolymph (Zucca, 1978)
  • 16. CRP for left PSCC BPPV
  • 20. diagnostic matrix for acute vertigo VERTIGO EPISODIC PERSISTENT HEARING LOSS Meniere’s + disease BPPV
  • 21. Meniere’s disease • repeated attacks of spontaneous vertigo (hours) with nausea & vomiting • unilateral hearing loss, tinnitus & aural fullness • occurs in clusters • otolithic crises of Tumarkin
  • 22. Meniere’s disease : natural history • variable • single bout for a few months • relentless course • permanent loss of auditory & vestibular function as disease progresses • burnt-out Meniere’s disease • becomes bilateral in about 40-50%
  • 23. Meniere’s disease : medical treatment • buccastem • salt restriction • stemetil <2000mg/day suppositories • life style changes • diuretics • betahistine • urea
  • 24. Meniere’s disease : surgical treatment • aimed at destroying inner ear balance function • intra-tympanic gentamicin injections • labyrinthectomy • vestibular nerve section • ‘conservative’ surgery • endolymphatic sac surgery
  • 25. diagnostic matrix for acute vertigo VERTIGO EPISODIC PERSISTENT HEARING LOSS Meniere’s + disease labyrinthitis BPPV vestibular neuritis
  • 26. vestibular neuritis • sudden onset of intense vertigo, lasting several days with vomiting • spontaneous nystagmus away from affected ear • usually able to stand without support • disequilibrium may last for months • “labyrinthitis” – labyrinthine infarction with severe or total acute unilateral hearing loss
  • 27. vestibular neuritis : natural history • only 50% recover peripheral vestibular function • 20% experience persistent subjective imbalance • 20% develop BPPV • bilateral sequential vestibular neuritis • Meniere’s disease
  • 28. vestibular neuritis : treatment • no effective treatment • stop vestibular suppressants early • early mobilization • vestibular rehabilitation : Cawthorne-Cooksey exercises
  • 29. conditions that do not fit ‘the matrix’ • migraine-associated dizziness • progressive disequilibrium of aging • cervical vertigo
  • 30. migraine-associated dizziness patterns of vestibular dysfunction • vertigo aura with hemi-cranial headache • migraine equivalent vertigo • basilar artery migraine • disturbed baseline vestibular function • more likely to develop BPPV
  • 31. progressive disequilibrium of ageing • aged patient brought in by adult children • multi-system decline: • ear – vestibular presbyastasis • proprioception – arthritis in major joints • eyes – poor vision & cataracts • CNS – loss of Purkinje’s cells in cerebellum • gradual downward trajectory: gait instability & falls
  • 32. progressive disequilibrium of ageing treatment • stop vestibular suppressants & sedatives • correct vision & hearing • occupational therapist • hard sole-high top shoe • hand rails, lighting, loose carpets • physiotherapist • exercise gait training • stick or frame
  • 33. cervical vertigo : risk factors • whiplash injury • cervical disc disease • degenerative arthritis • ergonomic/repetitive stress injury
  • 34. cervical vertigo : clinical features • provoked by head-on-body movement • combination of floating dysequilibrium & brief episodes of vertigo • cervical trigger points may produce vertigo and/or nystagmus: fibromyalgia
  • 35. summary • what is the ‘flavour’ of dizziness? • what is the ‘trajectory’? • exclude patient’s medication as a factor • if acute vertigo, does it fit ‘the matrix’? • if not, is it PDA, MAD or CV • if none of the above, consider neurological referral