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four types of dizziness. Vertigo lightheadedness, presyncope, dysequilibrium. . accounts for 54% of all dizziness. Vertigo. The big question

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1. Vertigo Chris Edwards, DO Wednesday, 2/6/2007

2. four types of dizziness Vertigo lightheadedness, presyncope, dysequilibrium

3. accounts for 54% of all dizziness

4. The big question…

5. Central causes Cerebellopontine angle?tumor Vestibular schwannoma (acoustic neuroma) as well as infratentorial ependymoma, brainstem glioma, medulloblastoma or neurofibromatosis Cerebrovascular disease (TIA or stroke) Arterial occlusion causing ischemia or infarct, especially of VBS)

6. Central Causes Migraine Vertigo preceded by HA that is throbbing, unilateral, aura, NV, photophobia, phonophobia Multiple sclerosis Demyelination of white matter in CNS

7. Peripheral Causes Acute labyrinthitis Inflammation of the labyrinthine organs caused by viral or?bacterial infection Acute vestibular neuronitis (vestibular neuritis) Inflammation of the vestibular nerve, usually caused by viral infection Benign positional paroxysmal vertigo Transient vertigocaused by stimulation of vestibular sense organs, usually in middle age or older, women 2x that of men

8. Peripheral Causes Cholesteatoma Cyst like lesion filled with keratin debris, most often involving middle ear and mastoid Herpes zoster oticus (Ramsay Hunt syndrome) Vesicular eruption affecting ear Meniere's disease Recurrent vertigo, hearing loss, tinnitus, or aural fullness caused by increased volume of endolymph in semicircular canals Otosclerosis Hardening or thickening of tympanic membrane caused by age or recurrent infections Perilymphatic fistula Breech between middle and inner ear often caused by trauma or excessive straining

9. Other causes Cervical vertigo Triggered by somatosensory input from head and neck movement Drug induced vertigo (EtOH, aminoglycosides, anticonvulsants, antidepressants, antihypertensives, barbiturates, cocaine, diuretics, NTG, quinine, salicylates, sedative/hypnotics Psychological Mood, anxiety, somatization, personality, EtOH abuse

10. Start with a good history Hx alone will dx 3 out of 4 patients Start by asking “When you feel dizzy, do you feel lightheaded, or do you feel like the world is spinning around you?”

11. History Next, is it peripheral or central Timing and duration What provokes or aggravates Associated sxs Rotatory illusions (peripheral) Nausea, vomiting (peripheral) Nystagmus

12. History Timing and duration The longer the sxs last, the more likely it is central Sudden onset more suggestive of peripheral Early morning vertigo may be more suggestive of peripheral

13. History Provoking Factors Positional changes—usually BPPV Turning in bed, bending at waist and then straightening, or extending neck Recent viral illness– acute vestibular neuronitis, acute labyrinthitis Same provokers as those of migrainous HA Trauma, excessive straining (perilymphatic fistula) Psychosocial stress– anxiety, hyperventilation

14. History Associated sxs Hearing loss (usually peripheral cause) Exception is CVA involving internal auditory artery or inferior cerebellar artery Pain Acute middle ear, invasive of temporal bone, or meningeal irritation Nausea/vomiting Usually less severe in central disease Neuro Sxs Weakness, dysarthria, vision or hearing changes, change in consciousness, ataxia, motor/sensory changes Migrainous (21-35% of pts with migraines have vertigo)s

15. Medical History Medications Trauma Toxins Age related illness Diabetes, HTN Family Hx Migraines, CVA risk

16. Physical Examination Most importantly Neurological Head and Neck Cardiovascular

17. Physical Examination Head and Neck Tympanic membranes Vesicles suggest Ramsey Hunt Syndrome (herpes zoster oticus) Cholesteatoma Hennebert’s sign Vertigo caused by pushing on tragus or external auditory meatus of affected side ? perilymphatic fistula Valsalva maneuver Forced exhalation with mouth and nose closed? again ?perilymphatic fistula or semicircular canal dehiscence

18. Physical Examination Cardiovascular Orthostatic changes Drop of 20 mmHg or increase of 10 BPM may suggest dehydration or autonomic dysfunction Arrhythmias Carotid Bruits or other signs of atherosclerosis

19. Physical Examination Neurological Cranial nerves Palsies, sensorineural hearing loss Nystagmus Vertical– 80% sensitive for vestibular nuclear or cerebellar lesions Horizontal– with or without rotatory component suggests peripheral cause

20. Physical Examination Gait and balance If peripheral, pt will be able to walk Central –pt usually will be severely impaired in walking Psych Hyperventilation for 30 s may help in ruling out psychogenic causes, though this can exacerbate vertigo if it is a perilymphatic fistula or acoustic neuroma

21. Dix-Hallpike Maneuver MOST HELPFUL TEST!!! PPV of 83%, NPV of 52% in diagnosing BPPV Intensity of induced sxs should decrease with each maneuver if peripheral in origin Combo of +DH and hx of vertigo or N/V strongly suggests peripheral cause If provokes purely vertical (downbeating) or torsional w/o latent period, suggests central


23. Dix Hallpike Pt sits upright, warn pt, turn head 30-45 degrees to side being tested, pt keeps eyes open and focused on examiner’s eyes or forehead. Then, supporting head, pt quickly lies supine (<2 s), allowing head to hyperextend 20-30 degrees past horizontal After 2-20 s latent period, onset of torsional upbeat or horizontal nystagmus denotes positive test. Sxs can last for 20 to 40 seconds. Nystagmus will change direction when returning to upright

24. Dix Hallpike

25. Dix Hallpike

26. Nystagmus

27. Laboratory Evaluation Electrolytes, glucose, CBC, TSH? NO, they will identify the etiology of vertigo in less than 1 percent of patients with dizziness

28. Radiologic Studies Consider imaging if there are neurological sxs CVD risk factors Progressive unilateral hearing loss One study quoted by AAFP found that 40% of pts with neuro findings had relevant abnormalities on imaging

29. Radiologic Studies The preferred study is MR imaging of head Superior visualization of posterior fossa, where most CNS disease causing vertigo is found MRA or angiography Vertebrobasilar insufficiency Thrombosis of labyrinthine artery AICA or PICA insufficiency Subclavian steal syndrome

30. Treatment BPPV Caused by calcium debris in semicircular canals Canalith repositioning (Epley Maneuver) displaces debris back to vestibule Pts may need to remain upright for 24 hrs post procedure to prevent recurrence Contraindications includes: severe carotid stenosis, unstable heart disease, severe neck disease (cervical spondylosis or advanced RA)

31. Treatment of BPPV Initial studies suggested 80% success rate with Epley Maneuver first time, and 100% success rate with repeated treatments Repeat studies suggested 50-90% success Cochrane Review concluded EM is safe Rx that will likely improve sxs of BPPV Recurrence rate is about 15% per year

32. Epley Maneuver Pt sits on table with eyes open and head 45 degrees to right Pt’s head is supported and lies back quickly as in Dix-Hallpike Pt’s head is rotated 90 degrees to left and held for 30 seconds Pt’s head is rotated additional 90 degrees to left while pt rotates his or her body 90 degrees in same direction. This position is held for 30 seconds Pt sits up on left side of table This can be repeated on either side until symptomatic relief occurs

33. Epley Maneuver

34. Epley Maneuver

35. Rx of Vestibular Neuronitis and Labyrithitis Many cases are self limited viral illnesses Rx sxs with vestibular suppressants Meclizine (Antivert) Dimenhydrinate (Dramamine) N/V Promethazine (phenergan) Metoclopramide (Reglan)

36. Meniere’s disease Treatment involves lowering endolymphatic pressure Low salt diet and diuretics (usually dyazide [HCTZ+triamterene] improve vertigo, but not tinnitus and hearing loss Surgical intervention Endolymphatic shunt Ablation of vestibular hair cells by intratympanic injection of gentamycin

37. Migrainous Vertigo Treatment Dietary (avoid caffeine, chocolate, aspartamate, EtOH) Lifestyle (exercise, stress reduction, sleep patterns) Vestibular rehabilitation exercises Medications (benzos, TCAs, BB, SSRI, Ca Channel blockers, antiemetics)

38. Psychiatric Causes Anxiety? as would treat anxiety (hard to separate which causes which sometimes) Vestibular suppressants, benzos provide temporary relief SSRIs may be better CBT

39. CVA Treat by preventing future events (BP control, cholesterol, smoking cessation, ASA, antiplatelet therapy) Minimize head mvement and treat with vestibular suppressant meds for first day When tolerated, taper meds, initiate vestibular rehab exercises

40. Take Home points Benign Paroxysmal Positional Vertigo Easily diagnosed with hx and Dix Hallpike Easily treated with Epley Maneuver Vertigo 93% of primary care cases are BPPV Acute vestibular neuronitis Meniere’s Disease Do not need extensive lab workup Imaging not indicated unless PE suggests central cause of vertigo

41. That’s it! Sources AAFP, Volume 71, number 6, 3/15/2005 AAFP, Volume 73, number, 1/15/2006

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