a logical approach to the dizzy patient l.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
A LOGICAL APPROACH TO THE DIZZY PATIENT PowerPoint Presentation
Download Presentation
A LOGICAL APPROACH TO THE DIZZY PATIENT

Loading in 2 Seconds...

play fullscreen
1 / 80

A LOGICAL APPROACH TO THE DIZZY PATIENT - PowerPoint PPT Presentation


  • 554 Views
  • Uploaded on

A LOGICAL APPROACH TO THE DIZZY PATIENT. Dizziness and balance disorders center www.susqneuro.com. Conditions. Vertigo BPPV Labyrinthitis Other Conditions: MS, migraine, Meniere’s etc Non-Vertigo Gait Dysfunction (countless neurological oto, ortho conditions Elderly:

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'A LOGICAL APPROACH TO THE DIZZY PATIENT' - Gideon


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
a logical approach to the dizzy patient

A LOGICAL APPROACH TO THE DIZZY PATIENT

Dizziness and balance disorders center

www.susqneuro.com

conditions
Conditions
  • Vertigo
    • BPPV
    • Labyrinthitis
    • Other Conditions: MS, migraine, Meniere’s etc
  • Non-Vertigo
    • Gait Dysfunction (countless neurological oto, ortho conditions
  • Elderly:
    • PD, frontal lobe disease, neuropathy, multi-deficit, stroke
  • Post-Injury
  • Psych
a philosopher in the vestibule
A philosopher in the vestibule
  • We move
  • An unmoving earth is our base of operation
  • If our base moves we have no hope of orientation: hopelessly lost.
  • Discomfort comes from shift in orientation.
  • Need an absolute set of coordinates.
  • Problem of shifting base.
  • Developed from lateral line system in fish
  • Which way is down??
oscillopsia
Oscillopsia
  • Bilateral vestibular dysfunction
  • Shows function of vestibular system
  • When the world moves with your head it drives you crazy
  • We need a solid base of operations
  • Result: “Visual Dependence”
  • Foam Pad Romberg positive.
vestibulo ocular reflex vor
VESTIBULO-OCULAR REFLEX (VOR)

KEEP YOUR EYES ON THE PRIZE

Our world seems not to move though

We Do

dizziness logical approach strategy for lecture
Dizziness- Logical Approach -strategy for lecture
  • Go into some basic principles
  • applications and testing
  • get into a few prominent diagnoses
dizziness
DIZZINESS
  • EIGHT MILLION PHYSICIAN VISITS/YR
  • AVERAGE: 5 VISITS WITHOUT RESOLUTION OF PROBLEM
  • Dizziness affects 10% of adults over 40
  • LOSS OF LIVLIHOOD, FALLS INJURIES
  • SYSTEMATIC APPROACH
dizziness10
DIZZINESS
  • VERTIGO
  • LIGHT-HEADEDNESS
  • DYSEQUALIBRIUM
  • GAIT DYSFUNCTION
  • NEAR SYNCOPE
  • ANXIETY
dizziness pointed questions
Dizziness: Pointed questions
  • Vertigo or Not?
  • Standing or Seated?
  • Isolated or ass’d with Other symptoms?
  • Constant or paroxysmal?
  • Caused by positional change?
dizziness12
DIZZINESS:
  • A MULTIDIMENSIONAL APPROACH
  • AREAS OF EXPERTISE
    • NEUROLOGIST
    • OTOLOGIST
    • REHAB SPECIALIST
cows fast phase of nystagmus
COWS: Fast Phase of Nystagmus
  • Cold – Opposite
  • Warm – Same
  • Each vestibule tonically pushes eyes to opposite side
  • Cold inhibits, warm stimulates and ear
  • Fast phase of nystagmus: cortical correction
vertigo or not
Vertigo or not?

=Nystagmus or no nystagmus

inner ear teleology
Inner ear teleology
  • Utricle and Saccule – Gravity receptors
    • Which way is down??
  • Semicircular Canals - Planar angular accelerometers
    • What’s moving what is still??
    • Which Way is down??
why vertigo conditions
Why Vertigo?? conditions
  • Converting accelerometer (semi-circular canals) into gravitometers – BPPV
  • Stimulating accelerometer: Meniere’s, labyrinthitis
  • “central” mechanism: hallucination in CNS – much less potent
  • Something stimulates accelerometer (SCC)
vertigo ddx
Vertigo DDx

BPPV

Meniere’s

Vestibular neuritis

Bilateral vestibular Loss

Post-traumatic vertigo (labyrinthine concussion)

Perilymph fistula

Migraine and epilepsy

Cerebro-vascular Disease

dizziness battery
Dizziness Battery

Orthostatics and both arms

Hallpike

Fukada

Head Thrust

Head Shake

Romberg (conventional, tandem, foam pad)

Fistula test

benign paroxysmal positional vertigo
Benign Paroxysmal Positional Vertigo

Recurrent

One ear down position

Positive Hallpike

Transitory positional vertigo

“Vertigo induced by postional change” Unique

bppv history
BPPV History
  • Variable history: Many patients complain of waxing and waning dizziness, not always vertiginous and aren’t aware of episodic nature
  • Classic: In bed when turn, looking up, or down
    • Tie shoelace or put clothes on line
  • Remits and exacerbates
bppv predispositions
BPPV predispositions
  • Age
  • Post vestibular neuritis
  • Post trauma
  • Ear infections
slide28
BPPV
  • Canalithiasis: By far majority. Set up eddy currents in fluid filled canal
  • Cupulolithiasis: otoliths adherent to walls
slide29
Posterior nystagmus are delayed by approximately 15 seconds (latency), peak in 20-30 seconds, and then decay, with complete resolution of symptoms.
  • Symptoms and reversed nystagmus may recur when the patient is brought to a sitting position.Nystagmus fatigues on repeated trials. Peripheral nystagmus is latent, paroxysmal, geotropic, reversible, and fatigable.
  • Horizontal canal BPPV nystagmus is purely horizontal and asymmetric, with its stronger component beating toward the diseased canal.
  • Anterior canal nystagmus is rotary, with its vertical component beating downward. The vertical component of benign paroxysmal positioning nystagmus (BPPN) is best observed by asking the patient to move the eyes away from the down-most (tested) ear.
bppv variants eye movements
BPPV Variants – Eye Movements
  • Posterior SCC: Canalith or cupulo
    • Torsional to side down and upbeat
  • Horizontal SCC: Canalith
    • Horizontal geotropic
  • Horizontal SCC: Cupulolithiasis
    • Horizontal ageotropic
  • Anterior SCC: Canalith or Cupulo:
    • Downbeat and torsional to side down
paroxysmal psychological vertigo
Paroxysmal psychological Vertigo

Form of Panic Attack

Sensory overload

“Supermarket Syndrome”

Complication of untreated BPPV + Anxiety

Computation of position and movement

Worst in Aisles and small spaces: comparator of near and distant movement: Car +claustophobia??

Your life depends on it: Therefore intense fear

“Phobic positional vertigo”

vestibular neuritis
Vestibular Neuritis
  • Sudden Vertigo and vomiting
  • Emergency room
  • Extreme motion sensitivity: Pts lay like a rock.
  • Kinetophobia
  • Viral or ischemic
    • Herpes simplex and other viruses. Bell’s palsy of the vestib n.
  • Rarely recurs
  • Look for other signs that may relate to VB system or posterior fossa.
vestibular neuritis neuronitis or labyrinthitis
Vestibular neuritis, neuronitis or labyrinthitis
  • No loss of hearing indicates inflammation of vestibular nerve or scarpa’s ganglion (neuronitis)
    • Inferior vestib nerve goes to posterior canal
    • Superior nerve goes to utricle, sup, lat canal
    • Herpes virus?
  • Hearing loss: may be labyrinthitis
  • Any pain or inflammation: ? Bacterial or other treatable infection
  • Can’t distinguish 100% from brainstem stroke
vestibular neuritis findings
Vestibular Neuritis: Findings
  • Spontaneous horizontal or horizonto-rotatory nystagmus
    • You may have to block fixation to see it.
  • Fast phase away from the offending ear
  • Veer to slow phase
  • ENG suppressed on offending side
  • 5% or so cases may be recurrent
  • BPPV is frequent sequel
meniere s
Meniere’s

Severe vertigo and vomiting

Fluctuating Hearing Loss

Fullness

unilateral Tinnitus

Endolymphatic Hydrops

meniere s42
Meniere’s
  • Vertigo + Vomiting last hours
    • Few disorders are paroxysmal in just this way
  • Patients need not have entire tetrad
  • Most common: Severe vertigo, vomiting and tinnitus
  • A number of “Meniere-like” syndromes
    • Previous insults to inner ear
meniere s treatment
Meniere’s treatment
  • Avoid Salt and Caffeine
  • Diuretic
  • Surgeries
    • Gentamycin injection
    • Vestibular nerve section
    • Hearing sparing operations
perilymph fistula
Perilymph fistula
  • Dizziness with change in pressure
  • Nose-blowing dizziness
  • Sound sensitivity “Tullio Phenomenon”
  • Dizziness with exertion
  • Sensori-neural loss on audiogram
perilymph fistula45
Perilymph Fistula
  • Breach of Round window
  • Superior canal dehiscence
  • Cholesteatoma
  • Trauma
  • Post-surgical esp fenestration for otosclerosis
  • Scuba diving
fistula
Fistula
  • Strain against closed glottis
    • Upbeat nystagmus CW for right ear CCW for left ear
  • Pull in thru closed nostrils
    • Downbeat nystagmus CW for left ear, CCW for right ear
  • OR do fistula test with bulb
  • OR Test for Tullio phenonenon
cholesteatoma49
cholesteatoma
  • Hearing loss and loss of balance or vertigo
  • Chronic infection or congenital
  • Basically tumor in middle ear and petrous bone
construct program elements
Construct Program. Elements:
  • Clinicians to Evaluate
    • PM&R, Neurology
      • Diagnosis
      • Therapeutic Recommendations
    • Gait Analysis
  • Treatment
    • Vestibular (habituation, exercise, Canalith)
    • Gait and Balance
    • Devices trial and recommendation
vestibular rehabilitation
Vestibular Rehabilitation

Compensations

Avoidance (BPPV)

Substitution (Bilateral Vestibular Loss)

Plasticity (Vestibular Neuritis)

Massed practice to retune CNS and compensate

“habitutation”

Repositioning

Gait retraining

vestibular rehab
Vestibular Rehab
  • Habituation
  • Canalith repositioning
  • Balance Retraining Exercises and retraining
  • Conditioning
  • Compensation Strategies
    • As in visual dependence
  • Assistive devices
  • Bracing
  • Muscle strengthening
vestibular rehabilitation55
Vestibular Rehabilitation
  • VOR Stimulation Exercises
  • Oculomotor Exercises
  • Balance Exercises
  • Gait exercise
  • Obstacle course

www.emedicine.com/ent/topic666.htm#target1

cawthorne cooksey exercises
Cawthorne-Cooksey Exercises
  • In bed or sitting
    • Eye movements -- at first slow, then quick
      • up and down
      • from side to side
      • focusing on finger moving from 3 feet to 1 foot away from face
    • Head movements at first slow, then quick, later with eyes closed
      • bending forward and backward
      • turning from side to side
  • Sitting
    • Eye movements and head movements as above
    • Shoulder shrugging and circling
    • Bending forward and picking up objects from the ground
  • Standing
    • Eye, head and shoulder movements as before
    • Changing form sitting to standing position with eyes open and shut
    • Throwing a small ball from hand to hand (above eye level)
    • Throwing a ball from hand to hand under knee
    • Changing from sitting to standing and turning around in between
  • Moving about (in class)
    • Circle around center person who will throw a large ball and to whom it will be returned
    • Walk across room with eyes open and then closed
    • Walk up and down slope with eyes open and then closed
    • Walk up and down steps with eyes open and then closed
    • Any game involving stooping and stretching and aiming such as bowling and basketball
vestibular rehabilitation57
VESTIBULAR REHABILITATION

HABITUATION

ADAPTATION OF OTHER SENSORY SYSTEMS

neurologic syndromes
Neurologic Syndromes

MS

PD

NPH

Stroke

Aging

Multi-sensory Deficit

tinetti
Tinetti

Sitting Balance Leans or slides in chair

Steady, safe

= 0

= 1

2. Arises Unable without help

Able, uses arms to help

Able without using arms

= 0

= 1

= 2

3. Attempts to arise Unable without help

Able, requires > 1 attempt

Able to rise, 1 attempt

= 0

= 1

= 2

tinetti 2
Tinetti (2)
  • 4. Immediate standing
  • balance
  • (first 5 seconds)
  • Unsteady (swaggers, moves feet, trunk sway)
  • Steady but uses walker or other support
  • Steady without walker or other support0,1,2
  • 5. Standing Balance Unsteady
  • Steady but wide stance (medial heels > 4
  • inches apart) and uses cane or other support
  • Narrow stance without support0,1,2
  • 6. Nudged (subject at
  • max position with feet
  • as close together as
  • possible, examiner
  • pushes lightly on
  • subject’s sternum with
  • palm of hand 3 times.
  • Begins to fall
  • Staggers, grabs, catches self
  • Steady0,1,2
tinetti 3
Tinetti (3)
  • 7. Eyes closed (at
  • maximum position #6)
  • Unsteady
  • Steady0,1
  • 8. Turning 360 degrees Discontinuous steps
  • Continuous steps
  • Unsteady (grabs, swaggers)
  • Steady0,1,2
  • 9. Sitting Down Unsafe (misjudged distance, falls into chair)
  • Uses arms or not a smooth motion
  • Safe, smooth motion0,1,2
tinetti gait
Tinetti Gait
  • 10. Initiation of gait
  • (immediately after told
  • to “go”)
  • Any hesitancy or multiple attempts to start
  • No hesitancy0,1
  • 11. Step length and
  • height
  • a. Right swing foot does not pass left stance
  • foot with step
  • b. Right foot passes left stance foot0,1
  • c. Right foot does not clear floor completely
  • with step0,1
  • d. Right foot completely clears floor0,1
  • e. Left swing foot does not pass right stance
  • foot with step0,1
  • f. Left foot passes right stance foot0.1
  • g. Left foot does not clear floor completely with
  • Step0.1
  • h. Left foot completely clears floor 0.1
tinetti gait 2
Tinetti Gait 2
  • 12. Step Symmetry Right and left step length not equal (estimate)
  • Right and left step appear equal0,1
  • 13. Step Continuity Stopping or discontinuity between steps
  • Steps appear continuous0,1,2
  • 14. Path (estimated in
  • relation to floor tiles,
  • 12-inch diameter;
  • observe excursion of
  • 1 foot over about 10
  • feet of the course).
  • Marked deviation
  • Mild/moderate deviation or uses walking aid
  • Straight without walking aid0,1,2
  • 15. Trunk Marked sway or uses walking aid
  • No sway but flexion of knees or back, or spreads
  • arms out while walking
  • No sway, no flexion, no use of arms, and no use of
  • walking aid0,1,2
  • 16.
  • Walking Stance Heels apart
  • Heels almost touching while walking0,1
multiple sclerosis
Multiple Sclerosis

May present as typical peripheral vestibulpathy

? lesion at root entry zone

multi sensory deficit
Multi-sensory deficit
  • Aging
  • Loss of neurons in CNS
    • degenerative
    • vascular
  • Arthritis
  • Peripheral nerve dysfunction
  • Vestibular dysfunction
multi sensory deficit68
Multi-sensory deficit
  • Physical therapy
    • falls prevention
    • muscle strengthening
    • trying out assistive devices
    • minimizing deficits
acoustic neuroma70
Acoustic Neuroma

Unilateral Hearing Loss

VII and V

Unsteadiness rarely paroxysmal vertigo

vertebrobasilar insufficiency
Vertebrobasilar Insufficiency

Vertigo

Diplopia

Dysarthria

Dysphagia

Ataxia

Sensory or Motor Loss

Drop attack

Most feared misdiagnosis in older vertiginous patient

post traumatic vertigo
Post-Traumatic Vertigo

BPPV

Meniere’s

“Cervical” vertigo

Perilymph fistula

Factitious (psychological) vertigo

migraine associated vertigo
Migraine Associated Vertigo

Headache

Bickerstaff

Vertigo occurs as aura or part of HA syndrome

autoimmune inner ear disease aied
Autoimmune Inner Ear Disease (AIED)

Hearing Loss

Vertigo

Bilateral “meniere’s”

slide75
AIED

Anti HSP-70

Anti Raji Cell

Sed, ANA, RF, C1Q, FTA, Lyme, Thyroids

bilateral vestibular loss
Bilateral Vestibular Loss

Oscillopsia

Visual Dependence

Aminoglycosides

Advanced Age + Chronic ear disease

bilateral vestibular dysfunction
Bilateral vestibular dysfunction
  • Advanced age
  • Unsureness on feet. Symptomatic only when up
  • Positive Romberg
  • Foam Pad Romberg which diminishes proprioception – hallmark
  • Help by increasing proprioceptive feedback –assistive device, practice.
motion sickness
MOTION SICKNESS

CHRONIC SENSITIVITY TO MOTION

OTHER PERSON DRIVING

DISCOMFORT WITH MOTION

VESTIBULAR REHAB: HABITUATION

mal de debarquement
Mal de Debarquement

Persistence of perception of motion after a cruise

Psychophysiological (?)

bibliography
Bibliography
  • www.susqneuro.com
    • “Dizziness Explained”, “Benign Positional Vertigo”, “Vertigo: A Logical Approach”
  • www.thain.com. by Tim Hain, MD
  • www.ivertigo.net by Todd Troost, MD
  • www.onbalance.com: Posturography