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Dizziness. A Patient Complaint That Can Make the Doctor’s Head Spin. What Is Dizziness ? . A non-specific term used to describe a number of signs and symptoms Unsteadiness Giddiness Light-headed Disequilibrium Vertigo. Focus of Diagnostic Workup. Vertigo – auditory and Vestibular system

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Dizziness


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    1. Dizziness A Patient Complaint That Can Make the Doctor’s Head Spin.

    2. What Is Dizziness ? • A non-specific term used to describe a number of signs and symptoms • Unsteadiness • Giddiness • Light-headed • Disequilibrium • Vertigo

    3. Focus of Diagnostic Workup • Vertigo – auditory and Vestibular system • Near-faint dizziness– cardiovascular system • Psychophysiological dizziness - psychiatric • Hypoglycemic dizziness- metabolic assessment • Disequilibrium – peripheral nerves, spinal cord, inner ear, vision, CNS Dizziness, Hearing Loss, and Tinnitus/ Baloh,R.W 1998,F.A.Davis Co

    4. Vertigo • An illusion of movement in space • Rotation (most common) • Linear • Tilt

    5. History of the Dizzy Patient • Detailed description of dizziness • Differentiate vertigo from non-vertigo • Determine onset, length, and if recurrent • Associated neurological or systemic signs • Any hearing loss? • Current medications • Differentiate Peripheral vs. Central cause

    6. Peripheral Labyrinth or vestibular nerve dysfunction Recurrent Nystagmus-horizontal Position change Moderate to severe vertigo Central Cerebellum or brain stem dysfunction Continuous Nystagmus-vertical Mild vertigo Non-positional Peripheral or Central Cause? Differential Diagnosis and Management for the Chiropractor, Aspen Publishers, Inc 2001

    7. BPPV Labrynthitis Meniere’s disease Acoustic Neuroma Motion sickness Cervicogenic Perilymphatic fistula Vestibular neuronitis Semicircular canal infection Semicircular canal water penetration Peripheral Vestibular Disorders Assessment of the dizzy patient, Australian Family Physician Vol. 31, No. 8, August 2002

    8. Brain stem lesion Basilar artery migraine TIA Stroke MS Cerebellar lesions Metastatic Tumor Meningioma Central Vestibular Disorders Assessment of the dizzy patient, Australian Family Physician Vol. 31, No. 8, August 2002

    9. Anatomic and Physiologic Components of Balance • Vestibular – labyrinth, vestibular nuclei • Visual – CN III, IV, VI • Proprioceptive – upper cervical ms and joints

    10. Subjective vertigo The patient feels that they are spinning Objective vertigo The patient feels still but objects appear to be moving around them Types of Vertigo

    11. Causes of Vertigo • Ear disease • Toxic conditions (alcohol, food poisonings) • Postural hypotension • Infectious disease • Cervicogenic • Disease of the eye or brain • Psychological

    12. Schimp D. A diagnostic algorithm for the dizzy patient Chiropractic Technique, vol 6(4) Nov 1994

    13. Benign Paroxysmal Positional Vertigo (BPPV) 20% • Brief episodes – recurrent • Moderate to severe • Associated with head position • Gradually diminishes over a month or two • No hearing loss • Latency or delayed onset of S/S • Positive Nylen-Barany maneuver • Caused by otoconia (debris) floating in PSC

    14. Nylen-Barany AKA Dix-Hallpike • Patient seated, head turned 45 degrees • Patient quickly lays supine • Latency period, then horizontal or rotational nystagmus • Nystagmus decreases after 10-20 seconds • Affected ear is the side head is turned toward when nystagmus and vertigo occurs

    15. Nylen-Barany Maneuver Dizziness, Hearing Loss, and Tinnitus R.W. Baloh, F.A. Davis Company 1998

    16. Treatment Options for BPPV • Epley’s • Sermont’s • Habituation exercises (Brandt-Daroff) • Cervical adjusting

    17. Modified Epley’s Maneuver • Patient placed supine with head turned 45 degrees toward the affected ear (30 sec.) • Dr. turns head 90 degrees so affected ear is up. (30 sec.) • Patient rolls on to side, head looking toward the floor (30 sec.) • Patient is lifted into sitting position • Procedure is repeated until no nystagmus

    18. Modified Epley Maneuver Dizziness,Hearing Loss, and Tinnitis R.W. Baloh, F.A. Davis Company 1998

    19. Sermont’s Maneuver • Patient can be instructed to do this at home. • Patient turns head 45 degrees away from the affected side • Quickly lays down maintaining head position (4 minutes) • Brought up and placed on other side with same head position. (4 min) Sit up normal

    20. Sermont’s Maneuver Archives Otolaryngol Head Neck Surgery, Vol 119, p452, 1993

    21. Post Maneuver Instructions • Patient waits 10 min. before leaving office. • Other person drives them home. • Sleep half-reclined 2-3 days. • Avoid laying on bad side. • Avoid extreme head extension for 2-3 days

    22. Cervicogenic Vertigo • Hx of neck trauma, muscle spasm • Limited cervical ROM • Positive chair rotation test (Fitz-Ritson) • Patients may complain of dysequilibrium (tilt) more than rotational vertigo • Overstimulation of upper cervical proprioceptors • May overlap BPPV or Meniere’s disease

    23. Vertebrobasilar Insufficiency TIA’s • Vertigo with associated Neurological signs • Diplopia • Ataxia • Drop attacks • Dysarthria • Paralysis/weakness/Numbness • Headache • Risk factors (HTN, Diabetes, Coronary Disease)

    24. Meniere’s Disease • Sudden and recurrent (paroxysmal) attack of severe vertigo (4th leading cause) • Low-tone hearing loss • Low-tone tinnitis • Sense of fullness in the ear • Vertigo lasts for hours to a day then burn out • Hearing loss may progress

    25. Cause of Meniere’s • Overproduction or retention of endolymph • Possible autoimmune etiology • Head trauma • Previous infection • Pregnant females are more prone

    26. Management of Meniere’s • Salt-restriction diet • Diuretic therapy • Cervical adjusting (overlaps with cervicogenic vertigo

    27. Perilymphatic Fistula • Hx of barometric pressure changes (airplane or weight lifting) • Opening develops between middle and inner ear (oval window rupture) • Rare cause of vertigo • Bearing down reproduces s/s • Tx - surgical

    28. Labyrinthitis • Sudden severe vertigo that last days to weeks • Maybe nausea and vomiting • Viral infection - no hearing loss • Bacterial infection hearing loss

    29. Acoustic Neuroma • Mild but constant hearing loss • Dizziness with possible tinnitis • Gradual onset • Benign schwannoma of 8th CN • Other CN findings as tumor grows • Surgical excision

    30. Cerebral Hemorrhage • Sudden vertigo and nausea • Vomiting associated with a headache • Inability to stand • Nystagmus, nuchal rigidity, facial paralysis, ataxia, dysrythmia, small reactive pupils • Hx of HTN in 2/3 of patients

    31. When to refer to a specialist • Serious vertigo that is disabling • Ataxia out of proportion to vertigo • Vertigo longer than 4 weeks • Changes in hearing • Vertical nystagmus • Focal neurological signs • Systemic disease or psychological origin Australian Family Physician Vol. 31, No 8, August 2002