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Dizziness. Dr Madeline Rogers GP & GPwSI in ENT Asplands Medical Centre Woburn Sands. Balance-input. Eyes Somatosensors esp neck. Also joints/muscles/skin Labyrinth Brain stem & vesicular nuclei Cerebellum Cortex. “ What do you mean by dizziness?”. Giddiness Lightheadedness

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Dizziness


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    1. Dizziness Dr Madeline Rogers GP & GPwSI in ENT Asplands Medical Centre Woburn Sands

    2. Balance-input Eyes Somatosensors esp neck. Also joints/muscles/skin Labyrinth Brain stem & vesicular nuclei Cerebellum Cortex

    3. “ What do you mean by dizziness?” • Giddiness • Lightheadedness • Vertigo • Unsteadiness • Clumsiness • faintness

    4. Balance Impairment Eyes- Poor vision- balance worse in poor lighting. Poor propioceptive input & loss of visual horizon Impaired somatosensors- elderly; peripheral neuropathies Labyrinth- vertigo Brain stem- CVA; tumours; MS- initial attack may be difficult to differentiate from acute vestibulitis. Patient may complain of “lightheadedness”, being clumsy and /or vertigo. The vertigo tends to be persistent & non-positional Cerebellum- clumsiness Move to side of lesion. Symptoms are progressive. Cortex- syncope Anxiety- hyperventilation etc

    5. Balance Impairment • Light-headedness- syncope- • positional- postural hypotension; autonomic neuropathy (DM) anaemia; hypovolaemia; • Non positional - hypoglycaemia; cardiac e.g. arrhythmias; gastrointestinal e.g. dumping • Functional- anxiety / hyperventilation • Unsteadiness- periperal neuropathies • e.g. neuropathic feet in DM; alcohol; small cell lung Ca; B12 deficiency; Drugs eg allopurinol,INAH,nitrofurantoin; heavy metals • Clumsiness- stagger to side of lesion; • past-pointing; loss of fine movement;hypotonia • Vertigo- peripheral & central • Mixed- MS; CVA;

    6. Vertigo • Hallucination of movement • Is it vertigo? Is it dizziness? • “did you feel light-headed or did the world spin as if you had just got off a playground roundabout” Establishing vertigo narrows the diagnosis to disorders of labyrinth or its central connections. Peripheral - Middle ear disease Benign Paroxysmal Positional Vertigo Acute vestibular Neuronitis-labyrithitis/acute vestibular failure Menieres Head injury-fracture of temporal bone/surgery Drugs- aminoglycosides/ furosemide Central- Vestibular migraine Cerebellar or brainstem stroke MS Tumour

    7. Middle ear disease • Acute AOM- • Chronic suppurative otitis media- cholesteatoma eroding into inner ear & labyrinth- suspect with vertigo and discharging ear • Trauma after stapedectomy for otosclerosis due to perilymph leak.

    8. Acute Vestibular Failure • Aka- acute labyrinthitis/ acute vestibular neuronitis • Probably viral . Acute vertigo with vomiting Usually lasts 1-7 days but takes weeks for compensation to occur. • Seasonal outbreaks • Central compensation can be delayed but use of vestibular sedatives eg prochlorperazine. Ok for short use in acute phase as inj/ supp/s/l • BPPV may follow because calcium deposits break off damaged otoconia. Thus prolonging symptoms. • Central compensation may be very delayed or incomplete in elderly

    9. Benign Paroxysmal Positional Vertigo • May follow acute vestibular failure or head injury. • Episodic • Positional- provoked by turning to affected side. • Lasts seconds –minutes. Often when turns in bed • Effect fatigues eg in repeated testing • Otoconial debris ; usually in posterior canal • Dix-Hallpike test- vertigo provoked with torsional nystagmus; short duration; fatiguability • Vestibular sedatives no therapeutic advantage. • Positional manoeuvres & exercises to treat eg Epley; Daroff-Brandt

    10. Meniere’s Disease Triad of symptoms: Rotational vertigo Loss of hearing Tinnitus Affects young- middle aged Lasts 1-24 hrs Prodromal phase- feeling of fullness in ear No vertgo between attacks Hearing loss- low frequency ;progressive with attacks Can be unilateral or progress to bilateral Management:initially medical. Stop smoking; reduce salt & caffeine. diuretics; vestibular sedatives

    11. Meniere’s Disease • If medical fails; • Surgical referral: • Grommets • Chemical ablation of labyrinth with gentamycin instilled transtympanically or directly to round window niche. • Surgical labyrinthectomy • Neurosurgical division of vestibular nerve • Hearing loss

    12. Examination • Good history essential; examination may be normal • Observe • CVS- pulse / BP /carotids • Ears- tympanic membrane; tuning fork testing • Romberg- perform standing on thick foam. Removes proprioception via long tracts. Isolates vestibular mechanism • Unterberger- turns to hypoactive side. Problem if other muscle /joint disorders • Neuro-otological exam- Cranials . Cerebellar function • Head Thrust- Vestibulo- ocular reflex • Dix- Hallpike test

    13. Investigations • Audiometry- asymmetrical snhl- • MRI to exclude acoustic neuroma or any cerebello-pontine angle tumour

    14. Red Flags Refer- • Severe progressive symptoms • Balance disorder associated with hearing loss • Vertigo with unilateral snhl or unilateral tinnitus • Any assoc neurological symptoms suggestive of brainstem CVA • Vertigo with chronic suppurative otitis media-chloesteatoma eroding into inner ear

    15. Dizziness in The Elderly Multisystem failure Polypharmacy Poor eyesight Cardiac problems Cerebrovascular disease BPPV Burnt out meniere’s Vestibular failure Incomplete central compensation Peripheral neuropathies Muscle weakness Arthritic joints