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Vertigo Clearing confusion for patients and doctors. Dr SK Ng Specialist in Otorhinolaryngology Division of ENT NT East cluster The Chinese University of Hong Kong. Dizziness and vertigo are common. Dizziness and Vertigo. Ear dysfunction Vascular insufficiency Neurological dysfunction

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Vertigo Clearing confusion for patients and doctors


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    1. VertigoClearing confusion for patients and doctors Dr SK Ng Specialist in Otorhinolaryngology Division of ENT NT East cluster The Chinese University of Hong Kong

    2. Dizziness and vertigo are common

    3. Dizziness and Vertigo • Ear dysfunction • Vascular insufficiency • Neurological dysfunction • Psychological problems

    4. Radiological and Laboratory Tests: • Rarely helpful

    5. Systematic Approach • Arrive at diagnosis • Recognize potentially dangerous condition • Specialist attention

    6. Diagnostic Approach • History • Physical examination • Investigations

    7. The First Question: • What does the patient mean by dizziness? • Giddiness vs Vertigo

    8. Giddiness • Most common form: non-specific light-headedness • Vague and Subjective • Never actual fall or veer

    9. Nonspecific light-headedness • Psychogenic • Hyperventilation • Hypoglycemia • Anemia

    10. Near-syncope • Light-headedness • Generalised weakness • Faintness • Rise from lying or sitting

    11. Typically worse in the morning • When supine: No symptoms • Causes: • 1. Autonomic dysfunction • DM • Drugs: anti-HT, anti-arrhythmic • Cardiovascular disease

    12. Dysequilibrium • Feeling of unsteadiness • No actual illusion of movement • No sensation of faintness

    13. Cause • Dysequilibrium of ageing • multi-sensory deficits • vestibular sedatives not useful • vestibular rehabilitation program • a walking stick

    14. Refer for neurological evaluation • Dysequilibrium + poor gait

    15. Vertigo • Hallucination of movement • Typically but not necessarily rotatory • Lesion in the vestibular system

    16. The Second Question • Is it Benign Paroxysmal Positional Vertigo? • (BPPV)

    17. BPPV • Common • Very characteristic • Highly treatable

    18. Benign Paroxysmal Positional Vertigo(BPPV) • Rotatory vertigo last for seconds • Positional: looking up rapidly • rolling over in bed • Nausea, no vomiting • No tinnitus/ hearing loss

    19. Diagnosis confirmed by Dix Hallpike maneuver

    20. Pathophysiology

    21. Benign Paroxysmal Positional Vertigo(BPPV) • Drugs: USELESS • Treatment of choice: Epley maneuver

    22. 30 Seconds each step

    23. 90% chance of success • What if the maneuver fails?

    24. Try again!

    25. If still fails, • Refer to ENT

    26. The Third Question • Is the vertigo central in origin?

    27. Central Vertigo • Uncommon • Potentially fatal • Refer

    28. Central Vertigo • Associate neurological symptoms • Risk factors for CVA • Severe imbalance • Vertical nystagmus

    29. Peripheral Vertigo

    30. Peripheral Vestibular Disorders • Meniere’s disease • Vestibular neuronitis

    31. Meniere’s disease • rotatory vertigo lasting for hours • Classic triad hearing loss • tinnitus • to 60 years of age • nausea and vomiting

    32. Meniere’s disease Pathogenesis: over-accumulation of fluid within the inner ear Meniere’s disease Normal

    33. Meniere’s disease • Treatment: • Vestibular sedatives • Prophylactic treatment: ? • Ablative surgery

    34. Vestibular neuronitis • Rotatory vertigo last for days • Nausea and vomiting • No otological symptoms • Commonly follow a flu

    35. Vestibular neuronitis • Natural course: • Vertigo followed by a period of unsteadiness • Treatment • Vestibular sedatives • Vestibular rehabilitation

    36. Rarer Peripheral Disorders • Acute suppurative labyrinthitis • Perilymph fistula

    37. Acute suppurative labyrinthitis • Bacterial infection of inner ear • Severe vertigo + hearing loss + ear discharge • Refer ENT

    38. Perilymph fistula • Violation of barrier between middle and inner ear • Vertigo onset after trauma • Refer ENT

    39. To Sum Up ….

    40. Approach to Dizziness • Vertigo vs Giddiness • ? BPPV • ?Central vertigo • Peripheral vertigo: duration of attack • associated otological symtoms

    41. Duration of Vertiginous Attacks • Seconds: BPPV • Minutes: vertebrobasilar insufficiency/ TIA • Hours: Meniere’s disease, migraine

    42. Days: vestibular neuronitis • acute labyrinthitis • cerebellar stroke • Constant: neurological disorder • incomplete recovery of vestibular failure • psychogenic

    43. Physical examination

    44. Dix Hallpike Maneuver • Confirm BPPV

    45. Treatment of Peripheral Vertigo • BPPV • Epley maneuver • 2. Acute sustained vertigo • Vestibular sedatives e.g. stemetil, stugeron