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  1. HKCEM College Tutorial Dizziness (Scenario A) Author Dr. TW Wongrevised by Dr. Lam Pui Kin, Rex Oct., 2013

  2. Scenario A--F/65, DM, HT • Onset Today, gradual • ProvokeHx of URI recently • QualitySpinning sensation + • Relief Better with eyes closed, worse with neck movement • Severity Cannot get up • Time for a few hours already • Associated symptoms: Nausea + vomiting; no tinnitus/hearing loss • Exam: essentially normal

  3. CNS problem Cerebellar stroke Brain stem stroke TIA (vertebro-basilar insufficiency) CP angle tumor Demyelination disease Vestibular migraine Peripheral Labyrinthitis Vestibular neuronitis BPPV Meniere’s disease Ramsay Hunt syndrome Concussion (labyrinthine) Acoustic neuroma What are the common DDx of vertigo? Drugs can cause both types of vertigo

  4. Vertigo less intense Constant symptom Imbalance: severe Hearing loss and tinnitus less common CNS / Cerebellar sign +ve More intense Paroxysmal acute relapse Imbalance: milder Hearing loss and tinnitus more common No cerebellar sign Peripheral Central These are NOT INVARIABLE!!!

  5. Otogenic vertigo: DDx matrix

  6. What do you do now? • Symptomatic treatment • investigations...

  7. Vestibular sedatives • Prochlorperazine (Stemetil) • Anti-emetic, phenothiazine group • CNS acting • Not for children • Caution in young adults (dyskinesia) • Dimenhydrinate (Gravol) • First generation antihistamine • Anti-motion sickness (unknown mechanism) • Betahistine(Merislon)– antivertigo/selective vasodilator • Diazepam (Valium)—BZD Not For Brief Episodes Beware: not useful if not vestibular ds.

  8. Investigations • Hb 12.4 g/dL • H’stix 7 mmol/L • ECG NSR, non-specific ST/T changes Patient is better but still dizzy after stemetil, what now?

  9. Patient is admitted to EM ward for further management • BP/P • CBP, L/RFT • Symptomatic treatment

  10. Any special test for vestibular disease? • Dix-Hallpike test (For BPPV only) • Head Thrust Test (to test on the vestibulo-ocular reflex)

  11. Dix-Hallpike test (Nylen-Barany)

  12. Dix Hallpike test (Nylen-Barany)

  13. Dix-Hallpike: Traditional and Sideway Position Traditional position Sideway position Barraclough, Kevin; Bronstein, Adolfo. Vertigo. BMJ. 339:b3493, September 26, 2009

  14. Hallpike test +veWhat manoeuvre can be done? • Canalith-repositioning techniques • The Epleymanoeuvre • The Semontmanoeuvre

  15. The Epleymanoeuvre Ann Emerg Med. April 2001;37:392-8.

  16. The Semontmanoeuvre Ann Emerg Med. April 2001;37:392-8.

  17. Progress • Patient’s condition gradually improves • Gait is normal • No neurological deficit • Discharge with Stemetil Who should be referred?

  18. Referral • ENT • unilateral hearing loss • tinnitus • ear discharge etc. • Medical • neck bruit • ? Arrhythmia • ? Cardiac ischemia • headache...

  19. The end Back to Dizziness (introduction)