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Title: Dizziness

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Face or arm weakness/numbness. Frequency. Single: labyrinthitis, MS ... Cawthorne-Cooksey vestibular rehabilitation exercises. Meniere's Disease. Key features: ... – PowerPoint PPT presentation

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Title: Dizziness

1
Dizziness
Paul Chatrath Consultant ENT Surgeon Barking
Havering Redbridge Hospitals NHS Trust 21st
January 2009
2
Objectives

Definitions
Clinical history examination
Multiple factors
Key conditions BPPV Menieres labyrinthitis
non-vestibular

3
Dizziness

Presyncopal faintness
Loss of balance/imbalance
Unsteadiness
Light-headedness
Whooziness
Vertigo
Feeling of rotation or movement

4
Balance

Vestibular system
Peripheral vestibular (labyrinth)
Cerebellar
Visual system - VOR
Proprioceptive system - VSR

5
Vestibular Labyrinth

3 semicircular canals
rotational movement
cupula
2 otolithic organs - utricle saccule
linear acceleration
macula

6
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7
Clinical approach

Vertigo vs dizziness
Vertigo peripheral vestibular or cerebellar
Dizziness non vestibular
Questions to establish causes for each of these

8
Vertigo vs Dizziness

Definition of vertigo
Illusion of movement of oneself or the
surroundings
Typically rotatory
Looking for vestibular causes
If no rotatory component
Likely to be nonspecific dizziness
Looking for non-vestibular causes

9
Vertigo vs Dizziness Unclear

Vertigo
Rotatory
Worse on head movements
Nausea/vomiting on head movements
Vague descriptions rarely true vertigo

10
Vertigo - causes

Vestibular
Viral labyrinthitis
BPPV
Menieres disease
Acute Otitis Media
Trauma
Cholesteatoma
Drug induced
Postsurgical

Central
Migraine
Vertebrobasilar ischaemia
MS
Tumours
Cerebellopontine angle
Acoustic neuroma
Brainstem
CVA
Psychogenic

11
History Vertigo

Vestibular
Viral labyrinthitis
BPPV
Menieres disease
Acute Otitis Media
Trauma
Cholesteatoma
Drug induced
Postsurgical

Onset
After URTI or ear infection
Duration
gt24hrs Viral labyrinthitis
Several hours Menieres migraine
lt1min BPPV Psychogenic
Associated ear features
Tinnitus
Hearing loss
Headache
Discharge

Central
Migraine
Vertebrobasilar ischaemia
MS
Tumours
Cerebellopontine angle
Acoustic neuroma
Brainstem
CVA
Psychogenic

12
History Vertigo

Vestibular
Viral labyrinthitis
BPPV
Menieres disease
Acute Otitis Media
Trauma
Cholesteatoma
Drug induced
Postsurgical

Associated central features
Face or arm weakness/numbness
Frequency
Single labyrinthitis MS
Constant
decompensation
neurological
psychogenic
Trauma
Drug history
Aminoglycosides
Diuretics
Aspirin
Chemotherapy
Surgery

Central
Migraine
Vertebrobasilar ischaemia
MS
Tumours
Cerebellopontine angle
Acoustic neuroma
Brainstem
CVA
Psychogenic

13
Non-specific dizzinessCauses

Peripheral neuropathy
DM
Renal or hepatic failure
Alcohol
Vasculitis
Infections
Leprosy TB syphilis
Vitamin deficiencies
B1 B6 B12
Genetic - Refsums disease
Toxins
Lead metronizadole
Psychogenic

Cardiovascular
Arrhythmias
Reduced cardiac output
Carotid artery stenosis
Arteriosclerosis
Hypotension (postural)
Proprioception
Arthritis
Metabolic
DM
Hypothyroidism
Hypercholesterolaemia
Anaemia

14
Examination

Ears
TMs
Cranial nerves
All are useful!
General examination

Nystagmus rhythmic oscillating involuntary
movement of eyes
Cerebellar
Posture
Rombergs
Unterbergers
Hallpikes

15
Nystagmus

Movement of the eyes
Rhythmic
Oscillating
Synchronous
Involuntary

Two phases
Slow phase (pathological)
Fast phase (corrective)
Direction described in terms of fast phase

16
Nystagmus
Abnormal Right Labyrinth
Normal labyrinths
R
L
Slow drift to right Rapid corrective flick to
left Left nystagmus
Eyes central
17
VertigoVestibular v Central

Vestibular

Central

Type of dizziness Vertigo Vertigo /
Dizzy Effect of head movement Worse Equivocal
Tinnitus/hearing loss May be
present Absent Compensation Occurs Does not
occur Nystagmus Horizontal Horizontal or
vertical unilateral bilateral away
from affected ear
18
VertigoCompensation

Vestibular phenomenon
Steady accommodation to the effects of vertigo
Gradual resolution of symptoms over time
Typically occurs 6-12 weeks after acute insult

Mechanisms
Habituation
Reduced output good side
Increased output affected side
Sensory substitution
Increased reliance on eyes and musculoskeletal
system

19
VertigoCompensation

Impaired compensation due to
Poor visual acuity
Musculoskeletal problems
Reduced peripheral sensory input
Ongoing vestibular pathology
Medication (prolonged stemetil)

Rehabilitation
General fitness
Vision walking stick
Physical programs
Cawthorne-Cooksey
Psychological support
Specific exercises
Eg. Brandt-Daroff exercises for BPPV

20
Cawthorne - Cooksey

Developed in 1940s
Head movements
Balance tasks
Coordination of eyes with head
Total body movements
Eyes open closed
Noisy environments
Early exacerbation of vertigo

21
Investigations

Radiology (anatomical imaging)
MRI good for IAMs
CT good for vestibular anatomy
Audiogram
Asymmetry needs further imaging

Tests of vestibular function
ENGs (electronystagmography)
Caloric tests
Rotation tests

22
Symptomatic Tx

Acute phase
Phenothiazines
Prochlorperazine
(Stemetil)
Antihistamines
Cinnarizine (Stugeron)
Cyclizine (Valoid)
Promethazine (Avomine)
Histamine analogues
Betahistine (Serc)

Longer term
Depends on specific condition

23
CautionProchlorperazine

Powerful vestibular sedative
Suppresses acute vertiginous symptoms
BUT
Also suppresses natural compensatory response
LT use non-specific dizziness persists

24
Psychogenic

Type of dizziness any (nonspecific or vertigo)
Frequency constant
Duration Typically brief lt1min
Trigger Stress anxiety crowds
Associated features palpitations sweating
tremor
Examination Normal

25
Labyrinthitis

Otitic
Infective
Viral (serous)
CMV influenza adenovirus
Bacterial (suppurative)
Strep pneumoniae
Haemophilus
Moraxella
Other causes
cholesteatoma

Other source
Meningeal
TB
Syphilis
Neoplasia
Haematogenic

26
Labyrinthitis

History
Vertigo
gt24hrs
Vomiting
Constitutional symptoms
Examination
Nystagmus
Fast phase away from affected ear
Pyrexia

Treatment
Bed rest
Vestibular sedatives
Fluids
Cawthorne-Cooksey vestibular rehabilitation
exercises

27
Menieres Disease

Key features
Vertigo
Hours not minutes or days
Associated tinnitus and hearing loss
Before during or after vertigo
Other symptoms
Pressure feeling
Nausea

Aetiology
Vascular
Hydrops
Natural history
One episode
Episodic
Increasing frequency

28
Menieres DiseaseMedical therapy

Salt restriction
Diuretics
Thiazides - Na absorption in distal tubule
Side effects - hypokalemia hypotension
hyperuricemia hyperlipoproteinemia

Vasodilators
Betahistine cinnarizine
Evidence no RCTs
Cinnarizine gt placebo
Diuretics placebo
Serc of marginal benefit
Salt restriction of marginal benefit

29
Menieres DiseaseSurgical therapy

Hearing preservation
Vestibular preservation
Endolymphatic sac drainage
Intratympanic injection of steroid
Vestibular destruction
VIII nerve section

Hearing destruction
Intratympanic injection gentamicin
Labyrinthectomy

30
ITAG
31
BPPVBenign Paroxysmal Position Vertigo

Primary
Secondary
Trauma (HI)
Prolonged bed rest
Otological condition (up to 70)
Labyrinthitis
Central

Calcific debris in semicircular canals
Cupulolithiasis
Canalolithiasis
Vertigo
Brief (lt1min)
On head turn in a particular direction
Typically self-limiting

32
BPPVBenign Paroxysmal Position Vertigo

Posterior SCC
In plane on lying in bed
Hallpikes test
Nystagmus on lying back to one side
Problem how to distinguish BPPV from central
causes

33
BPPVHallpikes test Character of Nystagmus

BPPV

Central

Latency 5-10s None Adaptation Gone in
50s Persists Fatiguable Yes No Vertigo A
lways Absent Direction Rotatory
(geotropic) Variable Incidence Common Rare
34
BPPV - Epley
Epley 1992
35
BPPV - Brandt Daroff
Brandt Daroff 1980
36
Migraine

Clinical features
family history
motion intolerance
Vertigo occurs with classical headache
ENT/vestibular examination usually NAD
Lifestyle change
exercise diet avoidance of stimulants
Medication
Abortive therapy eg. Sumatriptan
Prophylactic therapy eg. B blockers

37
Vertebrobasilar Insufficiency

Vertigo diplopia dysarthria ataxia sensory
and motor disturbance
NOT synonymous with cervicogenic vertigo
30 of TIAs
Aspirin

38
Dizziness
Any Questions

Paul Chatrath
Consultant ENT Surgeon
Queens/King Georges Hospitals

Email paul.chatrath_at_bhrhospitals.nhs.uk paul_at_chat
rath.com
39
A Final Thought......

Q In a patient with vertigo if you had only
one question to ask him/her what would it be
A How long does the vertigo last for
- BPPV Seconds
- Menieres Hours
- Labyrinthitis Day

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