5 Diziness Vertigo

7/31/2019 5 Diziness Vertigo

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Dizziness

A Patient Complaint That Can

Make the Doctors Head Spin.


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What Is Dizziness ?

A non-specific term used to describe anumber of signs and symptoms

Unsteadiness Giddiness

Light-headed

DisequilibriumVertigo


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Dizziness, Hearing Loss, and

Tinnitus/ Baloh,R.W1998,F.A.Davis Co

Focus of Diagnostic Workup

Vertigo auditory and Vestibular system Near-faint dizziness cardiovascular

system Psychophysiological dizziness - psychiatric Hypoglycemic dizziness- metabolic

assessment

Disequilibrium peripheral nerves, spinalcord, inner ear, vision, CNS


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Vertigo

An illusion of movement in space Rotation (most common)

Linear Tilt


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History of the Dizzy Patient

Detailed description of dizziness Differentiate vertigo from non-vertigo

Determine onset, length, and if recurrentAssociated neurological or systemic signsAny hearing loss? Current medications Differentiate Peripheral vs. Central cause


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Differential Diagnosis and

Management for the Chiropractor,Aspen Publishers, Inc 2001

Peripheral or Central Cause?

Peripheral

Labyrinth orvestibular nervedysfunction

Recurrent Nystagmus-horizontal

Position change Moderate to severe

vertigo

Central

Cerebellum or brain

stem dysfunction Continuous Nystagmus-vertical

Mild vertigo Non-positional


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Assessment of the dizzy patient,

Australian Family Physician Vol.31, No. 8, August 2002

Peripheral Vestibular Disorders

BPPV Labrynthitis

Menieres disease Acoustic Neuroma Motion sickness

Cervicogenic Perilymphatic fistula

Vestibular neuronitis Semicircular canal

infection Semicircular canal

water penetration


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Assessment of the dizzy patient,

Australian Family Physician Vol.31, No. 8, August 2002

Central Vestibular Disorders

Brain stem lesion Basilar artery

migraine TIA Stroke

MS Cerebellar lesions

Metastatic Tumor Meningioma


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Anatomic and Physiologic

Components of BalanceVestibular labyrinth, vestibular nucleiVisual CN III, IV, VI

Proprioceptive upper cervical ms andjoints


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Types of Vertigo

Subjective vertigo The patient feels that

they are spinning

Objective vertigo The patient feels still

but objects appear tobe moving aroundthem


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Causes of Vertigo

Ear disease Toxic conditions (alcohol, food poisonings)

Postural hypotension Infectious disease Cervicogenic Disease of the eye or brain Psychological


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Schimp D. A diagnostic algorithm

for the dizzy patient ChiropracticTechnique, vol 6(4) Nov 1994

Vertigo

Episodicpositional

EpisodicNon-positional

Non-episodicNon-positional


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Episodicpositional

Benignpositional

CervicogenicVertebobasilar

ischemia

gradualsudden sudden

Fades 30-60seconds

persists progression


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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


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Nylen-Barany AKA Dix-Hallpike

Patient seated, head turned 45 degrees Patient quickly lays supine

Latency period, then horizontal orrotational nystagmus

Nystagmus decreases after 10-20 seconds

Affected ear is the side head is turnedtoward when nystagmus and vertigooccurs


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Dizziness, Hearing Loss, and

Tinnitus R.W. Baloh, F.A. DavisCompany 1998

Nylen-Barany Maneuver


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Treatment Options for BPPV

Epleys Sermonts

Habituation exercises (Brandt-Daroff) Cervical adjusting


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Modified Epleys Maneuver

Patient placed supine with head turned 45degrees toward the affected ear (30 sec.)

Dr. turns head 90 degrees so affected earis 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


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Dizziness,Hearing Loss, and

Tinnitis R.W. Baloh, F.A. DavisCompany 1998

Modified Epley Maneuver


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Sermonts Maneuver

Patient can be instructed to do this athome.

Patient turns head 45 degrees away fromthe affected side Quickly lays down maintaining head

position (4 minutes)

Brought up and placed on other side withsame head position. (4 min) Sit up normal


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Archives Otolaryngol Head NeckSurgery, Vol 119, p452, 1993

Sermonts Maneuver


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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


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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 cervicalproprioceptors May overlap BPPV or Menieres disease


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Vertebrobasilar Insufficiency

TIAs Vertigo with associated Neurological signs Diplopia

Ataxia Drop attacks Dysarthria

Paralysis/weakness/Numbness Headache Risk factors (HTN, Diabetes, Coronary Disease)


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Episodic non-positional

Menieres Perilymph fistula


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Menieres Disease

Sudden and recurrent (paroxysmal) attackof 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 burnout Hearing loss may progress


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Cause of Menieres

Overproduction or retention of endolymph Possible autoimmune etiology

Head trauma Previous infection Pregnant females are more prone


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Management of Menieres

Salt-restriction diet Diuretic therapy

Cervical adjusting (overlaps withcervicogenic vertigo


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Non-episodicNon-positional vertigo

Labyrinthitis Acoustic neuroma Cerebral hemorrhage


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Labyrinthitis

Sudden severe vertigo that last days toweeks

Maybe nausea and vomitingViral infection - no hearing loss Bacterial infection hearing loss


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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


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Cerebral Hemorrhage

Sudden vertigo and nauseaVomiting 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


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Australian Family Physician Vol.31 No 8 August 2002

When to refer to a specialist

Serious vertigo that is disablingAtaxia out of proportion to vertigo

Vertigo longer than 4 weeks Changes in hearingVertical nystagmus Focal neurological signs Systemic disease or psychological origin

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5 Diziness Vertigo