The Dizzy Patient4x4 Method

Dr Ahmad Alamadi FRCS

Consultant, HOD

Al Baraha Hospital

Vestibular Physiology

Orientation of our body in space is the primary function of the vestibular system. This is achieved by integration of signals from vestibular, visual and proprioceptive receptors at the level of brain stem.

Information regarding the movement of the head relative to the body is largely provided by paired vestibular sensory endorgans

Vestibular Sensory Endorgans

Cristae & Otolithic organ

Peripheral Vestibular System

EYES Proprioceptive Receptors

Central Vestibular Nuclei

Vestibulocerebellar tracts (VCT)

Vestibulospinal (VST)

Vestibulo-Ocular reflex (VOR)

Information Relay

VOR

Keeps a stable retinal image during head movement

As the head moves in one direction there should be an equal and opposite conjugate movement of the eyes (sometime known as the doll’s eye maneuver)

VOR Defect

Bilateral Defect : (for example from systemic aminoglycoside toxicity) the patient will complain of imbalance and a blurring of vision with head movement better known as oscillopsia

Unilateral defect : the equilibrium of the push-pull forces between the inner ears is altered. This result in a drift of the eyes away from side of lesion followed by a quick central nervous system (CNS) mediated saccade in a repetitive to and fro fashion better known as nystagmus.

Nystagmus is the cardinal sign of a central or peripheral vestibular disorder

History Steps

1. Organic Vs Psychogenic

2. Vestibular Vs Non vestibular

3. Peripheral Vs Central

4. Which Peripheral Vestibular Disorder

Organic Vs Psychogenic

Features Organic vestibular Psychogenic

Duration Usually well defined i.e. seconds, minutes or hours

(never a “flash”)

Variable from a “flash” to daysNot well defined

Frequency Except for benign paroxysmal positional vertigo (BPPV), rarely more than once a day

Constant or many times a day

Head Movement Intensifies symptoms Symptoms usually unaffected

Ataxia during spell Usually prominent Insignificant

Effect of Hyperventilation Not like the attack Often reproduces symptoms accurately

Vestibular Vs Non vestibular

True Vertigo (hallucination of movement relative to self) Vs Non specific Dizziness

Note patient with non specific dizziness need to be investigated for cardiac and neurological causes.

Patients with true vertigo have a vestibular disease which can be central or peripheral

Peripheral Vs Central

Ask for associated symptoms i.e. discharge, tinnitus, aural fullness and hearing loss

Ask for focal neurological complaints i.e. diplopia, dysphagia, dysarthria, paresis, parasthesia or incontinence and LOC.

Inner ear disorders should never be associated

with a loss of consciousness

Which Peripheral Vestibular Disorder

Benign paroxysmal positional vertigo (BPPV) seconds; several attacks /day; positional

Meniere's disease minutes to hours; tinnitus; fluctuating hearing loss; aural fullness

Recurrent Vestibulopathy minutes to hours

Vestibular Neuronitis (acute viral labyrinthitis) Hours to days

Examination Steps

1. Otological examination

2. Neurological examination

3. Special clinical vestibular tests

4. Important Diagnostic Tests

Otological examination

Otoscopy

Hearing assessment (Weber and Rinne tests)

Fistula Test

Neurological examination

Cranial Nerves

Cerebellar Tests

Oculomotor Tests Smooth pursuit, saccades, visual fixation and vergence

Balance Tests proprioception, Romberg’s and tandem gait tests (both eyes

open and closed).

When Smooth Pursuit is Normal it would be unlikely for a central disorder to be present

Special clinical vestibular tests

The Halmagyi maneuver

The head shake test

The oscillopsia test

VOR suppression test

Important Diagnostic Tests

Dix-Hallpike Positional Test

Hyperventilation Test

Conclusion

4 steps in History

x = 99% Diagnosis 4 steps in Examination

Soon on DVD and Internet

Interactive Multimedia Textbook of Otologywww.otologytextbook.com

Thank You