Transcript DIZZINESS”
November 12, 2011 Kansas Association of Osteopathic Medicine Primary Care Update G. Marcus Stephens, D.O. A 67 year-old man rolled over in bed early in the morning and suddenly developed severe nausea as well as the unpleasant sensation that the room was spinning around him. The spinning resolved within 30 seconds but recurred again in the opposite direction when he rolled back to his original position. This had never happened to him before. The patient denied tinnitus, hearing loss, recent viral illness, or head trauma. The patient's past medical history was remarkable only for hypertension for which he took atenolol. Surgical history was unremarkable. He did not smoke, drank only occasionally, and denied illicit drug use. Family history was non-contributory. He had no known drug allergies. VS: 37.2, 70, 140/85, 12, 98%. The head, eyes, ears, neck, and cardiac examinations were unremarkable. A detailed neurological examination, including mental status, cranial nerves, motor function, sensory function, and cerebellar function, was normal. A DixHallpike (aka Nylan-Barany) test was performed and showed torsional nystagmus in the right head-hanging position, along with reproduction of the patient's symptoms. What are the 4 major categories of dizziness? How is it worked up? How is it treated? What is vertigo? How is it worked up? Review Inner Ear anatomy and physiology Understand BPPV. Learn the DixHallpike Maneuver Learn Canalith Repositioning technique Common and Treatable Dx by history The physical exam is just confirmational. The dx does not yield to technology, some tests may lead astray. NEVER suggest any symptom, especially with dizziness, or any other sensorineurologic condition, e.g. headache, numbness, etc. You are interviewing the affected organ Family docs are usually the first to work up The first 30 seconds in the life of a dizzy complaint are the most important The psychiatrists approach: “Feeling dizzy lately?” Then WAIT! Average time a doctor waits for an answer is 8 seconds. No questionnaires! ‘Dizzy’ is a lay term Synonyms include woozy, lightheaded, drunk-feeling, unstable. Vertigo is becoming a lay term Listen for localizing symptoms, e.g.. Hearing loss, tinnitis, double vision, dysarthria, ataxia, 4-limb weakness (points to CNS rather than peripheral lesion) A landmark study done several years ago at Northwestern University on hundreds of patients complaining of dizziness found that the complaints could be categorized into 4 main types: Vertigo: an illusion or hallucination of motion Dysequilibrium: a gait disorder Near-syncope: a sensation of impending faint Ill-defined lightheadedness: a metaphor for anxiety An illusion or hallucination of motion The most common of the 4 types We’ve all experienced it, e.g. spinning on a stool Illusion: a misperception of a stimulus, accounts form most forms of vertigo Hallucination: a perception without a stimulus, e.g. vertiginous migraine, temporal lobe seizure A sensation of impending faint. We’ve all experienced this, e.g. hyperventillating, standing up to fast after squatting, etc. Only about 50% do faint. Workup same as for syncope German study on medical students with EEG and Video monitoring: “looks like a seizure” A gait disorder “I stagger” “I feel like I’m drunk” “I feel like I’m going to fall” “I feel unbalanced” About 50% do fall Aka Type IV Dizziness A metaphor for anxiety “What do you mean, dizzy?” “I’m just dizzy. I’m dizzy all the time. Nothing really helps.” Try to use another word to describe how you feel… “Dizzy!” There is more dizziness than there are dizzy people There are roughly 1.5 dizzy complaints per dizzy person. About half of all dizziness is vertigo, the other half is about a third each of the other 3 types. Some may have a mixture of types…try to ascribe percentages, e.g. 75% vertigo, 25% type IV. Always look in the ear Test hearing Look for nystagmus Positional exam Neuro exam Is there hearing loss? (Finger rubs) Is it sensorineural or conductive (Rinne test) If it’s sensorineural, is it cochlear or retrocochlear (speech discrimination) If it’s retrocochlear, do MRI If you can’t rember all this, do audiogram Aka Barany’s test Start seated Supine with neck extended 20 degrees Head rotated 45 degrees Watch for nystagmus and ask about vertigo Repeat on other side cranial nerve findings Hemiparesis Facial weakness Diplopia Hypesthesia Horner’s sign Gait ataxia-may have no limb ataxia hearing loss (AICA exception) Able to walk Nystagmus ◦ horizonto-rotary ◦ Gaze-independent ◦ Reduced with visual fixation Dix-Hallpike differences Dix Hallpike Peripheral Central Latency 2-40 seconds None Severity of Vertigo Severe Mild Duration <1 minute >1 minute Fatigability Yes No Habituation Yes No Postural Instability Can walk Falls, very unstable Hearing loss May be present Usually absent Other neuro sxs Absent Usually present Nystagmus Only one position In all positions Benign paroxysmal positional vertigo Usually in elderly Self-limited Responds poorly to antivertigo drugs Due to canaliths 1. 2. 3. 4. 5. 6. Seated Supine with head rotated 45 degrees toward the involved side Rotate to opposite side Roll to lateral recumbent Nose down Sit up Sleep upright 2 nights Cervical collar?? Avoid head back position No dentist, hair dresser Don’t drive home 2 pillows at night for a wk Watch eye drops, shaving Avoid BPPV position Perilymphatic fistula Vestibular neuronitis Labyrinthitis Meniere’s Disease Traumatic Vertigo Acoustic Neuroma Near-syncope ◦ Usually due to impaired ability to vasoconstrict in the upright posture, e.g. hypovolemia, high ambient temperature, hyperventilation, alphablockers, ACEi, bp meds. ◦ Overactive baroreceptor response in elderly (treat w betablocker-blocks beta receptor and allows unopposed alpha action) Dysequilibrium ◦ Gait disorders, e.g. Parkinsonism, ◦ Cervical spondylosis ◦ Myelopathy, e.g. B12 deficiency Type IV: Ill-defined lightheadedness ◦ “dizzy all the time” a metaphor for anxiety ◦ Replace the word dizzy with the word anxious ◦ Hyperventillation For BPPV if Epley fails For motion sickness (physiologic vertigo) Use anticholinergic drugs that cross the blood-brain barrier Works better prophylactically NASA experience Antihistamines (sedating) Benzodiazepines (Type IV) a. Diminishes with fixation b. Unidirectional fast component c. Can be horizontal, rotary or vertical d. Nystagmus increases with gaze in direction of fast component e. Can be accentuated by head movement a. Diminishes with fixation b. Unidirectional fast component c. Can be horizontal, rotary or vertical d. Nystagmus increases with gaze in direction of fast component e. Can be accentuated by head movement a. Does not change with gaze fixation b. Can be unidirectional or bidirectional c. Can be horizontal, rotary or vertical d. Nystagmus increases with gaze in direction of fast component e. Can be dramatically accentuated by head movement a. Does not change with gaze fixation b. Can be unidirectional or bidirectional c. Can be horizontal, rotary or vertical d. Nystagmus increases with gaze in direction of fast component e. Can be dramatically accentuated by head movement Montani Semper Liberi