Transcript Benign Paroxysmal Positional Vertigo (BPPV)

Vertigo
Dr Tharaka Chandrakumar GPST2
Dr Emma Humphreys GPST1
The Mill Medical Practice, Godalming
Case discussion
Case discussion
• 58 yr old lady
Case discussion
• 58 yr old lady
• Awoke feeling room was spinning
Case discussion
• 58 yr old lady
• Awoke feeling room was spinning
• Vomited twice
Case discussion
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58 yr old lady
Awoke feeling room was spinning
Vomited twice
Seemed anxious
Case discussion
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58 yr old lady
Awoke feeling room was spinning
Vomited twice
Seemed anxious
Slightly unsteady on her feet
Case discussion
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58 yr old lady
Awoke feeling room was spinning
Vomited twice
Seemed anxious
Slightly unsteady on her feet
Hyperventilating
Case discussion
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58 yr old lady
Awoke feeling room was spinning
Vomited twice
Seemed anxious
Slightly unsteady on her feet
Hyperventilating
No fever, but had sore throat
Case discussion
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58 yr old lady
Awoke feeling room was spinning
Vomited twice
Seemed anxious
Slightly unsteady on her feet
Hyperventilating
No fever, but had sore throat
Slight difficulty swallowing
Case discussion
On examination
• Red throat
• Positionally induced nystagmus was sustained
Case discussion
On examination
• Red throat
Case discussion
On examination
• Red throat
• Positionally induced nystagmus was sustained
“I felt dizzy Doctor”
“I felt dizzy Doctor”
Light-headedness
• Presyncope, eg
transient hypotension
• Disequilibrium of
elderly
• Anxiety or
hyperventilation
“like I’d just got off a roundabout”
“like I’d just got off a roundabout”
Vertigo
• illusory sense of movement or orientation
• disorder of labyrinth or brainstem
“like I’d just got off a roundabout”
Vertigo
• illusory sense of movement or orientation
• disorder of labyrinth or brainstem
But which?
Differential Diagnosis
Peripheral
Central
Differential Diagnosis
Peripheral
– Benign Positional Paroxsymal Vertigo (BPPV)
– Acute Vestibular Neuritis
– Meniere’s Disease
Central
Differential Diagnosis
Peripheral
– Benign Positional Paroxsymal Vertigo (BPPV)
– Acute Vestibular Neuritis
– Meniere’s Disease
Central
– Brainstem stroke / tumour / demyelination
– Vertiginous Migraine (dx of exclusion)
History
• Headache?
History
• Headache?
• Hearing?
History
• Headache?
• Hearing?
• Tinnitus?
History
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Headache?
Hearing?
Tinnitus?
Positional vertigo?
History
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Headache?
Hearing?
Tinnitus?
Positional vertigo?
Vision?
History
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Headache?
Hearing?
Tinnitus?
Positional vertigo?
Vision?
Swallowing?
Examination
• Cranial nerves
Examination
• Cranial nerves
• Eye movements (?nystagmus)
Examination
• Cranial nerves
• Eye movements (?nystagmus)
• Ears
Examination
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Cranial nerves
Eye movements (?nystagmus)
Ears
Hearing
Examination
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Cranial nerves
Eye movements (?nystagmus)
Ears
Hearing
Gait (?unsteady)
Examination
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Cranial nerves
Eye movements (?nystagmus)
Ears
Hearing
Gait (?unsteady)
Coordination
Examination
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Cranial nerves
Eye movements (?nystagmus)
Ears
Hearing
Gait (?unsteady)
Coordination
Head Thrust test or Hallpike Manouevre
(positional provocation tests)
Red flags
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Neurological symptoms or signs
New headache (esp occipital)
Acute deafness
Vertical nystagmus
Anatomy and pathophysiology
Tharaka Chandrakumar
Objectives
• Labyrinthine cavity (inner ear)
- osseous labyrinth
- membranous labyrinth
• Membranous labyrinth - endolymph
- vestibular
- cochlear
- semicircular canals
• Hair cells
• Pathology
Middle and inner ear
Vestibule
Bony Vestibule - lateral wall
- medial wall
- roof
- posterior
- anterior
Membranous vestibule - utricle (close to
semicircular canals
- saccule (close to cochlea)
Hair cells within membranous
vestibule
Kinetic labyrinth; semicircular canals
Pathology
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Meniere’s disease
Meniere’s syndrome
BPPV
Vestibular neuritis
Labyrinthitis ; viral/bacterial
Acute Vestibular Neuritis
Acute Vestibular Neuritis
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Common
?preceding viral infection
Sustained vertigo
Unsteady gait
Unidirectional horizontal nystagmus
Positive ocular reflex (“head thrust”)
Halmagyi Head Thrust
Halmagyi Head Thrust
• http://www.youtube.com/watch?feature=play
er_detailpage&v=CZXDNLLGG8k
Acute Vestibular Neuritis
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Self-limiting
Acute illness up to a week
Several weeks to resolve completely
Symptomatic relief Prochlorperazine
(Stemetil)
• Vestibular rehab exercises BD
Benign Paroxysmal Positional Vertigo
(BPPV)
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Common
Female: male = 2:1
Brief episodes (<1 min)
Specific positions
Posterior canal common
Intense vertigo +/- nausea
Prolonged dizziness may last hours
Benign Paroxysmal Positional Vertigo
(BPPV)
Risk Factors:
• Advancing age
• Head trauma
• Migraine
• Inner ear disease
• General anaesthesia
BPPV – How to diagnose
• Hallpike Manouevre
• http://www.youtube.com/watch?v=ttgaqpIv_
wM
• Typical rotatory nystagmus
• Careful explanation
BPPV – How to Treat
• Epley Manoeuvre
• http://www.youtube.com/watch?v=LsPURdtM
jac
BPPV – How to Treat
• Semont Manoeuvre
Final Part of Case
• More careful questioning
elicited facial numbness
and slight clumsiness of
left hand
• On admission to hospital
the patient;
• Sustained nystagmus on
positioning
Take-Home Messages
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Vestibular problems common
Ensure no red flags
Vestibular sedatives short term use only
Learn Hallpike and Epley or Semont
AKT QUESTIONS
QUESTION 1
• A 45-year-old man presents with dizziness and rightsided hearing loss to his GP. Which one of the
following tests would most likely indicate an acoustic
neuroma?
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A.Jerky nystagmus
B.Left homonymous hemianopia
C.Tongue deviated to the left
D.Fasciculation of the tongue
E.Absent corneal reflex
QUESTION 2
• Which one of the following medications is
most useful for helping to prevent attacks of
Meniere's disease?
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A.Promethazine
B.Prochlorperazine
C.Betahistine
D.Chlorphenamine
E.Cinnarizine
QUESTION 3
• Which one of the following statements regarding Meniere's
disease is correct?
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A.More common in patients from the Indian Subcontinent
B.Symptoms resolve in the majority of patients after 6-12
months
C.It is very rare that patients develop permanent hearing loss
D.More common in children
E.Approximately equal incidence in males and females
References
• Barraclough & Bronstein Vertigo:diagnosis in
general practice, BMJ 2009; 339:b3493
http://www.bmj.com/content/339/bmj.b3493
• Bronstein BPPV - Diagnosis and Physical
Treatment, ACNR Vol 5 No 3, July/Aug 2005
http://www.acnr.co.uk/pdfs/volume5issue3/v
5i3revbbpv.pdf
references
• Anatomy and Physiology, 7th edition, Seeley, Stephens, Tate
2005
• http://projects.cbe.ab.ca/Diefenbaker/Biology/Bio%20Website
%20Final/notes/nervous_system/9_the_ear.html
• Clinical Medicine 5th edition, Kumar and Clark
• Vertigo: A Review of Common Peripheral and Central
Vestibular Disorders Timothy L. Thompson, MD and Ronald
Amedee, MD Ochsner J. 2009 Spring; 9(1): 20–26.
• http://emedicine.medscape.com/article/1948907-overview
• Vertigo, K.Barraclough, A Bronstein, Diagnosis in General
practice, BMJ Sept 2009 Vol 339
• Lateral medullary infarct, West Indian med. j. vol.61 no.7
Mona Oct. 2012
Manoeuvres
• Epley
http://www.youtube.com/watch?v=59EIKztATiw
• Semont
http://www.youtube.com/watch?v=pg_SjWG-L9c
• Brand-Daroff exercises
http://www.youtube.com/watch?v=NWuEJxJ5s7c
• Have a practice!