Dr. Rick Balys MD, FRCSC Sue Ehler, BSC PT ; Steven MacNeil, BSC PT, RCA MPT
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1 Dizziness Coles Notes Dr. Rick Balys MD, FRCSC Sue Ehler, BSC PT ; Steven MacNeil, BSC PT, RCA MPT
2 CFPC CoI Templates: Slide 1 Faculty/Presenter Disclosure Faculty: Dr. Rick Balys, FRCSC Otolaryngology Relationships with commercial interests: Grants/Research Support: None Speakers Bureau/Honoraria: None Consulting Fees: None Other: None
3 CFPC CoI Templates: Slide 2 Disclosure of Commercial Support None Potential for conflict(s) of interest: None
4 Objectives Provide an approach to the dizzy patient Help differentiate the most common forms of dizziness and vertigo Discuss when to refer and resources
5 Philosophy Rule out the bad stuff Treat the treatable stuff Make patients feel better / compensate Make sure patients don t get worse (fall)
6 Method 1. Get them to describe it 2. Classify it 3. What is the timing and trajectory 4. Associated symptoms / signs
7 What do you mean Dizzy? Lightheaded Faint Off-Balance Clumsy Unable to concentrate Weak Leaning Trouble focusing Disorientated Anxious Floating Confused Shaky Nauseous Sweating Fatigue/exhaustion Spinning Pulled to one side
8 The 4 Flavor s of Dizzyness 1. Lightheaded / presyncopy 2. Disequilibrium (others notice) A. Gait B. Global 3. Vertigo The illusion of motion 4. Psychogenic / vague / disconnected / floating (others don t notice)
9 1. Presyncope nearly blacking out, nearly fainting When you spin around, you might vomit but you never think you are about to pass out lasts seconds to minutes Medications Orthostatic hypotension Cardiac arrhythmias Vasovagal attacks Severe Anemia / Hypoglycemia Hyperventilation / Anxiety
10 2A. Gait Disequilibrium Only when standing / walking Fine when sitting - able to drive Imbalance / Unsteady / Fall Neurology / Neuromuscular Multisensory / Progressive disequilibrium of aging Joints, spine Cerebellar / movement disorders Muscular disorders: PMR / MG / GBS / ALS
11 Progressive Dysequilibrium of Aging - *** Fall Risk *** Multisensory disorder: 1. peripheral neuropathy 2. visual impairment 3. musculoskeletal issues 4. vestibular disorder 5. central problems with integration 6. bunyons and improper footwear 7. general weakness Medications, especially antidepressants, benzo s and anticholinergics
12 Progressive Dysequilibrium of Aging - *** Fall Risk *** Slowly get more rickety Reach a tipping point: New drug New joint New injury New environment New illness, usually with weight loss BPPV
13 2B. Global Disequilibrium Symptoms even when sitting Unable to drive May be central or peripheral vestibular Look for ataxia
14 3. Vertigo The Illusion of Motion Never all the time Worse with head movement Often associated with N/V, Sweating, Pale There is usually nystagmus Rotating, tilt, rock, bounce, floor drops
15 4. Psychogenic Spacey / Disconnected / Watching world on TV Stress, Anxiety, Sleep issues, Medications (including caffeine) Possibly Migraine a global distortion of sensory perception Chronic Subjective Dizziness Persistent activation of the Threat State MOST COMMON FORM IN PTS < 40
16 Method 1. Get them to describe it 2. Classify it 3. What is the timing and trajectory 4. Associated symptoms / signs
17 Timing (of Vertigo) is Everything Seconds Minutes BPPV Minutes to Hours Migraine or Meniere s CNS (VBI, TIA brainstem or labyrinth) Days Vestibular Neuronitis Cerebellar CVA, Lateral Medullary syndrome, MS Chronic continuous Psychogenic, Migraine, CSD, Post-concussion, Chronic pain
18 Associated Symptoms You can get to know a person by looking at who their friends are CNS: PD3, Weak, Numb, Ataxia Meniere s: Single sided fullness/pressure, Tinnitus, Fluctuating hearing loss Migraine: Aura, SS Pounding Headache, Photo/phonophobia Motion sickness, Family History, Menstruation related H/S Anxiety: SOB, Palpitations, Hyperventilation With noise or exertion: PLF, SCDS, Meniere s, Syphilis
19
20 BPPV Episodes of true, often violent spinning Brief <1min but often followed by N/V When you think your dying, a minute is an eternity No hearing change, no tinnitus, no pressure Occurs in 10%, responsible for about 50% of Vertigo in Elderly
21 BPPV What is Provocative? 1. Rolling in bed (which side?) 2. Looking up and to one direction (grocery store, lightbulb) 3. Putting your head between your legs Still feel off between events Can last for days to years but you can take it away instantly!
22 BPPV Pathophysiology Otoconia (CaCO 3 ) from the Utricle gets loose and gets trapped in the posterior canal (usually) Where is the posterior Canal???
23 BPPV the Dix Hallpike The Provocative Position: Head slightly extended and turned 45 o 1. Usually a brief delay 2. Rotatory geotropic nystagmus with a vertical component (in the plane of the PSSC) 3. Lasts 10 sec to 1 min 4. Vertigo returns but nystagmus less pronounced on return to upright 5. Fatigable
24 BPPV the Dix Hallpike (Also the first position of Epley)
25 Meniere s Disease One Sided Ear Symptoms! 1. CONTINUOUS Vertigo lasting minutes to hours (can have a few days of fatigue) 2. Fluctuating Unilateral SNHL 3. Unilateral Tinnitus Usually low pitch Can intensify before an attack 4. Unilateral pressure / fullness
26 Meniere s / Endolymphatic Hydrops
27 Meniere s Treatment Low salt diet (<1500mg/d) Avoid caffeine, cola, nicotine, alcohol, chocolate HCTZ Serc (8-24mg TID) Tympanostomy tube Intratympanic steroids Intratympanic gent
28 Migraine & Vertigo 15x more common than Meniere s(rauch) Problem with brain chemistry dysfunction of sensory signal processing Migrainous vertigo: 2 episodes of vertigo concurrent with migraine features (H/A, PP, PP, Aura) Migraine-associated vertigo: Episodic vertigo in a pt with migraine disorder (HIS criteria) Mimics Meniere s but no hearing loss Motion Sensitivity
29 Migraine Associated Vertigo Treatment Avoid triggers Stress change, caffeine change, weather change, hormone change. Dietary triggers TCA, B-Blocker, CCB, Topiramate,SSRI s Manage flare ups
30 Vestibular Neuronitis Constant Vertigo x Days Usually with nausea, vomiting, and nystagmus Often a URTI within 2 wks before event No other neurological or audiological symptoms Horizontal and slight torsional nystagmus COWS (fixed direction) and Alexander s Law Fixation suppression, worse with head movement
31 Vestibular Neuronitis Ensure hearing is not involved Vertigo stops in days Use Vestibular suppressants for 5 days tops Imbalance persists for weeks Expect full recovery Can be followed by BPPV Rarely recurrent (recurrent vestibulopathy)
32 Central Nystagmus Can be purely vertical, purely horizontal Can change in direction with gaze change (bidirectional) No fixation suppression No significant change with head motion Doesn t stop (BPPV) Not fatigable Other neurological findings
33 Red Flags - Image Neck injuries / Head injuries Hx of Significant Ear disease / surgery / trauma Unexplained Neurolgical Findings Exam findings Vertical nystagmus, direction changing, not following the rules Horners CVA RF Advanced age Previous TIA / CVA / CAD Hypertension DM Hypercholesterolemia Smoking Atrial fibrillation
34 Exam Otoscopy Gait Ataxic, Staggering, Wide based gait Nystagmus CN testing, Horner s Cerebellar testing Finger nose RAM Toe tapping and Heel shin Romberg testing With distraction Stepping Test With distraction Dix Hallpike
35 Describe it Classify it: 1. Lightheaded 2. Vertigo 3. Gait vs Global dysequilibrium 4. Spacey Timing Cheat Sheet Min: BPPV Hours: Migraine, Meniere s (ss ear sx), VBI Days: Vestibular neuronitis, MS, VBI/CVA Weeks:?anxiety Associated symptoms Focal neurological Single side tinnitus, pressure and hearing loss Motion sickness, photophobia, phonophobia, headache SOB, palpitations, anxiety
36 When To Refer Red Flags Suspected Central Cause Not responding / Symptoms progressing Associated hearing loss Deteriorating quality of life
37 Who to refer to? Audiology (hearing assessment) Radiology (head and temporal bones) Physiotherapy specialists Atlantic Balance and Dizziness Centre Vest Rehab Adv Comp (Emmory) ENT Neurology
38 If all else fails.
39 Meniere s Natural History Exacerbations and remissions Within 10 years most patients are in remission Often with a 50dB hearing loss 10-50% can get bilateral disease
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