Dizziness A Patient Complaint That Can Make the Doctor’s Head Spin.

What Is Dizziness ?

• A non-specific term used to describe a number of signs and symptoms – Unsteadiness – Giddiness – Light-headed – Disequilibrium – Vertigo

Focus of Diagnostic Workup • • • • • Vertigo – auditory and Vestibular system Near-faint dizziness– cardiovascular system Psychophysiological dizziness - psychiatric Hypoglycemic dizziness- metabolic assessment Disequilibrium – peripheral nerves, spinal cord, inner ear, vision, CNS Dizziness, Hearing Loss, and Tinnitus/ Baloh,R.W oC sivaD.A.F, 1998

Vertigo • An illusion of movement in space – Rotation (most common) – Linear – Tilt

History of the Dizzy Patient • • • • • • • Detailed description of dizziness Differentiate vertigo from non-vertigo Determine onset, length, and if recurrent Associated neurological or systemic signs Any hearing loss?

Current medications Differentiate Peripheral vs. Central cause

Peripheral or Central Cause?

• • • • • Peripheral Labyrinth or vestibular nerve dysfunction Recurrent Nystagmus-horizontal Position change Moderate to severe vertigo • • • • • Central Cerebellum or brain stem dysfunction Continuous Nystagmus-vertical Mild vertigo Non-positional Differential Diagnosis and Management for the Chiropractor, Aspen Publishers, Inc 2001

Peripheral Vestibular Disorders • • • • • • • BPPV Labrynthitis Meniere’s disease Acoustic Neuroma Motion sickness Cervicogenic Perilymphatic fistula • • • Vestibular neuronitis Semicircular canal infection Semicircular canal water penetration Assessment of the dizzy patient, Australian Family Physician Vol. 2002 tsuguA , 8 .oN , 31

Central Vestibular Disorders • • • • • • Brain stem lesion Basilar artery migraine TIA Stroke MS Cerebellar lesions • • Metastatic Tumor Meningioma Assessment of the dizzy patient, Australian Family Physician Vol. 2002 tsuguA , 8 .oN , 31

Anatomic and Physiologic Components of Balance • • • Vestibular – labyrinth, vestibular nuclei Visual – CN III, IV, VI Proprioceptive – upper cervical ms and joints

Types of Vertigo • Subjective vertigo – The patient feels that they are spinning • Objective vertigo – The patient feels still but objects appear to be moving around them

Causes of Vertigo • • • • • • • Ear disease Toxic conditions (alcohol, food poisonings) Postural hypotension Infectious disease Cervicogenic Disease of the eye or brain Psychological

Episodic positional Vertigo Episodic Non-positional Non-episodic Non-positional Schimp D. A diagnostic algorithm for the dizzy patient Chiropractic Technique, vol 1994 voN ) 4 ( 6

Benign positional sudden Fades 30-60 seconds Episodic positional Cervicogenic sudden Vertebobasilar ischemia gradual persists progression

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

Nylen-Barany AKA Dix-Hallpike • • • • • Patient seated, head turned 45 degrees Patient quickly lays supine Latency period, then horizontal or rotational nystagmus Nystagmus decreases after 10-20 seconds Affected ear is the side head is turned toward when nystagmus and vertigo occurs

Nylen-Barany Maneuver Dizziness, Hearing Loss, and Tinnitus R.W. Baloh, F.A. Davis Company 1998

Treatment Options for BPPV • • • • Epley’s Sermont’s Habituation exercises (Brandt-Daroff) Cervical adjusting

Modified Epley’s Maneuver • • • • • Patient placed supine with head turned 45 degrees toward the affected ear (30 sec.) Dr. turns head 90 degrees so affected ear is 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

Modified Epley Maneuver Dizziness,Hearing Loss, and Tinnitis R.W. Baloh, F.A. Davis Company 1998

Sermont’s Maneuver • • • • Patient can be instructed to do this at home.

Patient turns head 45 degrees away from the affected side Quickly lays down maintaining head position (4 minutes) Brought up and placed on other side with same head position. (4 min) Sit up normal

Sermont’s Maneuver Archives Otolaryngol Head Neck Surgery, Vol 1993 , 452 p , 119

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

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 cervical proprioceptors May overlap BPPV or Meniere’s disease

Vertebrobasilar Insufficiency TIA’s • • • • • • • • Vertigo with associated Neurological signs Diplopia Ataxia Drop attacks Dysarthria Paralysis/weakness/Numbness Headache Risk factors (HTN, Diabetes, Coronary Disease)

Meniere ’s Episodic non-positional Perilymph fistula

Meniere’s Disease • • • • • • Sudden and recurrent (paroxysmal) attack of severe vertigo (4 th leading cause) Low-tone hearing loss Low-tone tinnitis Sense of fullness in the ear Vertigo lasts for hours to a day then burn out Hearing loss may progress

Cause of Meniere’s • • • • • Overproduction or retention of endolymph Possible autoimmune etiology Head trauma Previous infection Pregnant females are more prone

Management of Meniere’s • • • Salt-restriction diet Diuretic therapy Cervical adjusting (overlaps with cervicogenic vertigo

Perilymphatic Fistula • • • • • Hx of barometric pressure changes (airplane or weight lifting) Opening develops between middle and inner ear (oval window rupture) Rare cause of vertigo Bearing down reproduces s/s Tx - surgical

Labyrinthitis Non-episodic Non-positional vertigo Acoustic neuroma Cerebral hemorrhage

Labyrinthitis • • • • Sudden severe vertigo that last days to weeks Maybe nausea and vomiting Viral infection - no hearing loss Bacterial infection hearing loss

Acoustic Neuroma • • • • • • Mild but constant hearing loss Dizziness with possible tinnitis Gradual onset Benign schwannoma of 8 th CN Other CN findings as tumor grows Surgical excision

Cerebral Hemorrhage • • • • • Sudden vertigo and nausea Vomiting 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

When to refer to a specialist • • • • • • • Serious vertigo that is disabling Ataxia out of proportion to vertigo Vertigo longer than 4 weeks Changes in hearing Vertical nystagmus Focal neurological signs Systemic disease or psychological origin Australian Family Physician Vol. 2002 tsuguA , 8 oN , 31