“as the world turns” saleh fares aal-ali frcp-r3
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““As the world Turns”As the world Turns”
Saleh Fares Aal-AliSaleh Fares Aal-Ali
FRCP-R3FRCP-R3
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Objective to be Objective to be addressed:addressed: Difference between dizziness and vertigo.Difference between dizziness and vertigo.
• Treatment Considerations.
• Characteristics of central vertigo.
• Characteristics of peripheral vertigo.
• Diagnostic approach to True vertigo.
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Patients refer to Dizziness Patients refer to Dizziness as:as:
• “out-of-it”
• Imbalanced
• Giddy
• Faintness• Sense of strangeness
• Light headednessLight headedness
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Most dizzy patients can be placed Most dizzy patients can be placed in to one of four categories:in to one of four categories:
1- True Vertigo (50%)
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2-Pre-syncope:2-Pre-syncope:
Transient sensation that a faint in Transient sensation that a faint in about to occur.about to occur.
• Transient.
• May present as nausea ,weakness, SOB or change in vision.
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3-Dysequilibrium:3-Dysequilibrium:
A sensation of imbalance when A sensation of imbalance when standing or walking.standing or walking.
• No sense of faintness.
• No illusion.
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4-Vague 4-Vague lightheadedness:lightheadedness: Holds the reminder of symptoms Holds the reminder of symptoms
of dizziness (which can’t fit to of dizziness (which can’t fit to the other categories)the other categories)
1.Psychiatric disorders,
2.Hyperventilation syndrome
3.Encephalopathies
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What is Vertigo?What is Vertigo?
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True vertigo:True vertigo:
Defined as an “illusion” or Defined as an “illusion” or “hallucination” of movement.“hallucination” of movement.
• Both vertigo and dysequilibrium imply a loss of balance, but vertigo involves a sense of motion.
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How do we maintain How do we maintain equilibrium?equilibrium?
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Visual inputVisual input
Proprioceptiual
input
Vestibular input
labyrinths.
equilibrium
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Anatomy: Semicircular Anatomy: Semicircular canalscanals
Semicircular Canals Semicircular Canals (SCC)(SCC) HorizontalHorizontal AnteriorAnterior PosteriorPosterior
CupulaCupula End organ receptorsEnd organ receptors
EndolymphEndolymph
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Anatomy: UtricleAnatomy: Utricle
UtricleUtricle Connected to SCCConnected to SCC Contains Contains
endolymphendolymph Otoliths Otoliths
(otoconia)(otoconia) Calcium carbonateCalcium carbonate Attached to hair Attached to hair
cellscells Macule (end organ)Macule (end organ)
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Vestibular systemVestibular system
Tells brain which way the head Tells brain which way the head moves without lookingmoves without looking SCC: angular accelerationSCC: angular acceleration Utricle: linear accelerationUtricle: linear acceleration
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How can we clinically How can we clinically evaluate the patient with evaluate the patient with
vertigo?vertigo?
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labyrinthCN VIII
(Vestibular portion)
Vestibular
nuclei
Brainstem
VertigoCerebellum
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VertigoVertigo
Central peripheral
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Key points in History:Key points in History:
•Is true vertigo present?
•Are there associated neurologic symptoms?
•What is the pattern of onset ?
•What is the duration of the symptoms?
•Have there been auditory symptoms?
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•Are there other associated symptoms?
•What medications is the patient taking?
•What is the patient’s past medical history?
•Any recent or remote head or neck injury?
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Key points in the physical Key points in the physical examination:examination:
•Vital signs
•Bruits
•Ear exam
•Eye exam
•Positional testing
•Neurological exam (including gait)
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SPINNEDSPINNED
SSudden (Onset)udden (Onset) YesYes Slow, gradualSlow, gradualPPositionalositional YesYes NoNoIIntensityntensity SevereSevere Ill definedIll definedNNausea/ausea/DiaphoresisDiaphoresis
FrequentFrequent InfrequentInfrequent
NNystagmusystagmus Torsional/Torsional/horizontalhorizontal
VerticalVertical
EEar (hearing loss)ar (hearing loss) Can be presentCan be present AbsentAbsentDDurationuration ParoxysmalParoxysmal ConstantConstantCNS signsCNS signs AbsentAbsent Usually Usually
presentpresent
PERIPHERAL CENTRAL
Carvalho et al. CTU , Oct, 2004
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Case 1Case 1
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Peripheral vertigo:Peripheral vertigo:•Approximation 85% of ED patients with vertigo.
•Due to dysfunction of one of vestibular organs.
•Asymmetry of input
•Sensation of rotation
•Associated with nausea, pallor and diaphoresis.
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Differential DiagnosisDifferential Diagnosis Benign paroxysmal positional Benign paroxysmal positional
vertigo (BPPV) (50%)vertigo (BPPV) (50%) Vestibular neuritisVestibular neuritis Labyrinthitis (suppurative, serous, Labyrinthitis (suppurative, serous,
toxic, chronic) toxic, chronic) Meniere’s diseaseMeniere’s disease FB in ear canalFB in ear canal A cute otitis mediaA cute otitis media Perilymphatic fistula.Perilymphatic fistula.
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BPPVBPPV
Benign Paroxysmal Positional Benign Paroxysmal Positional VertigoVertigo
Age 60- 70 (F:M 2:1)Age 60- 70 (F:M 2:1) Head traumaHead trauma
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Characteristic storyCharacteristic story
Turn headTurn head After a few seconds delay, vertigo After a few seconds delay, vertigo
occursoccurs Resolves within 1 minute if you don’t Resolves within 1 minute if you don’t
movemove If you turn your head back, vertigo If you turn your head back, vertigo
recurs in the opposite directionrecurs in the opposite direction
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““BBPPV”PPV”
““B” = BenignB” = Benign Not a brain Not a brain
tumortumor Can be Can be
severe and severe and disablingdisabling
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““BBPPPV”PV”
““P” = ParoxysmalP” = Paroxysmal Episodic, not persistentEpisodic, not persistent Helpful feature in the differential Helpful feature in the differential
diagnosis diagnosis
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““BPBPPPV”V”
““P” = PositionalP” = Positional Occurs with position of headOccurs with position of head
Turning over in bedTurning over in bed Looking upLooking up Bending overBending over
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““BPPBPPVV””
““V” = VertigoV” = Vertigo An illusion of motionAn illusion of motion ““The room is spinning”The room is spinning” Other descriptionsOther descriptions
RockingRocking TiltingTilting SomersaultingSomersaulting Descending in an elevatorDescending in an elevator
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Pathophysiology of BPPVPathophysiology of BPPV
Otoliths become Otoliths become detached from detached from hair cells in hair cells in utricleutricle
Inappropriately Inappropriately enter the enter the posterior posterior semicircular semicircular canalcanal
. Parnes LS, McClure JA. Laryngoscope 1992;102:988-92.
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PhysiologyPhysiology
Normal situationNormal situation As one turns head to the rightAs one turns head to the right Endolymph moves Endolymph moves SCC receptors SCC receptors
fire fire “head turning right” “head turning right” Stop turning headStop turning head endolymph endolymph
stops moving stops moving SCC receptors stop SCC receptors stop firing firing “head has stopped moving” “head has stopped moving”
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Pathophysiology of BPPVPathophysiology of BPPV BPPVBPPV
Stop turning head Stop turning head otoliths otoliths keep movingkeep moving drag endolymph drag endolymph receptors continue to fire receptors continue to fire inappropriately inappropriately “head is still “head is still moving”moving”
Eyes Eyes “head is NOT moving” “head is NOT moving”
Brain Brain room must be spinning room must be spinning in the opposite directionin the opposite direction
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Dix-Hallpike ManeuverDix-Hallpike Maneuver
•The diagnosis of BPPV is generally from the
history.•Can confirm the diagnosis of BPPV
•First described by Dix and Hallpike in 1952.
•Also called the Nylen-BárányBárány, BárányBárány, Nylen, or Hallpike maneuver
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Dix-Hallpike ManeuverDix-Hallpike ManeuverThey include:
1- Nystagmus
2- Provocative head position
3- Brief latency to symptoms after change in position
4- Short duration of attack
5- Fatigability of nystagmus on repeat testing
6-Reverse of nystagmus on returning to upright position.
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Lab studiesLab studies
In a straightforward case, no In a straightforward case, no lab studies are needed! lab studies are needed!
HemoglobinHemoglobin Fingerstick glucose Fingerstick glucose Electrolytes if prolonged Electrolytes if prolonged
vomitingvomiting BHCG
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1-The Epley Maneuver1-The Epley Maneuver
First described in 1992First described in 199222
BedsideBedside Immediate reliefImmediate relief
2. Epley J. Otolaryngol Head Neck Surg 1992;107:399-4043. Lynn S, et al. Otolaryngol Head Neck Surg 1995;113:712-20.
ED Therapy:
Epley reported an 80% success rate after a single time and 100% success rate after more than one session
30% recurrence rate over a
30-month period.
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Epley Maneuver:Epley Maneuver:
Randomized controlled trials reported Randomized controlled trials reported success rates ranging fromsuccess rates ranging from
44% - 88%44% - 88%
•Froehling et al. Mayo clin proc Jul 2000
•Wolf et al. Clin otolaryngol feb 1999
•Asawarichianginda et al. ENT J Sep 2000
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Epley maneuverEpley maneuver
Canalith repositioning maneuverCanalith repositioning maneuver 5 step head hanging maneuver5 step head hanging maneuver
Moves otoliths out of the Moves otoliths out of the posterior semicircular canal and posterior semicircular canal and back into utricle where they back into utricle where they belongbelong
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Epley maneuverEpley maneuver
1. Repeat 1. Repeat Hallpike Hallpike Previously Previously
performed performed diagnostic diagnostic Hallpike test tells Hallpike test tells you the starting you the starting position (right or position (right or left)left)
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Epley maneuverEpley maneuver
2. Turn head 90 2. Turn head 90 degrees in the degrees in the other directionother direction
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Epley maneuverEpley maneuver
3. Patient rolls 3. Patient rolls onto shoulder, onto shoulder, rotates head and rotates head and looks down looks down towards floortowards floor
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Epley maneuverEpley maneuver
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Epley maneuverEpley maneuver
Repeating the Epley maneuverRepeating the Epley maneuver Post procedurePost procedure
Remain upright for 8-24 hoursRemain upright for 8-24 hours
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The Epley ManeuverThe Epley Maneuver
ContraindicationsContraindications Unstable heart diseaseUnstable heart disease High grade carotid stenosisHigh grade carotid stenosis Severe neck diseaseSevere neck disease Ongoing CNS disease (TIA/stroke)Ongoing CNS disease (TIA/stroke) Pregnancy beyond 24Pregnancy beyond 24thth week week
gestation (relative)gestation (relative)
Furman JM, Cass SP. N Engl J Med 1999;341:1590-96
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ComplicationsComplications
VomitingVomiting Converting to horizontal canal Converting to horizontal canal
BPPVBPPV
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ED therapyED therapy
2- Vestibular Suppressants:
•Meclizine is the most commonly used (H1 – antagonist)
•Can significanthy reduce symptoms.
Cohen et at. Arch Nenrol. Aug 1972(RCT)
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•Dimenhydrinate (Gravol) and diphenhydramine (Benedryl) have also been used.
•Their efficacy is likely mediated by their anticholinergic activity.
•They inhibit muscarinic acetylcholine receptors involved in feedback from the brainstem to the vestibular labyrinth.
•If N/V promethazine (phenergan) or prochlorperazine (stemetil)
(extrapyramidal effect)
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BenzodiazepinesBenzodiazepines generalized inhibition of neural generalized inhibition of neural
activityactivityIn a review article:Authors did not encourage the use of vestibular suppressants:
• suppress the intensity of symptoms.
• but do not reduce the frequency of attacks.
Furman JM, Cass SP. N Engl J Med 1999;341:1590-96
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The Vast majority of peripheral The Vast majority of peripheral vertigo can be managed vertigo can be managed conservatively.conservatively.
Surgery for intractable and Surgery for intractable and incapacitating symptoms.incapacitating symptoms.
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Labyrinthitis and Vestibular Labyrinthitis and Vestibular neuronitisneuronitis
A cute unilateral loss of peripheral A cute unilateral loss of peripheral vestibular functionvestibular function
Associated with vertigo, N/V, and Associated with vertigo, N/V, and nystagmusnystagmus
Worsened by head movementWorsened by head movement Occurs in healthy young to middle-Occurs in healthy young to middle-
aged adultsaged adults Often after respiratory infections Often after respiratory infections self-limitingself-limiting
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Perilymphatic fistula:Perilymphatic fistula:
Due to a traumatic “fistula” at the Due to a traumatic “fistula” at the round or oval window.round or oval window.
After forceful cough, sneeze, scuba After forceful cough, sneeze, scuba diving or direct blow to the ear.diving or direct blow to the ear.
Recurrence of vertigo with pneumo-Recurrence of vertigo with pneumo-otoscopy (Hennebert’s sign)otoscopy (Hennebert’s sign)
Self-limitingSelf-limiting
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Meniere’s disease:Meniere’s disease:
Characterized by triad of:Characterized by triad of:• vertigovertigo• tinnitustinnitus• hearing loss (sensorineural)hearing loss (sensorineural)
Chronic relapsing illness (? familial)Chronic relapsing illness (? familial) Due to a build-up of endolymphatic Due to a build-up of endolymphatic
pressure in the labyrinth.pressure in the labyrinth. Treatment: vestibular suppressants.Treatment: vestibular suppressants.
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Meniere’s diseaseMeniere’s disease
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When to D/C?When to D/C?
1- Peripheral vertigo.1- Peripheral vertigo.2- Healthy
3- Help at home.
4- Symptoms controlled.
5- Able to ambulate.
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F/U with PMD to arrange F/U with PMD to arrange further evaluation if patient further evaluation if patient does not improve. does not improve.
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Case 2Case 2
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Central vertigoCentral vertigo
May include disorders with May include disorders with significant potential significant potential morbidity.morbidity.
Warrants the initiation of Warrants the initiation of further work-up.further work-up.
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SPINNEDSPINNED
SSudden (Onset)udden (Onset) YesYes Slow, gradualSlow, gradualPPositionalositional YesYes NoNoIIntensityntensity SevereSevere Ill definedIll definedNNausea/ausea/DiaphoresisDiaphoresis
FrequentFrequent InfrequentInfrequent
NNystagmusystagmus Torsional/Torsional/horizontalhorizontal
VerticalVertical
EEar (hearing loss)ar (hearing loss) Can be presentCan be present AbsentAbsentDDurationuration ParoxysmalParoxysmal ConstantConstantCNS signsCNS signs AbsentAbsent Usually Usually
presentpresent
PERIPHERAL CENTRAL
Carvalho et al. CTU , Oct, 2004
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Differential DiagnosisDifferential Diagnosis::
Vertebral-basilar Vertebral-basilar circulation events:circulation events:1.1. Vestibular nuclei (TIA or Vestibular nuclei (TIA or
stroke)stroke)2.2. Cerebellar infarction or Cerebellar infarction or
hemorrhagehemorrhage3.3. Lateral medullary Lateral medullary
infarction (Wallenberg’s infarction (Wallenberg’s syndrome)syndrome)
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4. Vertebral artery dissection4. Vertebral artery dissection MigraineMigraine Post concussive syndrome.Post concussive syndrome. Tumors (acoustic reuromas)Tumors (acoustic reuromas) Multiple sclerosisMultiple sclerosis Infection (encephalitis, Infection (encephalitis,
meningitis)meningitis)
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Neuroimaging in vertigo:Neuroimaging in vertigo:
Headache(sudden onset or severe)Headache(sudden onset or severe) Hard neurological findingsHard neurological findings No imaging for patients with no No imaging for patients with no
risk factors and exam suggestive risk factors and exam suggestive of peripheral vertigo.of peripheral vertigo.
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Twenty four patients with risk factors Twenty four patients with risk factors with stroke with history of vertigo with stroke with history of vertigo (>48 hrs) and normal neurologic (>48 hrs) and normal neurologic exam (except nystagemus) 25% exam (except nystagemus) 25% had inferior cerebellar infarction.had inferior cerebellar infarction.
Norrving et al. Norrving et al. Acta Neurol Scand.Acta Neurol Scand. Jan 1995 Jan 1995
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CT CT vs vs MRI:MRI:
MRI/MRA for vertebrobasilar MRI/MRA for vertebrobasilar disease and cerebellar ischemia .disease and cerebellar ischemia .
CT is more sensitive for CT is more sensitive for hemorrhagehemorrhage
negative CT is not always negative CT is not always reassuring. reassuring.
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Bad Excuses In Court:Bad Excuses In Court:
1. "I thought the medications 1. "I thought the medications would help…not cause her to fall would help…not cause her to fall and break her hip.“and break her hip.“
2. "I know it was vertical 2. "I know it was vertical nystagmus, but there were no nystagmus, but there were no other neurological findings so I other neurological findings so I assumed it was peripheral assumed it was peripheral vertigo." vertigo."
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3. "I thought it was obvious that 3. "I thought it was obvious that the patient shouldn’t drive." the patient shouldn’t drive."
4. "The vertigo had subsided, so 4. "The vertigo had subsided, so I thought it was okay for him to I thought it was okay for him to walk to the bathroom.“walk to the bathroom.“
5. "The patient was too young to 5. "The patient was too young to worry about a stroke”.worry about a stroke”.
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6. "I didn’t know that the patient 6. "I didn’t know that the patient had decreased hearing.“had decreased hearing.“
7. "The CT was normal, so I 7. "The CT was normal, so I thought it was safe to send the thought it was safe to send the patient home." patient home."
8. "The patient came from the 8. "The patient came from the psychiatric hospital, so I psychiatric hospital, so I assumed that he was crazyassumed that he was crazy." ."
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The endThe end