“doctor i feel dizzy” aimgp seminar 2004 yash patel
TRANSCRIPT
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“Doctor I feel Dizzy”
AIMGP Seminar 2004Yash Patel
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Objectives
Develop an approach to the evaluation of “dizziness”
Review EtiologyPrognosisDiagnostic EvaluationTreatment
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Background
Acute Vestibular Syndrome NEJM 1998; 339:680-5
Vestibular Neuritis NEJM 2003; 348:1027-32
Benign Paroxysmal Positional Vertigo NEJM 1999; 341:1590-96
Vertigo Lancet 1998; 352: 1841-46
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“Take Home Message”
Dizziness is a common symptomClinical History is very important in determining the “Type” of dizziness
The Prognosis for most patients is good
Investigations are helpful only in selected patients
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Real Cases…
Case A 61 M Sudden onset
dizziness, sweating, blurred vision
Wobbling when walking, holding on to things
Case B 79 F “Weak and dizzy” Episodic dizziness
and “roaring in the ear”
Felt unsteady on her feet
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Real Cases…
Case A Nystagmus horizontal
gaze, no diplopia Broad based gait Positive Romberg
sign Normal motor and
sensory exam CT head normal
Case B CN II-XII normal Normal motor and
sensory exam Cerebellar testing
normal Gait was broad
based
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Background
Dizziness is a non-specific term used by patients to describe symptoms
It is a common symptom 7 million clinic visits/year in U.S. Dizziness can represent many
different overlapping sensations Caused by different pathophysiologic
mechanisms
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Mechanism of Balance
Visual receptorsprovide a stable retinal image during movement
Proprioceptive receptorsprovide info on gravity, position, and motion of muscles and joints
Vestibular receptorsprovide info on the direction and speed of motion
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Mechanism of Balance
Integration of receptor information at the vestibular nuclei and cerebellum
Perception of balance is the role of cortical integration and interpretation of signals
Dizziness results when a mismatch occurs between these receptors or levels of the balance system
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Approach to Dizziness
History important to ask open-ended questions and
listen to the description of symptom
Symptom Based Approach (Drachman and Hart,
Neurology; 1972)
Proposed a “complaint-oriented” approach to classifying patients with dizziness
Although symptoms are described differently by each patient they can be classified into one of four categories
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Four symptom categories
A. Sensation of Motion (vertigo)B. Sensation of Impending Faint (pre-syncope)C. Sensation of Losing one’s balance
(dysequilibrium)D. Ill-Defined Lightheadedness (not A,B,C)
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A. Vertigo
Experience an illusion of motion between self and environment.
Perception that the world is moving or the body is moving
Usually accompanied with excessive autonomic activity (Nx/Vx, pallor, diaphoresis)
Disturbance of vestibular function “Central”: lesions of brainstem or cerebellum “Pheripheral”: lesions of labyrinth or VIIIth nerve
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A. Vertigo
“Central” (lesions of brainstem or cerebellum)
Vertigo is NOT the dominant symptom Signs/symptoms of brainstem or
cerebellar involvement
CausesBrainstem or cerebellar
infarctionPosterior fossa tumorsMultiple sclerosis
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A. Vertigo
“Peripheral” (lesion of the labyrinth or VIII nerve)
vertigo ± auditory symptoms
CausesBenign Paroxysmal Positional
VertigoVestibular Neuronitis/LabyrinthitisMeniere’s SyndromePost traumatic or Ototoxicity
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A. Vertigo
Aids to differentiate Central vs Peripheral
Nausea
and Vomiting
Imbalance
Hearing
Loss
Neurologic Symptoms
Compensation
Peripheral Severe Mild Common Rare Rapid
Central Moderate Severe Rare Common Slow
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A. Vertigo
BPPVbrief episodes of vertigo with position
changeusually lasts < 30sidiopathic, after viral infection or traumano hearing change
Vestibular Neuronitissudden onset severe vertigo with nausea
and vomitinglasts hours to daysno hearing loss
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A. Vertigo
Labyrinthitissudden onset severe vertigo with nausea
and vomitinglasts hours to daysassociated hearing loss or tinnitususually follows viral upper respiratory tract
infection
Menieresepisodic vertigolasts hoursfluctuating hearing loss, tinnitus
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A. Vertigo
Vertigo lasting day or longer Vestibular neuritis, labyrinthitis Brainstem/Cerebellar infarction MS
Vertigo lasting hours or minutes Meniere’s TIA or Migraine headache
Vertigo lasting for seconds BPPV
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B. Presyncope
Involves the patient’s perception that they are about to faint
Can be associated with Nx, pallor, diaphoresis, or narrowing of visual field
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B. Presyncope
No difference in the DDx of presyncope and syncope
Cardiovascular (20%)ArrhythmicObstruction to cardiac output
Noncardiovascular (45%)Vasovagalorthostaticpsychogenic
Unknown (35%)
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C. Dysequilibrium
Sensation of losing one’s balance without a feeling of illusionary movement
Typically patients do not report symptoms sitting or lying, but notice unsteadiness standing or walking
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C. Dysequilibrium
Neurologic disorderdisruption in the integration of sensory inputs and motor output
Causes Peripheral neuropathy
alcohol, drugs, DM, B12 Central
C-P angle or posterior fossa tumors Cerebellar degeration Extrapyramidal disorders (Parkinson’s) Drugs (carbamazepine, phenytoin)
Multiple sensory deficits (decreased vision and sensation)
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D. Ill Defined Lightheadedness
Vague sensation not characteristic of vertigo, pre-syncope, or dysequilibrium
Psychophysiologic dizziness impaired central integration of sensory
signals
Psychiatric disorders primary cause of nonspecific dizziness
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D. Ill Defined Lightheadedness
Causes Major depression (25%) Generalized anxiety or panic disorders
(25%) Somatization disorders Alcohol dependence Personality disorders
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Focus of Evaluation
Type of Dizziness Focus of Evaluation
A. Vertigo Auditory and vestibular system
B. Presyncope Cardiovascular system
C. Dysequilibrium Visual, peripheral and central nervous system
D. Ill-defined Psychosocial issues
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Physical Examination
A. VertigoEyes for nystagmusAssess hearingSigns of brainstem involvementAble to walkHallpike maneuver (see next
slide)
B. PresyncopeCardiac and vascular examHeart rhythmOrthostatic blood pressure
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Hallpike Maneuver
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Physical Examination
C. Dysequilibrium
VisionSensation and PositionCerebellar testingGait
D. Ill-defined
No diagnostic physical signs
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Special Tests
A. VertigoCentral: neuroimaging of brainstemPeripheral: audiometry,
electronystagmography
B. PresyncopeCardiac: ECG, Holter, EchocardiogramNoncardiac:Tilt table testing
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Special Tests
C. DysequilibriumVisual testingNeuroimagingNerve conduction studies
D. Ill-definedPsychiatric evaluation
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Treatment
Treatment can be considered in terms of three categories1. Specific
Treat the underlying cause
2. SymptomaticControl symptoms of vertigo, nausea and
vomitingAntihistamines (meclazine,
diphenhydramine)
Phenothiazines (CPZ)
Anticholinergic (scopolamine)
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Treatment
3. RehabilitativeVestibular exercises to stimulate
“dizziness” is necessary for compensation to occur
Physiotherapy
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Etiology, Prognosis, and Evaluation (Hoffman, Am J Med. 1999)
Etiology (most common etiologies)Peripheral vestibular (35-55 %)Psychiatric (10-25 %)Cerebrovascular disease (5 %)Brain Tumors (< 1%)
History and Physical lead to diagnosis in 75 %
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Etiology, Prognosis, and Evaluation (Hoffman, Am J Med. 1999)
PrognosisMost symptoms were self limitedPersistent dizziness impaired quality of life
Diagnostic TestingRoutine lab testing as well as
cardiovascular and neurologic testing had a low yield in unselected patients
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Back to Cases…
Case A 61 M Sudden onset
dizziness, sweating, blurred vision
Wobbling when walking, hold on to things
Case B 79 F “Weak and dizzy” Episodic dizziness
and “roaring in the ear”
Felt unsteady on her feet
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Back to Cases…
Case A Nystagmus horizontal
gaze, no diploplia Broad based gait Positive Rhomberg sign Normal motor and
sensory exam CT head normal Dx: Vestibular
Neuronitis
Case B CN II-XII normal Normal motor and
sensory exam Cerebellar testing
normal Gait was broad
based Dx: Menieres
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“I am dizzy”
Veritigo (sensation of motion)
Presyncope (sensation of fainting)
Dysequilibrium
(unstedy gait)
Ill-defined
Disturbance of vestibular function
Central
Peripheral
Decreased cerebral perfusion
Cardiac
Noncardiac
Neurologic disorder
Psychosocial disorder
Peripheral neuropathy
Central
Brainstem/Cerebellar infarctionPosterior fossa tumorsMS
BPPV/Vestibular neuritisLabyrinthitis/Meniere’sPost traumatic vertigo
ArrhythmiaAortic stenosis/HOCM
VasovagalOrthostatic
AlcoholDM/B12Drugs
Cerebellar diseasePosterior fossa tumorsExtrapyramidal disordersDrugs
DepressionAnxiety or Panic disorderPersonality disorderHyperventilation
Approach to Dizziness
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“Take Home Message”
Dizziness is a common symptom Clinical History is very important in
determining the “Type” of dizziness The Prognosis for most patients is
good Investigations are helpful only in
selected patients