DIZZINESS & VERTIGO evaluation of dizzy patient

Vertigo is a mainstream requirement of treatment in the current times

1. EVAULATION OF DIZZY PATIENT DR ADHYASHA ( MODERATOR ) BY DR. SONALI SIBY

2. AGENDA Introduction > Causes > Approach to a Patient • History • Examination • Testing > Differential Diagnosis • Vestibular Neuritis • BPPV • Vestibular Migraine • Meniere's Disease. • Vestibulr Schwannoma • Bilateral Vestibular Hypofunction • Central Vestibular Disorders • Functional Dizziness > Treatment

3. INTRODUCTION - A term that is commonly used to describe wide range of sensation - Dizziness Vertigo, Light-headedness, Faintness, & Imbalance Vertigo-Sense of spinning Physiological Pathological Light-Headedness Pre-syncopal sensations Brain Hypoperfusion

4. TYPES OF DIZZINESS Vertigo: C haracterized by a false sense of spinning or motion. Common causes include BPPV and Ménière's disease. Typically associated with vestibular system disorders. Presyncope: Feeling of impending loss of consciousness . Often related t o cardiovascular issues l ike arrhythmias or orthostatic hypotension. Disequilibrium: Sensation o f unsteadiness or imbalance . Can be seen in conditions affecting p roprioception or motor control, such as Parkinson's disease. Lightheadedness: Vague, floating sensation. Often associated with systemic conditions like anemia, anxiety, or medication side effects. Clinical significance: Identifying the specific type of dizziness is crucial for narrowing down potential causes and guiding further evaluation and management.

5. INTRODUCTION AND IMPORTANCE D izziness prevalence: D izziness is a common complaint in medical practice, affecting approximately 15-20% o f adults annually. This high prevalence underscores its importance in clinical settings. Symptom ambiguity : The term "dizziness" is often vague and can mean different things to different patients, ranging from vertigo to lightheadedness. Differential diagnosis: It's crucial to differentiate between various causes of dizziness, as they can range from benign conditions to life-threatening emergencies. Systematic approach : A structured evaluation is necessary to accurately diagnose and treat dizziness, involving careful history-taking, physical examination, and sometimes additional tests. P otential severity : While many cases of dizziness are benign, it can sometimes indicate serious underlying conditions, making thorough assessment vital.

6. CASE OF A DIZZY MAN 50M with hypertension Sudden onset dizziness when raising from bed No sensation of room spinning Worsened with positional change Dizziness is continuous Unsteadiness while walking Nauseated, and vomited twice No hearing changes, recent illness

7. PATIENT'S NEUROLOGICAL EXAMINATION BP 159/64, HR 70, RR 16, T 98.6F No corrective saccades on head impulse test Direction changing nystagmus Absent skew No appendicular ataxia No weakness, dysarthria, dysphagia, sensory loss

8. VESTIBULAR ANATOMY

9. VESTIBULAR ANATOMY VESTIBULAR EXAM AND LESION LOCALIZATION

10. H.I.N.T.S C.D EXAMINATION

11. BACK TO PATIENT... 50M, hypertensive Acute spontaneous continuous dizziness Negative head impulse test Present direction changing nystagmus Absent skew No focal neurological deficits, appendicular ataxia Veering to right when walking What is the likely localization of his lesion?

12. WHAT DO PATIENTS MEAN BY DIZZINESS? "I feel wobbly on my feet, like I am on a ship." "I feel like the world spinning around me" "I feel dizzy with a constant feeling of nausea and desire to vomit." "I feel like I am constantly being pushed when I walk." "I feet lightheaded and unsteady with difficulties focusing." Which of the following implies vestibulopathy ?

13. WHAT DO PATIENTS MEAN BY DIZZINESS? "I feel wobbly on my feet, like I am on a ship." "I feel like the world spinning around me" "I feel dizzy with a constant feeling of nausea and desire to vomit." "I feel like I am constantly being pushed when I walk." "I feet lightheaded and unsteady with difficulties focusing." Which of the following implies vestibulopathy ? ALL OF THESE

14. HOW DO WE NARROW DOWN THIS LONG LIST OF DIFFERENTIALS?

15. EXAMPLES :

16. DIX-HALLPIKE MANEUVER Purpose: This test is specifically designed to diagnose Benign Paroxysmal Positional Vertigo (BPPV). Initial positioning: Turn the patient's head 45 degrees to the side being tested. Movement: Quickly lay the patient back with their head hanging about 20 degrees off the end of the exam table. Observation: Watch for rotatory nystagmus, which typically has a latency of a few seconds and lasts less than a minute. Interpretation: A positive test, indicated by vertigo and characteristic nystagmus, confirms the diagnosis of BPPV.

17. HORIZONTAL SCC :PROVOCATION TEST : SUPINE ROLL TEST . MC CLURE PIGNINI NYSTAGMUS : HORIZONTAL , DIRECTION

18. POSTERIOR CANAL 81- 89 %, PROVOCATION TESTS : DIX HALLIPIX NYSTAGMUS : UPBEAT , TORSIONAL .

19. SUPERIOR SCC : 1-3 % SUPINE HEAD HANGING TESTS DOWNWARD BEAT , TORSIONAL NYSTAGMUS

20. WHAT IS THE NEXT STEP IN THE MANAGEMENT? DIAGNOSIS DIAGNOSTIC TESTING What's the most sensitive diagnostic test in an acutely dizzy patient?

21. INVESTIGATIONS Clinical diagnosis: Many cases of dizziness can be diagnosed based on history and physical examination alone. Audiometry: Hearing tests are valuable when inner ear disorders are suspected, especially in cases of asymmetric hearing loss. Neuroimaging: MRI of the brain is indicated when central causes like stroke or multiple sclerosis are suspected. C ardiac monitoring: ECG or Holter monitoring may be necessary if cardiac arrhythmias are suspected as a cause of presyncope. Laboratory tests: Basic blood work including CBC, glucose, and thyroid function tests can help identify systemic causes of dizziness.

22. RED FLAGS (URGENT REFERRAL) Acute onset with focal deficits: Sudden dizziness accompanied by neurological deficits could indicate a stroke or other central nervous system emergency. Abnormal nystagmu s: Vertical or direction-changing nystagmus suggests central pathology rather than a peripheral vestibular disorder. S evere headache and neck stiffness: These symptoms, especially if accompanied by fever, could indicate meningitis or subarachnoid hemorrhage. Ataxia without vertigo: D ifficulty with coordination in the absence of spinning sensations may indicate a cerebellar problem. S udden hearing los s: New-onset hearing impairment, especially if unilateral, can be a sign of inner ear damage or acoustic neuroma.

23. COMPREHENSIVE MANAGEMENT PRINCIPLES PRIMARY APPROACH: • Treatment must target specific underlying conditions • Each disorder has a distinct management protocol • Evidence-based interventions are essential CONDITION-SPECIFIC TREATMENTS: • BPPV: Epley maneuver (repositioning procedure) • Vestibular Neuritis: Dual approach with steroids and vestibular rehabilitation • Ménière's Disease: Lifestyle modifications (salt restriction) plus medical therapy (diuretics) • Anxiety-Related: Psychological interventions (CBT) and medication (SSRIs) • Cardiogenic: Complete cardiac evaluation and appropriate management

24. ACADEMIC FOUNDATION AUTHORITATIVE SOURCES: UpToDate: Current clinical guidelines Harrison's Internal Medicine: Comprehensive medical reference BMJ/NEJM articles: Peer-reviewed research Multiple source validation for best practices