vertigo1.ppt ent resident presentation first

vertigo1.ppt ent resident presentation first

1. Evaluation and Management of
Dizziness and Vertigo

2. Peripheral vestibulopathy

3. Anatomy of
Vestibulo-Cochlear System

4. Maintenance of balance
Higher centers:
* Extra pyramidal system
* Cerebellum
* Reticular formation
Brain stem
integrating center
(Vestibular nuclei)
(Sensory systems)
Vision
Proprioception
Vestibular
labyrinths
( Effector pathways )
Oculomotor system
(Vestibulo-ocular reflex)
Antigravity muscles
controlling posture &
gait (Vestibulo spinal
reflex)
Perception of
orientation
(in Vestibular cortex)

6. Vertigo
Illusion of movement of the patient or patient ‘s
surroundings
May be described as –rotatory, spinning, tilting or
swaying
Accompanying symptoms-
nausea, vomiting, diaphoresis, apprehension
Disequilibrium
nystagmus.
Disturbance in the peripheral or central nervous system

7. Dizziness
An ambiguous term that patients use to describe
several entirely different subjective states.
The complaint of dizziness generally can be
divided into 1 of 4 categories-
1. Vertigo
2. Syncope or presyncope
3. Disequilibrium
4. Ill-defined dizziness

8. Syncope
Sense of impending loss of consciousness or fainting. (When
the cerebral perfusion falls below the level required to
maintain O
2 and glucose to the brain)
Causes:
Cardiac –Vasovagal
Arrhythmias
Obstructive
Carotid sinus syndrome
Orthostatic hypotension-Drug induced
Volume depleted
Autonomic insufficiency

9. Disequilibrium
Sense of imbalance, unsteadiness or drunkenness without vertigo.
Mismatch of inputs from systems subserving spatial orientation
e.g. vestibular, proprioceptive, cerebeller, visual or extra
pyramidal systems.
Causes:
Multiple sensory deficits
Cerebeller dysfunction
Non-functioning labyrinths
Extra pyramidal disorders
Post. fossa tumour
Drug intoxication

10. Ill-defined dizziness :
(Other than vertigo, syncope, or disequilibrium)
Usually a vague light-headedness, giddiness
or fear of falling.
Causes:
Hyperventilation syndrome
Anxiety neurosis
Hysterical neurosis
Affective disorders
Depression

11. Vertigo
Causes :
Peripheral -Physiologic (motion sickness)
-Vestibular neuronitis
-Benign positional vertigo
-Menieres disease
-Post-traumatic vertigo
-Labyrinthine imbalance
Central -Brain-stem ischemia
-Multiple sclerosis
-Post. Fossa tumour
-Basilar migraine

13. Types of dizziness and vertigo
Sensation of motion (vertigo): central or
peripheral?
Sensation of black-out (near-syncope):
hypoperfusion (hypotension or cardiac origin)
Disequilibrium: with one of multiple sensory
deficits (visual, propioceptive, cerebellar…)
Ill-defined (head discomfort): mild headache,
anxiety, depression or hyperventilation
syndrome

14. Dizziness
1. Black-out: hypoperfusion (hypotension
or cardiac origin)
2. Disequilibrium: Some sensory deficits
3. Head discomfort: mild headache, anxiety,
depression or hyperventilation syndrome
＊Watch for unsteady gait
＊Dizziness is more complicated

15. Black-out (near syncope)
Postural hypotension [autonomic dysfunction
( esp. DM ), drug-induced, elderly, debilitated
or volume depletion]
Anemia
Cardiac arrhythmia
Obstructive (aortic or carotid stenosis)
Vasovagal syncope
Vertebro-basilar insufficiency (VBI)
Subclavian steal syndrome

16. D/D of vertigo
The ‘‘identificationof central or serious
vertigo’’ was voted as the toppriority for
clinical decision rule development in adults
The CT is not good enough; The MRI is not
available right now.
The most effective way to ‘‘rule-out’’ a
central disorder is to ‘‘rule-in’’ a specific
peripheral vestibular disorder.

19. Peripheral vestibulopathy
Vestibular neuronitis
Benign paroxysmal positional vertigo (BPPV)
Meniere’s disease
Post-traumatic vertigo
Viral or bact. labyrinthitis
Acoustic neuroma
Motion sickness

20. Vestibular neuritis
The most common cause of acute severe vertigo.
It is caused by a viral lesion of the eighth cranial nerve.
Vertigo is accompanied by severe nausea, vomiting, and
imbalance.
Typically hearing is not affected, but if severe vertigo is
accompanied by hearing loss then the most common cause
is labyrinthitis—also of a presumed viral etiology.
The hallmark examination signs of vestibular neuritis are a
spontaneous unidirectional horizontal nystagmus.
Patients with vestibular neuritis are typically debilitated for
the first day.
The natural history of the disorder is a gradual recovery
over weeks to months.

21. Meniere’s disease
Meniere’s disease patients are probably less likely to
present to the emergency department during acute attacks
compared with those with acute severe vertigo.
The reason may be that Meniere’s disease attacks are
typically limited to a few hours, and patients learn over
time that the attacks resolve with rest.
Unilateral hearing loss, which is typically a fluctuating
symptom early in the course, but then becomes a fixed and
progressive feature.
Unilateral tinnitus (typically a low roaring sound rather
than a high pitched sound) or bothersome pressure in one
ear

22. Benign paroxysmal positional
vertigo
The episodes are triggered by head movements, not simply
worsened by head movements.
It is important to know that dizziness of any cause can
worsen after certain position changes.
The patient with constant vertigo who reports that the
symptom is better in a certain position and worse with
movement should be classified as having acute severe
vertigo rather than BPPV
The vertigo attacks last less than one minute, followed by a
return to normal.
Some patients have dizziness between paroxysmal
positional vertigo

23. Central Vestibulopathy
Brainstem stroke or lesion
Cerebellar infarct, hemorrhage or tumor
Drug-induced ( phenytoin overdose, Tegretol
intolerance, aminoglycoside etc… )

24. Lobes:
flocculonodular,
anterior, posterior
has tonsils
Vertical division –
vermis (midline)
paravermis, lateral
hemispheres
Both divisions
correspond to
vestibulo-(arche),
spino-(paleo) ,
ponto-(neo)
erebellum

25. Coordination
Arm bounce：請病人手臂平舉，檢查者施予一股向下的力量，當
力量消失時，病人手臂呈現上下擺動的現象。
Finger-nose test: dysmetria, intentional tremor
Heel-knee-shin test: cerebellar or sensory ataxia
Past pointing: 將檢查者的手指固定在一處 ,請病人舉臂過頭，再將
它放下來碰觸檢查者的手指。重複數次之後，請病人閉上眼睛再試 .
若重複且固定的偏向一側 (lesion side)，就稱為past pointing。
(cerebellar and vestibular lesions 皆會發生， cerebellar為單手偏向病
側，vestibular為雙手偏向病側 )
Rapid alternating movement: 請病人用手心拍大腿，然後翻
面，再用手背拍同一個地方，盡可能快速的重複這個動作
(Dysdiadochokinesia)

26. Coordination
Romberg test
睜眼和閉眼都搖晃 cerebellar deficit (cerebellar
ataxia)
睜眼正常，閉眼搖晃 (positive Romberg’s sign)
proprioceptive deficit (sensory ataxia)
Tandem gait:

27. History taking
l.Ear Problem: ear pain or fullness sensation, tinnitus
(unilateral), hearing impairment.
2.Cardiovascular Problem: arrhythmia, orthostatic
hypotension.
3.Diplopia, dysphagia, dysarthria, drop attack,
numbness or weakness of the face or body.
4.Drug history.

28. Neurological examination
l. Nystagmus: gaze-evoked, positional (and
positioning).
2. Cranial nerve lesion and brainstem sign.
3. Cerebellar sign.
4. Any long tract sign.

29. Characteristics of nystagmus
Unidirectional or multidirectional ?
Horizontal, rotary(torsional) or vertical?
More severe than vertigo? (central)
Milder than vertigo? (peripheral) : due to visual
inhibition
Duration? latent? fatique?(Dix-Hallpike
maneuver for positional nystagmus)

30. SEMINARS IN NEUROLOGY/VOLUME 29,
NUMBER 5 2009

32. BPPV

33. Benign Paroxysmal Positional
Vertigo(BPPV)
Most common
Precipitated by movement or position change in the
head or body
Lasts only a few seconds
Aetiology:
•Head trauma
•Stapedectomy
•Intoxication –alcohol , barbiturates
•Canelithiasis –most common
Course –variable
•subsides spontaneously in weeks
•recurs months or years later

34. Otolithic membrane of the macula showing
the organization of calcium carbonate otoliths

36. ANATOMY & PHYSIOLOGY

37. BPPV by canal type
Posterior Horizontal Anterior
Estimated
frequency
81-89% 8-17% 1-3%
Provocative
maneuver
Dix Hallpike Supine Roll Test
(Pagnini-McClure)
Dix Hallpike
Nystagmus Upbeat,
torsional
Horizontal
Direction Changing
Downbeat,
torsional

38. Dix–Hallpike positioning maneuver

39. Supine head turn maneuver

41. Canalith repositioning maneuver
(Epley maneuver)

42. Semont liberatory maneuver

43. Lempert 360-(Barbeque) degree roll
maneuver

44. Forced prolonged position maneuver
即側躺眼振較弱側 (健側)12小時

45. Treatment
1. Antihistamine: Vena IM or IV, meclizine,
merislon etc…
2. Anticholinergic: Artane, akineton.
3. Phenothiazine: Novamin, primperan.
4. Sympathomimetic: Amphetamine, ephedrine.
5. Benzodiazepine:
6. Circulation improver: Diphadol, sanyl, suzin
(sibelium), perdipine etc...
7. Other: Dogmatyl, wintermin

47. Case 1
68 y/o female
Dizziness
Nausea and vomiting
99/8/4

48. Case 2
50y/o female
Dizziness
Revisit ER again
Vertical nystagmus
99/7/26

49. Case 3
56 y/o female
Dizziness
Lt hand dysmetria
99/9/3

50. Case 4
80y/o female
Falling down accident
Dizziness
Mild nausea sensation
100/4/3