CBL- 13- Dizzy Spell

mmgt of BBPV

- Brandt-Daroff exercises at home - in clinic Epley maneuver

counseling

- advise pt of benign prognosis - meds not indicated for treat of BPPV (including meclizine) - instruct pt to do Brandt-Daroff at home - if sx persists, arrange pt to oupt for Epley manuever

central localization of vertigo

- brainstem, cerebellum, temporal lobe assoca w/ diplopia, dysarthria, dysphagia, HA, sensory phobias= cranial cause

dizziness

- can be assoc w/ prescribed meds and recreational drug use - screen for new meds, changes in doses, recreational drug use and try to link the dizzy spell attack w/ timing of taking a med

vertigo localization

- central or peripheral cause peripheral= inner ear vestibular apparatus or vestibulocochelar nerve- CNVIII

nystagumus presentatio and localization

- may be asymp or report oscillopsia assoc w/ brainstem, cerebellum or inner-ear dysfxn

Pts w/ MS

- may have central vertigo in which sx persist even when lying still - pts w/ MS have a previous hx of multiple episodes of neuro dsyfunction

central differential for vertigo

- migraine w/ brainstem aura - brainstem ischemia - cerebellar mass- tumor, abscess - simple-partial seizure- temporal - MS

Pt w/ syncope

- most pts willl report heart fluttering, palpitations, rapid breathing, sweating or a feeling of faintness

Vertebrobasilar ischemia

- nearly always assoc w/ brainstem syx or a. diplopia b. dysarthria c. dysphagia d. hemisensory or crossed sensory deficit e. ataxia f. horner syndrome

canalolithiasis

- stimulation of semicircular canal by endolymph debris

Meniere's disease pathophysio and epi

- usually in midlife- 40-60 yo - pathophys: idiopathic endolymphatic hydrous - rare and overdiagnosed cause of vertigo

migraine w/ brainstem aura as c/o recurrent vertigo

- usually stereotypical presentation w/ other asst migraine features (headache, Naus/Vomit, sensory phobias and Identifiable triggers like stress changes) - treat w/ migraine prophylactic agents

sx of BPPV

- vertigo for < 1 min, few times/ day - resolves when head still (increase w/ head movement) - nausea and vomiting - no hearing loss

Maintenance of balance

- vestibular, proprioceptive and visual pthways all feed into cerebellum/brainstem all work together - person only needs 2/3 systems to maintain normal balance - on Romberg test, examiner eliminates vision by asking pt to close his or her eyes while standing w/ both feet together (if pt falls => they have dysfunc in either vestibular or proprioceptive system)

vestibular neuritis pathophysio

- viral infection of vestibular n or inner ear

differential for peripheral vertigo

1. BPPV 2. Meniere syndrome 3. vestibular neuritis/ labryinthitis 4. drug toxicity (amino glycosides, chemo) 5. CNVIII lesions a. acoustic neuroma b. cerebellopontine angle tumors c. VZV of CN 7 and 8 (Ramsay-Hunt syndrome) d. chronic meningitis e. vertebrobasilar dolichoectasia

eval of pt w/ vertigo

1. Dix-Hallpike maneuver 2. MRI brain w/ and w/out gad 3. vestibular testing

lightheadedness differential

1. hypovolemia- dehydration, blood loss 2. neurogenic syncope- vasovagal response 3. autonomic peripheral neuropathy- diabetic 4. cardiac arrythmia- tachy or brady 5. left ventricular outflow obstruction- aortic stenosis hypertrophic CM 6. migraine- syncopal often w/ brainstem aura - all these pts should be assessed for orthostatic hypotension w/ a bedside tilt test

Weber test

1. lateralize conductive hearing loss by making tuning fork (LOUDEST IN AFFECTED EAR) 2. lateralize sensorineural hearing loss- tuning fork (LOUDEST IN NORMAL EAR) 3. bilateral sensorineural hearing lsos- (REDUCED HEARING IN BOTH EARS SIMULTANEOUSLY TO TESTING)

steps of Epley maneuver

1. sit pt up w/ head turned 45 degrees to right 2. lower head rapidly below table edge 3. rotate head rapidly to L at 45 x 30 s 4. roll pt on L side w/o turning head x 30 s 5. sit pt up

Dix Hallpike maneuver steps

1. sit pt up, forward, eyes open 2. quickly lie pt back, head to 45 degrees, observe 30 sec 3. sit pt up, facing forward, eyes open- observe 30 S 4. lie pt back, head turned 45 degrees to R neck extended over table, observe 30 sec - looking for nystagmus

dx of BPPV

Dix-Hallpike maneuver

mgmt of meniere's disease

acetazolamide or HCTZ/ triamterene - sugery- decompression, labryinthectomy

head movement and vertigo

all types are associated with worse symptoms with head movement

CNS lesion--> vertigo localization

brainstem cerebellum temporal lobe- vertigo can occur in partial seizures w/ temporal focus

visual system fxn in balance

detection of head movement from horizon feedback on integrity of vestibule-ocular reflex

vestibular system fxn

detects change in gravity; adjusts balance - maintains eye steadiness during head turning

peripheral neuropathy differential

diabetic neuropathy B12 deficiency other

BPPV as c/o vertigo- pathophysio

due to canalolithiasis- stimulation of semicircular canal by endolymph debris- loose otoconia or otoliths-

sx of meniere's disease

episodic vertigo, tinnitus, hearing loss - episodes last 20 min- hours occur monthly may progress to hearing loss to low frequency over time

Brant- Daroff exercises for BPPV

exercises of head rotation at home to settle otoliths in correct position most pts experience relief in 10 days 1. Sit up on side of bed 2. lie on side (for 30 seconds) 3. sit up for 30 seconds 4. lie on other side for 30 seconds 5. sit up for 30 seconds

Rinne test

f/u for abnormal Weber (asymmetry) - helps diff between conductive deficit or sensorineuronal hearing loss - normal ear- bone conduction less than air conduction 1. test which ear that weber lateralized to (loudest) - if air conduction < bone then pt has lateralized conductive hearing loss in that ear 2. if bone conduction less than air conduction, pt has sensorineural hearing loss in CL ear

ataxia definition

gait imbalance or dysequilibrium 1. motor ataxia- not affected by vision, due to cerebellar dysfunction 2. sensory ataxia- worse when vision impaired due to proprioceptive defect

vertigo definition

hallucination of movement of pt or environment often spinning but may be due to side to side mvmt due to vestibular system dysfunc (inner ear, brainstem, cerebellum or temp cortex)

peripheral NS lesions that cause vertigo localization

inner ear or CNVIII - anywhere from inner ear to medullary vestibular nuclei

brainstem and cerebellar vestibular nuclei

integrate vestibular, proprioceptive and visual info send info to ear eye muscles cerebral cortes

oscillopsia

jumping, oscillating, stuttering or shaking vision

proprioceptive system fxn

knowledge of foot position detection of leg movement

lightheadedness definition

near syncope or syncope due to hypotension vibratory/ buzzing sensation due to migraine

otoliths as cause of BPPV

normally in utricle or saccule but break free and stimulate a semicircular canal (usually the posterior semicircular canal)--> vertigo

rotational tests for vestibular testing

observe eye mvmts of pt rotated in a chair controlled by a computer in the dark w/ eyes open

Epley maneuver

performed in clinic to move endolymph out of posterior semicircular canal into utricle - pt should avoid supine position from 2 days - may need to repeat until nystagmus abolished

myelopathy asst w/ proprioception deficit in both legs

posterior compression subacute combine degeneration- B12 deficiency or HIV vacuolar myelopathy tabes dorsalis- neurosyphillis

posturography

pt stands on specialized moving platform and computer measures change in body sway during Romberg

ENG- electronystagmogram

records eye movements - corneal surface electrodes

vertigo due to BPPV and head movement

resolves when the head is still

BPPV findings w/ Dix Hallpike

severe vertigo rotatory nystagmus (clockwise or counter-clockwise) latency- delay in response after assuming position fatigue- response lessens as position is maintained habituation- response lessens after repeat testing

medical terms for dizziness, spinning, lightheadedness or unsteady

syncope, vertigo, gait imbalance, dysequilibrium

looking for what w/ brain MRI for vertigo?

tumors at cerebellopontine angles

tinnitus/ hearing loss and vertigo

usually asst w/ peripheral cause

sx of vestibular neuritis

vertigo+ nausea and vomiting - if labyrinthitis- also tinnitus and/or hearing loss

mgmt of vestibuar neuritis

vestibular suppressant- benzo, antihistamine, antiemetic - corticosteroids if hearing loss