CLINICAL THERAPY

CASE
PRESENTATION

RISHI JAMIVIE D. AGBUGAY

(III-A)
Case: a 42 year old factory worker presents with complaints of dizziness. When asked to
describe what “dizzy” means to her, she relates a feeling of movement, even though she is
standing still. The first time it happened, she also felt a little nauseated. In her job, she has to
look down to fold clothes coming off the line, and the dizziness occurs if she looks down too
quickly. It only lasts about a minute, but it is disruptive to her work. The symptom has also
occurred when she is lying down and rolls over in bed. She has no medical history or related
family history. Her vital signs and heart, lung, and gastrointestinal (GI) examinations are normal.
Her pupils are equal, round, and reactive to light and accommodation. Extraocular movements
are intact, and no nystagmus is noted. Cranial nerve examination is normal. Strength, deep
tendon reflexes, and gait are normal.

OBJECTIVES
1.Learn how to categorize types of dizziness.
2. . Recognize the symptoms and signs related to positional vertigo.
3. Distinguish “benign” positional vertigo from more serious causes of vertigo
4. Understand the treatment options for vertigo.

DIAGNOSIS
Benign positional vertigo

BEST THERAPY FOR THE CONDITION

 Head position maneuvers. A technique called canalith repositioning (or Epley maneuver)
A maneuver to dislodge the loose otolith from the affected semicircular canal can be
performed in the office
 Balance therapy. You may learn specific exercises to help make your balance system
less sensitive to motion. This physical therapy technique is called vestibular rehabilitation.
It is used for people with dizziness from inner ear conditions such as vestibular neuritis.

 Psychotherapy. This type of therapy may help people whose dizziness is caused by

anxiety disorders.

 Medications:
 Meclizine
 Diazepam- for severe symptoms
 Valium or transdermal scopolamine patches

HOW TO CATEGORIZE TYPES OF DIZZINESS

 “Dizziness” is a myriad of symptoms, including lightheadedness, vertigo, “feeling out of

sorts,” and gait instability. The first step in evaluating patients with this complaint is to
ask open-ended questions about the sensation and to listen to the patient’s history.
 The majority of patients who complain of dizziness are suffering from a distinctive
symptom—presyncope, dysequilibrium, or vertigo— which can be clarified by history or
physical examination.
 Presyncope is the sensation associated with near-fainting. Patients may describe feeling
light-headed, a graying of vision, or “nearly blacking out.” This sensation typically is
brief, lasting seconds or minutes, and is self-resolving.
 Dysequilibrium is a sense of imbalance, usually while walking. It is a multifactorial
disorder, commonly seen in elderly patients with impaired vision, peripheral neuropathy
and decreased proprioception, and musculoskeletal problems causing gait instability. It
may also be one of the presenting symptoms of patients with primary movement
disorders such as parkinsonism.
 Vertigo is the illusory sensation of movement or spinning, and usually arises from a
disorder in the vestibular system.
 Physiologic vertigo includes motion sickness, or the sensation of movement that may
occur when watching motion pictures.
 nonspecific dizziness, which cannot be classified as vertigo, presyncope, or
dysequilibrium. Patients cannot clearly describe one of these syndromes, can report
only that they feel “dizzy,” have vague or unusual sensations, and have normal
neurologic and vestibular examinations. The majority of these patients have some
underlying psychiatric disorder.
 Pathologic vertigo occurs when there are lesions in one of the systems. The first task in
evaluating a patient with vertigo is to try to distinguish peripheral (labyrinthine
apparatus or vestibular nerve) from central (brainstem or cerebellum) causes of vertigo.
Central causes, such as cerebellar hemorrhage or infarction, can be immediately life
threatening or signify serious underlying disease and require urgent investigation.
Peripheral causes typically signify less serious diseases and can be managed
comfortably on an outpatient basis.
 SIGNS AND SYMPTOMS RELATED TO POSITIONAL VERTIGO
 sensation of spinning or swaying.
 vomiting
 blurred vision
 nausea
 brief periods of mild or intense dizziness Changing the position of your head can trigger
an episode such as
o tilting your head up or down
o lying down
o turning over
o getting up

 lightheadedness
 loss of balance
 unsteadiness
 (+) Dix-hallpike maneuver

TREATMENT OPTIONS FOR VERTIGO

Surgical Care
Surgery usually is reserved for those in whom canalith repositioning procedure is not successful.
Surgery is not the first line of treatment because it is invasive and carries the possibility of
complications (eg, hearing loss, facial nerve damage).
The options, all of which have a high chance of vertigo control, include the following:
 Labyrinthectomy
 Posterior canal occlusion
 Vestibular nerve section
 Singular neurectomy (ie, selective denervation of the posterior semicircular canal,
sparing the other parts of the ear)
Of all of these options, the posterior semicircular canal occlusion seems to be gaining the most
favor. This procedure has the capability of hearing preservation, without sacrifice of the entire
vestibular system. Only the affected posterior semicircular canal (or horizontal semicircular
canal) is ablated. The other semicircular canals, as well as the saccule and utricle, are left intact.
This procedure is far easier to perform than the singular neurectomy. Ongoing studies are
evaluating its effects. Some have reported 95% improvement.

Non-surgical
1. ANTIHISTAMINES
These agents prevent the histamine response in sensory nerve endings and blood vessels. They
are effective in treating vertigo.
MECLIZINE
INDICATION
- Decreases excitability of middle ear labyrinth and blocks conduction in middle ear
vestibular-cerebellar pathways. These effects are associated with therapeutic effects in
relief of nausea and vomiting.
DOSAGE
- 25-100 mg/day PO in single daily dose or divided q6-12hr
CONTRAINDICATION
- Hypersensitivity

ADVERSE EFFECT
- Drowsiness
- Thickening of bronchial secretions
- Acute glaucoma attack
- Blurred vision (rare)
- Constipation
- Fatigue
- Vomiting
- Headache
- Dry mouth
- Urinary retention

2. ANTICHOLINERGICS
These agents work centrally by suppressing conduction in the vestibular cerebellar
pathways.
Scopolamine (Isopto)

INDICATION:
- Blocks action of acetylcholine at parasympathetic sites in smooth muscle, secretory
glands, and CNS. Antagonizes histamine and serotonin action.
- Transdermal scopolamine may be most effective agent for motion sickness. Its use in
vestibular neuronitis is limited by its slow onset of action.
CONTRAINDICATION
- Hypersensitivity
- Closed-angle glaucoma
DOSAGE
- 1mg/72hr
- Nausea & Vomiting : 0.3-0.65 mg IV/IM/SC; repeat q6-8hr if necessary
- Motion Sickness Prophylaxis: Apply 1 patch behind ear at least 4-12 hours (preferably 12 hr)
before anticipated exposure to motion, then every 3 days PRN
- Transdermal patch: Apply 1 patch behind ear on night before scheduled surgery, then leave on
for 24 hours after surgery
ADVERSE EFFECT
- Dry mouth (29-67%)
- Drowsiness (17%)
- Dizziness (12%)
- Blurred vision

3. BENZODIAZEPINES
By binding to specific receptor sites, these agents appear to potentiate the effects of GABA and
facilitate inhibitory GABA neurotransmission and other inhibitory transmitters. These effects
may prevent vertigo and emesis.
Diazepam (Valium)

INDICATION
- Depresses all levels of CNS (eg, limbic and reticular formation), possibly by increasing
activity of GABA. Individualize dosage and increase cautiously to avoid adverse effects.
CONTRAINDICATION
- Documented hypersensitivity
- Acute alcohol intoxication
- Myasthenia gravis (allowable in limited circumstances)
- Acute narrow angle glaucoma and open angle Severe respiratory depression
- IV use in shock, coma, depressed respiration, patients who recently received other
respiratory depressants
- Sleep apnea
DOSAGE
- 2-10 mg PO q6-12hr, OR 2-10 mg IV/IM q6-12hr; no more than 30 mg/8 hours
ADVERSE EFFECT
- Euphoria (3%, rectal gel)
- Incoordination (3%, rectal gel)
- Somnolence (>1%)
- Rash (3%, rectal gel)
- Diarrhea (4%, rectal gel)

DEFINITIONS

BENIGN POSITIONAL VERTIGO

 Most common type of vertigo.
 It is caused by loose, floating calcium debris in the semicircular canals that causes an
increase in neurologic discharge from the vestibular system.
 Typically, this type of vertigo is precipitated by changes in head position, as in rolling
over in bed, bending over, or looking upward.
 Patients may not have all of the typical symptoms at the same time; however, the first
bout usually is abrupt in onset and associated with nausea. Subsequent occurrences
may be less severe.
DIX-HALLPIKE MANEUVER
 To confirm the diagnosis of BPV.
 The clinician holds the patient’s head and moves the patient rapidly from a sitting to a
head-hanging position, first with the head facing one side and then facing the other
side. Individuals with benign positional vertigo will demonstrate nystagmus after a delay
of a few seconds.
PATHOPHYSIOLOGY

Otoconial debris (calcium carbonate) released

from degenerating macula of adjacent utricle

Floats freely in endolymph

Settles on cupula of posterior

semicircular canal in a critical head
position

Displacement of cupula

VERTIGO