A LOGICAL APPROACH TO THE DIZZY PATIENT

Dizziness and balance disorders center www.susqneuro.com

Conditions
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Vertigo
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BPPV Labyrinthitis Other Conditions: MS, migraine, Meniere’s etc Gait Dysfunction (countless neurological oto, ortho conditions PD, frontal lobe disease, neuropathy, multi-deficit, stroke

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Non-Vertigo

Elderly:

Post-Injury Psych

A philosopher in the vestibule
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We move An unmoving earth is our base of operation If our base moves we have no hope of orientation: hopelessly lost. Discomfort comes from shift in orientation. Need an absolute set of coordinates. Problem of shifting base. Developed from lateral line system in fish Which way is down??

Oscillopsia n n n n n n Bilateral vestibular dysfunction Shows function of vestibular system When the world moves with your head it drives you crazy We need a solid base of operations Result: “Visual Dependence” Foam Pad Romberg positive. .

VESTIBULO-OCULAR REFLEX (VOR) KEEP YOUR EYES ON THE PRIZE Our world seems not to move though We Do .

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Logical Approach strategy for lecture n n n Go into some basic principles applications and testing get into a few prominent diagnoses .Dizziness.

FALLS INJURIES SYSTEMATIC APPROACH .DIZZINESS n n n n n EIGHT MILLION PHYSICIAN VISITS/YR AVERAGE: 5 VISITS WITHOUT RESOLUTION OF PROBLEM Dizziness affects 10% of adults over 40 LOSS OF LIVLIHOOD.

DIZZINESS n VERTIGO n LIGHT-HEADEDNESS n DYSEQUALIBRIUM n GAIT DYSFUNCTION n NEAR SYNCOPE n ANXIETY .

Dizziness: Pointed questions n n n n n Vertigo or Not? Standing or Seated? Isolated or ass’d with Other symptoms? Constant or paroxysmal? Caused by positional change? .

DIZZINESS: nA MULTIDIMENSIONAL APPROACH n AREAS OF EXPERTISE – NEUROLOGIST – OTOLOGIST – REHAB SPECIALIST .

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COWS: Fast Phase of Nystagmus n n n n n Cold – Opposite Warm – Same Each vestibule tonically pushes eyes to opposite side Cold inhibits. warm stimulates and ear Fast phase of nystagmus: cortical correction .

Nystagmus .

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Yaw . Roll.Pitch.

MODULAR VIEW OF VESTIBULAR SYSTEM .

Vertigo or not? =Nystagmus or no nystagmus utricle & saccule (gravity) semicircular canals (movement) cochlea (hearing) .

Planar angular accelerometers – – What’s moving what is still?? Which Way is down?? .Inner ear teleology n Utricle and Saccule – Gravity receptors – Which way is down?? n Semicircular Canals .

Why Vertigo?? conditions n n n n Converting accelerometer (semi-circular canals) into gravitometers – BPPV Stimulating accelerometer: Meniere’s. labyrinthitis “central” mechanism: hallucination in CNS – much less potent Something stimulates accelerometer (SCC) .

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Vertigo DDx n n n n n n n n BPPV Meniere’s Vestibular neuritis Bilateral vestibular Loss Post-traumatic vertigo (labyrinthine concussion) Perilymph fistula Migraine and epilepsy Cerebro-vascular Disease .

tandem. foam pad) Fistula test .Dizziness Battery n n n n n n n Orthostatics and both arms Hallpike Fukada Head Thrust Head Shake Romberg (conventional.

Benign Paroxysmal Positional Vertigo n n n n n Recurrent One ear down position Positive Hallpike Transitory positional vertigo “Vertigo induced by postional change” Unique .

looking up.BPPV History n n Variable history: Many patients complain of waxing and waning dizziness. or down – Tie shoelace or put clothes on line n Remits and exacerbates . not always vertiginous and aren’t aware of episodic nature Classic: In bed when turn.

BPPV predispositions n n n n Age Post vestibular neuritis Post trauma Ear infections .

Set up eddy currents in fluid filled canal Cupulolithiasis: otoliths adherent to walls .BPPV n n Canalithiasis: By far majority.

Horizontal canal BPPV nystagmus is purely horizontal and asymmetric.n Posterior nystagmus are delayed by approximately 15 seconds (latency). with its stronger component beating toward the diseased canal. Peripheral nystagmus is latent. and fatigable. peak in 20-30 seconds. n n n .Nystagmus fatigues on repeated trials. with complete resolution of symptoms. paroxysmal. The vertical component of benign paroxysmal positioning nystagmus (BPPN) is best observed by asking the patient to move the eyes away from the down-most (tested) ear. with its vertical component beating downward. and then decay. Anterior canal nystagmus is rotary. reversible. Symptoms and reversed nystagmus may recur when the patient is brought to a sitting position. geotropic.

BPPV Variants – Eye Movements n n n Posterior SCC: Canalith or cupulo – Torsional to side down and upbeat Horizontal geotropic Horizontal ageotropic Downbeat and torsional to side down Horizontal SCC: Canalith – Horizontal SCC: Cupulolithiasis – n Anterior SCC: Canalith or Cupulo: – .

BPPV .

Logroll maneuver for horiz canal .

CANALITH REPOSITIONING (EPLEY) .

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Semont Maneuver .

Brandt Daroff .

Paroxysmal psychological Vertigo n n n n n n n n Form of Panic Attack Sensory overload “Supermarket Syndrome” Complication of untreated BPPV + Anxiety Computation of position and movement Worst in Aisles and small spaces: comparator of near and distant movement: Car +claustophobia?? Your life depends on it: Therefore intense fear “Phobic positional vertigo” .

Kinetophobia Viral or ischemic – Herpes simplex and other viruses. Bell’s palsy of the vestib n.Vestibular Neuritis n n n n n n Sudden Vertigo and vomiting Emergency room Extreme motion sensitivity: Pts lay like a rock. n Rarely recurs Look for other signs that may relate to VB system or posterior fossa. .

neuronitis or labyrinthitis n No loss of hearing indicates inflammation of vestibular nerve or scarpa’s ganglion (neuronitis) – – – Inferior vestib nerve goes to posterior canal Superior nerve goes to utricle. sup.Vestibular neuritis. lat canal Herpes virus? n n n Hearing loss: may be labyrinthitis Any pain or inflammation: ? Bacterial or other treatable infection Can’t distinguish 100% from brainstem stroke .

n n n n n Fast phase away from the offending ear Veer to slow phase ENG suppressed on offending side 5% or so cases may be recurrent BPPV is frequent sequel .Vestibular Neuritis: Findings n Spontaneous horizontal or horizonto-rotatory nystagmus – You may have to block fixation to see it.

Meniere’s n n n n n Severe vertigo and vomiting Fluctuating Hearing Loss Fullness unilateral Tinnitus Endolymphatic Hydrops .

Meniere’s n Vertigo + Vomiting last hours – Few disorders are paroxysmal in just this way n n n Patients need not have entire tetrad Most common: Severe vertigo. vomiting and tinnitus A number of “Meniere-like” syndromes – Previous insults to inner ear .

Meniere’s treatment n n n Avoid Salt and Caffeine Diuretic Surgeries – – – Gentamycin injection Vestibular nerve section Hearing sparing operations .

Perilymph fistula n n n n n Dizziness with change in pressure Nose-blowing dizziness Sound sensitivity “Tullio Phenomenon” Dizziness with exertion Sensori-neural loss on audiogram .

Perilymph Fistula n n n n n n Breach of Round window Superior canal dehiscence Cholesteatoma Trauma Post-surgical esp fenestration for otosclerosis Scuba diving .

Perilymph Fistula: breach of round window. From Tim Hain .

Fistula n Strain against closed glottis – Upbeat nystagmus CW for right ear CCW for left ear n Pull in thru closed nostrils – Downbeat nystagmus CW for left ear. CCW for right ear n n OR do fistula test with bulb OR Test for Tullio phenonenon .

Cholesteatoma .

cholesteatoma n n n Hearing loss and loss of balance or vertigo Chronic infection or congenital Basically tumor in middle ear and petrous bone .

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INPUTS TO BALANCE 3 .

Construct Program. Elements:
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Clinicians to Evaluate

PM&R, Neurology
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Diagnosis Therapeutic Recommendations

Gait Analysis
Vestibular (habituation, exercise, Canalith) Gait and Balance Devices trial and recommendation

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Treatment
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Vestibular Rehabilitation
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Compensations
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Avoidance (BPPV) Substitution (Bilateral Vestibular Loss) Plasticity (Vestibular Neuritis) Massed practice to retune CNS and compensate “habitutation” Repositioning Gait retraining

Vestibular Rehab
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Habituation Canalith repositioning Balance Retraining Exercises and retraining Conditioning Compensation Strategies

As in visual dependence

Assistive devices Bracing Muscle strengthening

Vestibular Rehabilitation
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VOR Stimulation Exercises Oculomotor Exercises Balance Exercises Gait exercise Obstacle course
www.emedicine.com/ent/topic666.htm#target1

Cawthorne-Cooksey Exercises n In bed or sitting – Eye movements -. then quick n n n up and down from side to side focusing on finger moving from 3 feet to 1 foot away from face bending forward and backward turning from side to side – Head movements at first slow.at first slow. head and shoulder movements as before Changing form sitting to standing position with eyes open and shut Throwing a small ball from hand to hand (above eye level) Throwing a ball from hand to hand under knee Changing from sitting to standing and turning around in between Circle around center person who will throw a large ball and to whom it will be returned Walk across room with eyes open and then closed Walk up and down slope with eyes open and then closed Walk up and down steps with eyes open and then closed Any game involving stooping and stretching and aiming such as bowling and basketball Standing – – – – – n Moving about (in class) – – – – – . then quick. later with eyes closed n n n Sitting – – – n Eye movements and head movements as above Shoulder shrugging and circling Bending forward and picking up objects from the ground Eye.

VESTIBULAR REHABILITATION n n HABITUATION ADAPTATION OF OTHER SENSORY SYSTEMS .

Neurologic Syndromes n n n n n n MS PD NPH Stroke Aging Multi-sensory Deficit .

Normal Gait .

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Tinetti Sitting Balance Leans or slides in chair Steady. Attempts to arise Unable without help Able. requires > 1 attempt Able to rise. uses arms to help Able without using arms =0 =1 =2 3. safe =0 =1 2. 1 attempt =0 =1 =2 . Arises Unable without help Able.

Begins to fall Staggers. grabs. Standing Balance Unsteady Steady but wide stance (medial heels > 4 inches apart) and uses cane or other support Narrow stance without support0.1. trunk sway) Steady but uses walker or other support Steady without walker or other support0. moves feet.Tinetti (2) n n n n n n n n n n n n n n n n n n n n 4.1.2 6.1. catches self Steady0.2 . Nudged (subject at max position with feet as close together as possible.2 5. Immediate standing balance (first 5 seconds) Unsteady (swaggers. examiner pushes lightly on subject’s sternum with palm of hand 3 times.

2 . falls into chair) Uses arms or not a smooth motion Safe. smooth motion0. Sitting Down Unsafe (misjudged distance. swaggers) Steady0.Tinetti (3) n n n n n n n n n n n 7. Turning 360 degrees Discontinuous steps Continuous steps Unsteady (grabs.1.2 9.1.1 8. Eyes closed (at maximum position #6) Unsteady Steady0.

Left foot completely clears floor 0.1 11.Tinetti Gait n n n n n n n n n n n n n n n n n n n 10.1 . Step length and height a.1 g. Initiation of gait (immediately after told to “go”) Any hesitancy or multiple attempts to start No hesitancy0.1 h. Left swing foot does not pass right stance foot with step0.1 d.1 c.1 f. Left foot passes right stance foot0.1 e. Right foot passes left stance foot0. Right foot completely clears floor0. Left foot does not clear floor completely with Step0. Right swing foot does not pass left stance foot with step b. Right foot does not clear floor completely with step0.

Step Continuity Stopping or discontinuity between steps Steps appear continuous0.1. Path (estimated in relation to floor tiles.1 . Marked deviation Mild/moderate deviation or uses walking aid Straight without walking aid0. observe excursion of 1 foot over about 10 feet of the course). and no use of walking aid0. no flexion. Step Symmetry Right and left step length not equal (estimate) Right and left step appear equal0. no use of arms.2 16.Tinetti Gait 2 n n n n n n n n n n n n n n n n n n n n n 12. Walking Stance Heels apart Heels almost touching while walking0. or spreads arms out while walking No sway.1 13.1.1. Trunk Marked sway or uses walking aid No sway but flexion of knees or back. 12-inch diameter.2 14.2 15.

Multiple Sclerosis n n May present as typical peripheral vestibulpathy ? lesion at root entry zone .

Multi-sensory deficit n n Aging Loss of neurons in CNS – – degenerative vascular n n n Arthritis Peripheral nerve dysfunction Vestibular dysfunction .

Multi-sensory deficit n Physical therapy – – – – falls prevention muscle strengthening trying out assistive devices minimizing deficits .

Acoustic Neuroma .

Acoustic Neuroma n n n Unilateral Hearing Loss VII and V Unsteadiness rarely paroxysmal vertigo .

Vertebrobasilar Insufficiency n n n n n n n n Vertigo Diplopia Dysarthria Dysphagia Ataxia Sensory or Motor Loss Drop attack Most feared misdiagnosis in older vertiginous patient .

Post-Traumatic Vertigo n n n n n BPPV Meniere’s “Cervical” vertigo Perilymph fistula Factitious (psychological) vertigo .

Migraine Associated Vertigo n n n Headache Bickerstaff Vertigo occurs as aura or part of HA syndrome .

Autoimmune Inner Ear Disease (AIED) n n n Hearing Loss Vertigo Bilateral “meniere’s” .

C1Q. Thyroids . RF. ANA. Lyme. FTA.AIED n n n Anti HSP-70 Anti Raji Cell Sed.

Bilateral Vestibular Loss n n n n Oscillopsia Visual Dependence Aminoglycosides Advanced Age + Chronic ear disease .

Symptomatic only when up Positive Romberg Foam Pad Romberg which diminishes proprioception – hallmark Help by increasing proprioceptive feedback – assistive device.Bilateral vestibular dysfunction n n n n n Advanced age Unsureness on feet. . practice.

MOTION SICKNESS n n n n CHRONIC SENSITIVITY TO MOTION OTHER PERSON DRIVING DISCOMFORT WITH MOTION VESTIBULAR REHAB: HABITUATION .

Mal de Debarquement n n Persistence of perception of motion after a cruise Psychophysiological (?) .

“Benign Positional Vertigo”.onbalance.com – “Dizziness Explained”. MD www.net by Todd Troost. MD www.ivertigo.susqneuro.thain.com. “Vertigo: A Logical Approach” n n n www.com: Posturography .Bibliography n www. by Tim Hain.

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