Common complaint
Diagnosis is usually confirmed by:
Eg: Benign Paroxysmal Positional Vertigo (BPPV)
A PRACTICAL APPROACH
TO DIZZINESS
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Common complaint |
Diagnosis is usually confirmed by:
Eg: Benign Paroxysmal Positional Vertigo (BPPV)
!!! KEY: History begins by trying to understand what the patient means by "dizziness" !!!
Vertigo
Dysequilibrium
- Sensory (propriocetn/senstn)
- Motor (muscle weakness/arthritis
Light-headedness
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• Defn: similar symptoms to those preceding syncope |
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Eg: sitting up quickly |
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Cause: |
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• NOT Vestibular |
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• ? Cardiac, Vascular (VBI), vaso-vagal, metabolic, hyperventilation |
?? Try to simulate by hyperventilating
The History
"I understand you have been referred to me because you have dizziness, please tell me what you feel when you have this sensation and let us not use this word"
Attack characteristics
Otologic symptoms
* Hearing loss
* Tinnitus
* Ear Fullness/Pressure
Non-Otologic symptoms
• Neurologic: headaches (migranous vertigo)
• Psychiatric: anxiety, hyperventilation, halluc’n (not usually vertigo)
• Cardiac: palpitations
• Autonomic: dysautonomia may => postural hypotension
• Degenerative: presbystasis
• Metabolic
CLUES TO Diagnosis IF VERTIGO (ie Duration of VERTIGO)
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Seconds (5-90 secs): Benign Paroxysmal Positional Vertigo |
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Minutes (2-20mins): Vascular (usually assoc with other symptoms) (?? Under-reported) |
Non Vascular
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Hours (20 mins-24hrs): Meniere’s Disease (usually 4-8 hours) |
Migraine
Acoustic Neuroma (? Infarction of nerve)
(Tip: telephone positive sign)
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Days: Strongly suspect Vestibulo-Neuro-Labyrinthitis (VNL) |
NB: Perilymphatic fistula: any of above, usually assoc’d with hearing loss)
EXAMINATION OF THE DIZZY PATIENT
General Examination: PR, BP, Temp
ENT, Head & Neck Examination
Neurotologic Exam (Balance Testing):
Fistula Test
Eyes: Smooth Pursuit, Nystagmus, Head Shake, Snellen's oscillopsia
Gait
Romberg
Unterberger
Hallpike
Other Tests of co-ordination
EYES:
Smooth Pursuit:
- allows clear continuous vision of moving objects
- Test: target 1 m from pt
- If Ab(N) => ? B/Stem or cerebellar
medn’s: BZ’s, Anticonvul, Li
Saccadic Eye Movement:
- Test: 2 objects 1m away, 150 apart
- If Slowing: INO (B/S , MS)
- If Inaccurate: cerebellum
- Prob initiating: Parkinson’s
Nystagmus:
Direction = Fast Phase
Plane
Types: Spontaneous: Primary Gaze or <300 from midline
(Remember: End Point Nystagmus)
Evoked: Head shake, Positioning
Vestibular = "direction fixed" (vs Central)
? Side of Vestibular Lesion:
Acute Hypofunction (cut vestib nerve) = FAST PHASE C/LATERAL
Chronic Lesion (usually htpofunction) = FAST PHASE C/LATERAL
Acute Irritative lesion (VNL) = FAST PHASE IPSILATERAL
Snellen’s Oscillopsia:
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• Sensitive test for vestibular lesion |
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• Test: read Snellen's chart with head stationary then read with 60 deg head rotation (1-2 cycles/sec) |
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• (N) = degrade by 1 line |
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• Unilateral loss = degrade by 2-4 lines |
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• Bilateral loss = degrade by 5-6 lines |
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• Good test for monitoring ototoxic medications |
GAIT
Questions ??
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• Is the gait relatively normal ? |
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• wide based (? cerebellar disorder) |
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• shuffling (? Parkinson’s) |
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(?exaggerated ???? malingering) |
• Does the patient veer into wall ? (vestibular / cerebellar)
ROMBERG TEST
Sharpened (or Tandem) Romberg
Tests: dorsal white column & vestibular
UNTERBERGER (FUKUDA) TEST
Marching, eyes closed, arm extended
Positive if >45 deg turn in 50 steps
Good vestibular test
HALLPIKE TEST
Test of BPPV
Positive if: nystagmus +/- subjective vertigo
INVESTIGATIONS
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Audiogram (pure tone & speech discrimination) |
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Vestibular Function Tests (VFT’s) |
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• Electronystamography (ENG) |
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• Rotational Chair |
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• Posturography |
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• Electrocochleography (ECoG).. If suspect MD |
Imaging
If suspect a central lesion on Hx & Exam
Atypical clinical features
Asymmetry on above investigations
MRI & MRA (with Gadolinium)…. Soft tissue lesion
CT Petrous Temporal Bones…. Bony lesions
Bloods (rarely)
TRANSCRANIAL DOPPLER
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emits a signal => reflected off moving RBC’s |
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magnitude of change in frequency = velocity |
STENOSIS
DIZZINESS – SUMMARY
(VDLMOP)
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Disclaimer
Please note: The above is intended as a general guideline only for Dr. Becvarovski’s patients.
This material should not be used for purposes of diagnosis or treatment without consulting a physician.
Each patient is an individual and should be treated accordingly.
Please contact our rooms if you are concerned or require any further information.
Dr Zoran Becvarovski MBBS, FRACS
Consulting Rooms Hospital Appointments
St George Private Medical Complex St George Public Hospital
Suite 7A, Level 5, St George Private Hospital
1 South Street Kogarah 2217 Hurstville Community Private Hospital
Telephone: 9553 0066
Fax: 9553 0444
