November 12, 2011

Kansas Association of Osteopathic Medicine

Primary Care Update
G. Marcus Stephens, D.O.
 A 67 year-old man rolled over in bed early in
the morning and suddenly developed severe
nausea as well as the unpleasant sensation
that the room was spinning around him. The
spinning resolved within 30 seconds but
recurred again in the opposite direction when
he rolled back to his original position. This
had never happened to him before. The
patient denied tinnitus, hearing loss, recent
viral illness, or head trauma.
 The patient's past medical history was
remarkable only for hypertension for which
he took atenolol. Surgical history was
unremarkable. He did not smoke, drank only
occasionally, and denied illicit drug use.
Family history was non-contributory. He had
no known drug allergies.
 VS: 37.2, 70, 140/85, 12, 98%. The head,
eyes, ears, neck, and cardiac examinations
were unremarkable. A detailed neurological
examination, including mental status, cranial
nerves, motor function, sensory function, and
cerebellar function, was normal. A Dix-
Hallpike (aka Nylan-Barany) test was
performed and showed torsional nystagmus
in the right head-hanging position, along
with reproduction of the patient's symptoms.
 What are the 4  Review Inner Ear
major categories of anatomy and
dizziness? physiology
 How is it worked  Understand BPPV.
up?  Learn the Dix-
 How is it treated? Hallpike Maneuver
 What is vertigo?  Learn Canalith
 How is it worked Repositioning
up? technique
 Common and Treatable
 Dx by history
 The physical exam is just confirmational.
 The dx does not yield to technology, some
tests may lead astray.
 NEVER suggest any symptom, especially with
dizziness, or any other sensorineurologic
condition, e.g. headache, numbness, etc.
 You are interviewing the affected organ
 Family docs are usually the first to work up
 The first 30 seconds in the life of a dizzy
complaint are the most important
 The psychiatrists approach: “Feeling dizzy
lately?”
 Then WAIT!
 Average time a doctor waits for an answer is
8 seconds.
 No questionnaires!
 ‘Dizzy’ is a lay term
 Synonyms include woozy, lightheaded,
drunk-feeling, unstable.
 Vertigo is becoming a lay term
 Listen for localizing symptoms, e.g.. Hearing
loss, tinnitis, double vision, dysarthria, ataxia,
4-limb weakness (points to CNS rather than
peripheral lesion)
 A landmark study done several years ago at
Northwestern University on hundreds of
patients complaining of dizziness found that
the complaints could be categorized into 4
main types:
 Vertigo: an illusion or hallucination of motion
 Dysequilibrium: a gait disorder
 Near-syncope: a sensation of impending faint
 Ill-defined lightheadedness: a metaphor for
anxiety
 An illusion or hallucination of motion
 The most common of the 4 types
 We’ve all experienced it, e.g. spinning on a
stool
 Illusion: a misperception of a stimulus,
accounts form most forms of vertigo
 Hallucination: a perception without a
stimulus, e.g. vertiginous migraine, temporal
lobe seizure
 A sensation of impending faint.
 We’ve all experienced this, e.g.
hyperventillating, standing up to fast after
squatting, etc.
 Only about 50% do faint.
 Workup same as for syncope
 German study on medical students with EEG
and Video monitoring: “looks like a seizure”
 A gait disorder
 “I stagger” “I feel like I’m drunk” “I feel like
I’m going to fall” “I feel unbalanced”
 About 50% do fall
 Aka Type IV Dizziness
 A metaphor for anxiety
 “What do you mean, dizzy?”
 “I’m just dizzy. I’m dizzy all the time.
Nothing really helps.”
 Try to use another word to describe how you
feel…
 “Dizzy!”
 There is more dizziness than there are dizzy
people
 There are roughly 1.5 dizzy complaints per
dizzy person.
 About half of all dizziness is vertigo, the
other half is about a third each of the other 3
types.
 Some may have a mixture of types…try to
ascribe percentages, e.g. 75% vertigo, 25%
type IV.
 Always look in the ear
 Test hearing
 Look for nystagmus
 Positional exam
 Neuro exam
 Is there hearing loss? (Finger rubs)
 Is it sensorineural or conductive (Rinne test)
 If it’s sensorineural, is it cochlear or
retrocochlear (speech discrimination)
 If it’s retrocochlear, do MRI
 If you can’t rember all this, do audiogram
 Aka Barany’s test
 Start seated
 Supine with neck
extended 20 degrees
 Head rotated 45
degrees
 Watch for nystagmus
and ask about vertigo
 Repeat on other side
 cranial nerve  hearing loss (AICA
findings exception)
 Hemiparesis  Able to walk
 Facial weakness  Nystagmus
 Diplopia ◦ horizonto-rotary
 Hypesthesia ◦ Gaze-independent
◦ Reduced with visual
 Horner’s sign fixation
 Gait ataxia-may  Dix-Hallpike
have no limb ataxia differences
Dix Hallpike Peripheral Central
Latency 2-40 seconds None
Severity of Vertigo Severe Mild
Duration <1 minute >1 minute
Fatigability Yes No
Habituation Yes No
Postural Instability Can walk Falls, very
unstable
Hearing loss May be present Usually absent
Other neuro sxs Absent Usually present
Nystagmus Only one position In all positions
 Benign paroxysmal positional vertigo
 Usually in elderly
 Self-limited
 Responds poorly to antivertigo drugs
 Due to canaliths
1. Seated
2. Supine with head
rotated 45 degrees
toward the involved
side
3. Rotate to opposite
side
4. Roll to lateral
recumbent
5. Nose down
6. Sit up
 Sleep upright 2 nights
 Cervical collar??
 Avoid head back
position
 No dentist, hair dresser
 Don’t drive home
 2 pillows at night for a
wk
 Watch eye drops,
shaving
 Avoid BPPV position
 Perilymphatic fistula
 Vestibular neuronitis
 Labyrinthitis
 Meniere’s Disease
 Traumatic Vertigo
 Acoustic Neuroma
 Near-syncope
◦ Usually due to impaired ability to vasoconstrict in
the upright posture, e.g. hypovolemia, high
ambient temperature, hyperventilation, alpha-
blockers, ACEi, bp meds.
◦ Overactive baroreceptor response in elderly (treat w
betablocker-blocks beta receptor and allows
unopposed alpha action)
 Dysequilibrium
◦ Gait disorders, e.g. Parkinsonism,
◦ Cervical spondylosis
◦ Myelopathy, e.g. B12 deficiency
 Type IV: Ill-defined lightheadedness
◦ “dizzy all the time” a metaphor for anxiety
◦ Replace the word dizzy with the word anxious
◦ Hyperventillation
 For BPPV if Epley fails
 For motion sickness (physiologic vertigo)
 Use anticholinergic drugs that cross the
blood-brain barrier
 Works better prophylactically
 NASA experience
 Antihistamines (sedating)
 Benzodiazepines (Type IV)
a. Diminishes with fixation
b. Unidirectional fast component
c. Can be horizontal, rotary or vertical
d. Nystagmus increases with gaze in direction
of fast component
e. Can be accentuated by head movement
a. Diminishes with fixation
b. Unidirectional fast component
c. Can be horizontal, rotary or vertical
d. Nystagmus increases with gaze in direction
of fast component
e. Can be accentuated by head movement
 a. Does not change with gaze fixation
 b. Can be unidirectional or bidirectional
 c. Can be horizontal, rotary or vertical
 d. Nystagmus increases with gaze in
direction of fast component
 e. Can be dramatically accentuated by head
movement
 a. Does not change with gaze fixation
 b. Can be unidirectional or bidirectional
 c. Can be horizontal, rotary or vertical
 d. Nystagmus increases with gaze in
direction of fast component
 e. Can be dramatically accentuated by head
movement
Montani Semper Liberi