Documente Academic
Documente Profesional
Documente Cultură
Objective to be
addressed:
Difference between dizziness and vertigo.
Light headedness
Sense of strangeness
Faintness
Giddy
Imbalanced
out-of-it
2-Pre-syncope:
3-Dysequilibrium:
No illusion.
No sense of faintness.
4-Vague
lightheadedness:
What is Vertigo?
True vertigo:
Defined as an illusion or
hallucination of movement.
How do we maintain
equilibrium?
Visual input
equilibrium
Proprioceptiual
Vestibular input
input
labyrinths.
Anatomy: Semicircular
canals
Semicircular Canals
(SCC)
Cupula
Horizontal
Anterior
Posterior
End organ receptors
Endolymph
Anatomy: Utricle
Utricle
Connected to SCC
Contains
endolymph
Otoliths
(otoconia)
Calcium carbonate
Attached to hair
cells
Macule (end organ)
Vestibular system
CN VIII
labyrinth
Cerebellum
(Vestibular portion)
Vertigo
Brainstem
Vestibular
nuclei
Vertigo
Central
peripheral
SPINNED
PERIPHERAL CENTRAL
Yes
Yes
Severe
Frequent
Slow, gradual
No
Ill defined
Infrequent
Nystagmus
Torsional/horizont
al
Vertical
Can be present
Absent
Paroxysmal
Constant
Absent
Usually
Sudden (Onset)
Positional
Intensity
Nausea/Diaphores
is
Duration
CNS signs
Carvalho et al.
Case 1
Peripheral vertigo:
Approximation 85% of ED patients
with vertigo.
Due to dysfunction of one of vestibular organs.
Asymmetry of input
Sensation of rotation
Associated with nausea, pallor
and diaphoresis.
Differential Diagnosis
BPPV
Characteristic story
Turn head
After a few seconds delay, vertigo
occurs
Resolves within 1 minute if you dont
move
If you turn your head back, vertigo
recurs in the opposite direction
BPPV
B = Benign
Not a brain
tumor
Can be
severe and
disabling
BPPV
P = Paroxysmal
BPPV
P = Positional
BPPV
V = Vertigo
An illusion of motion
The room is spinning
Other descriptions
Rocking
Tilting
Somersaulting
Descending in an elevator
Pathophysiology of BPPV
Otoliths become
detached from
hair cells in
utricle
Inappropriately
enter the
posterior
semicircular
canal
. Parnes LS, McClure JA. Laryngoscope 1992;102:988-92.
Physiology
Normal situation
Pathophysiology of BPPV
BPPV
Dix-Hallpike Maneuver
The diagnosis of BPPV is generally from the
history.
Can confirm the diagnosis of BPPV
First described by Dix and Hallpike in 1952.
Also called the Nylen-Brny,
Brny Brny,
Brny
Nylen, or Hallpike maneuver
Dix-Hallpike Maneuver
They include:
1- Nystagmus
2- Provocative head position
3- Brief latency to symptoms after
change in position
4- Short duration of attack
5- Fatigability of nystagmus on repeat testing
6-Reverse of nystagmus on returning to
upright position.
Lab studies
In a straightforward case, no
lab studies are needed!
Hemoglobin
Fingerstick glucose
Electrolytes if prolonged
vomiting
BHCG
ED Therapy:
1-The Epley Maneuver
30%
30-month period.
2.
3.
Epley Maneuver:
Froehling et al.
Wolf et al.
Clin otolaryngol
Asawarichianginda et al.
Jul 2000
feb 1999
ENT J
Sep 2000
Epley maneuver
Epley maneuver
1. Repeat
Hallpike
Previously
performed
diagnostic
Hallpike test tells
you the starting
position (right or
left)
Epley maneuver
2. Turn head 90
degrees in the
other direction
Epley maneuver
3. Patient rolls
onto shoulder,
rotates head and
looks down
towards floor
Epley maneuver
Epley maneuver
Contraindications
Complications
Vomiting
Converting to horizontal canal
BPPV
ED therapy
2- Vestibular Suppressants:
Meclizine is the most commonly used
(H1 antagonist)
Can significanthy reduce symptoms.
Benzodiazepines
Perilymphatic fistula:
Menieres disease:
Menieres disease
When to D/C?
1- Peripheral vertigo.
2- Healthy
3- Help at home.
4- Symptoms controlled.
5- Able to ambulate.
Case 2
Central vertigo
May include disorders with
significant potential
morbidity.
Warrants the initiation of
further work-up.
SPINNED
PERIPHERAL CENTRAL
Yes
Yes
Severe
Frequent
Slow, gradual
No
Ill defined
Infrequent
Nystagmus
Torsional/horizont
al
Vertical
Can be present
Absent
Paroxysmal
Constant
Absent
Usually
Sudden (Onset)
Positional
Intensity
Nausea/Diaphores
is
Duration
CNS signs
Carvalho et al.
Differential Diagnosis:
Vertebral-basilar
circulation events:
1. Vestibular nuclei (TIA or
stroke)
2. Cerebellar infarction or
hemorrhage
3. Lateral medullary
infarction (Wallenbergs
syndrome)
Neuroimaging in vertigo:
CT vs MRI:
The end