2. Learning objectives
• What is vertigo and dizziness ?
• What are the causes of dizziness?
• What is the approach to reach the diagnosis?
• Mention steps and findings in examination of dizziness case ?
• Mention the investigation for a dizziness case?
• What is the treatment in the above case?
3. Case summary
A 45 years old female
presents with the primary
complaint of being “ dizzy ”
6. Types Of Dizziness
• Vertigo: sensation of movement either of the patient
or of the surroundings.
• Disequilibrium: sensation of imbalance.
• Pre-syncope : Sense of impending fainting .
• Syncope: sudden transient loss of consciousness with
concurrent loss of postural tone .
12. Benign paroxysmal
positional vertigo (BPPV)
• BPPV is caused by particles in the semicircular canals which
alter endolymph flow
• It may be due to minor head injury or because of repetitive
head movement
• symptoms sometimes occur at night during movement whihe
asleep
• vertigo = Less than one minute
• BPPV is common in women than men.
13.
14. Vestibular neuritis :
• This is inflammation of the vestibular nerve, possibly due
to viral infection.
• This inflammation disrupts the transmission of sensory
information from the ear to the brain.
• Vertigo Associated with severe nausea and vomiting
• vertigo = Longer than one day.
15. Meniere’s disease :
• It caused by increased volume of endolymph in the
semicircular canals.
• psychological factors such as stress can act as a
trigger mechanism for an attacks.
• Vertigo = less than one day and more than one minute.
• Associated symptoms :
• Tinnitus
• fluctuating hearing loss ( unilateral )
• Nausea & vomiting
16.
17. Central causes of vertigo
• Vascular disease ( vertebrobasilar
insufficiency): 50% of central causes
• Demyelinating (Multiple sclerosis)
• Drugs (anticonvulsants, alcohol, hypnotics)
18. Vertebrobasilar Insufficiency
• Is a condition where there is an
insufficient delivery of blood flow
via the vertebral and/or basilar
arteries to the brain.
• The vertebrobasilar system supports
the occipital lobes, which are
responsible for vision, and
the cerebellum, which is responsible
for balance and coordination.
19. Multiple Sclerosis (MS):
• Is an immune system disease that affects the central
nervous system.
• A lesion or lesions in the brain stem or cerebellum, the area of the
brain that controls balance & coordinate visual, spatial and other input
to the brain needed to produce and maintain equilibrium, May cause
vertigo.
20. Causes of Disequilibrium
• Common in the elderly people.
• caused by Multisensory disorder due to any combination
of:
·peripheral neuropathy
·visual impairment
·musculoskeletal disorder interfering with gait
·vestibular disorder
21. Causes of Pre-syncope
• Caused by psychiatric disorders:
·Major depression 25%
·Generalized anxiety or panic disorder 25%
·Somatization disorder
·Alcohol dependence
·Personality disorder
·Hyperventilation
22. Causes of Syncope
• Drop in blood pressure (orthostatic hypotension).
• Inadequate output of blood from the heart.
• Dehydration
• Low blood sugar
24. 1- Taking History
• History alone reveals the diagnosis in roughly three out
of four patients complaining of dizziness
25. What to ask!
1- ask patient what he mean by “ I’m dizzy” ?
26. What to ask!
2- Or ask the patient questions to identify the type of
dizziness.
27. What to ask!
3- When did the dizziness occur and the duration of it?
( Help to differentiate between the types of vertigo ).
4- Was is it associated with other symptoms?
(Tinnitus, hearing loss , nausea and vomiting.)
5- Are there certain body position that cause the dizziness?
6- Did it occur after performing certain activates ?
28. Medical history
1. Determine if the patient has a condition such as:
• Vascular disease
• Multiple sclerosis
• Cardic disease
• Hypertntion
• Or recent viral upper repiratory infection.
2- Ask the patient about the drug history.
3- Determine if the patient had an ear surgery.
• Family history .
29. Physical examination
• Review of vital signs :
BP (supine and standing), HR, presence of
fever, irregular pulse.
• Ear examination :
Examine the tympanic membrane for vesicles
or cholesteatoma.
38. • Laboratory tests tests such as
electrolytes, glucose, blood counts, and
thyroid function tests are rarely helpful.
• Except for patients with chronic vertigo
and bilateral hearing loss.
39. Treatment and Management
• Treatment is directed at the cause, including
stopping, reducing, or switching any
causative drugs.
• If a vestibular disorder is present and thought to
be secondary to active Meniere disease or
vestibular neuronitis or labyrinthitis, the most
effective vestibular nerve suppressants are
(diazepam). Antibiotics are rarely needed.
40. • Meniere disese diuretics & low salt diet.
• vestibular rehabilitation therapy – for recurrent
vertigo secondary to unilateral vestibular
weakness
• Vertigo associated with (BPPV) is treated with
the Epley maneuver (otolith repositioning).
41.
42. Complication
• Patients with frailty are at significant risk of falling with
consequent fractures;
• their fear of moving and falling often significantly
decreases their ability to do daily activities.
43. Prevention
Dizziness is neither predictable nor
preventable. However, we have some
guidelines:
• Avoid reading while traveling if it makes
you feel sick.
• Relaxation techniques can help ward
tension and anxiety that can cause
dizziness.
• Changes to the diet can also cut down
on episodes of dizziness.
• People with menier’s disease may avoid
episodes of vertigo by cutting salt,
alcohol and caffeine out of their diets.
44. Simple self-care tips that can lower you dizziness:
•Dizziness is always a symptom of danger and it is
better to consult the doctor immediately.
•Drink plenty of fluids.
•Have regular meals.
•Get plenty of rest.
•Practice relaxation by yoga or meditation.
There are four types of dizziness: vertigo, dysequilibrium, presyncope, and syncope.
The most prevalent type is vertigo which accounts for 54 percent of reports of dizziness in primary care.
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The body maintains balance with sensory information from three systems:
vision
proprioception (touch sensors in the feet, trunk, and spine)
vestibular system (inner ear)
Sensory input from these three systems is integrated and processed by the brainstem. In response, feedback messages are sent to the eyes to help maintain steady vision and to the muscles to help maintain posture and balance.
the utricle and saccule — contain crystals that make you sensitive to gravity.
For a variety of reasons, these crystals can become dislodged. When they become dislodged, they can move into one of the semicircular canals — especially while you're lying down.
this causes the semicircular canal to become sensitive to head position changes it would normally not respond to. As a result, you feel dizzy.
The vestibular nerve is one of the two branches of the vestibulocochlear nerve, functioning in tandem with the cochlear nerve. It has the job of transmitting data that has to do with the regulation of the sense of balance to and from the brain.
The semicircular canals sense movement of the head and help to control balance and posture. The cochlea is concerned with hearing. Messages of balance and sound are sent down nerves (the vestibular nerve and the cochlear nerve) to the brain.
The vertebrobasilar system is located at the back of the brain and includes several blood vessels, the vertebral and basilar arteries.
These vessels supply blood, oxygen and nutrients to vital brain structures.
In addition, the vertebrobasilar system supports the occipital lobes, which are responsible for vision, and the cerebellum, which is responsible for balance and coordination.
drugs (anticonvulsants, alcohol, hypnotics)
Improve dramatically when patient touches a stationary object.
Drop in blood pressure (orthostatic hypotension). A dramatic drop in your systolic blood pressure — the higher number in your blood pressure reading — may result in lightheadedness or a feeling of faintness. It can occur after sitting up or standing too quickly.
Inadequate output of blood from the heart. Certain conditions such as any of the various diseases of the heart muscle (cardiomyopathy), an abnormal heart rhythm (arrhythmia) or a decrease in blood volume may cause inadequate blood flow from your heart.
