OBJECTIVES TYPES OF DIZZINESS TYPES OF DIZZINESS. Type III Disequilibrium. Classifying Common Position Sense Disturbances

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2 OBJECTIVES Define four major types of dizziness Emphasizing vertigo Describe pathophysiology of dizziness Emphasizing BPPV Review how to cure BPPV How do you know where you are in 3-dimensional space? Vision Horizon Rotation Labyrinth Linear acceleration Angular acceleration Proprioception TYPES OF DIZZINESS TYPES OF DIZZINESS 1) Vertigo 2) Pre-syncope 3) Dysequilibrium 4) True dizziness 3) Disequilibrium 2) Pre-syncope 1) Vertigo 4) True dizziness Type III Disequilibrium Classifying Common Position Sense Disturbances Proprioception Pathological Syndromes Decreased Reflexes Variable Reflexes Increased Reflexes

3 Decreased Reflexes Diabetic neuropathy Subacute Combined Degeneration Pernicious Anemia Idiopathic Vitamin B-12 Deficiency Hypothyroidism Chemotherapy (platinum; vinca alkaloids) Amyloidosis Tabes Dorsalis Peripheral Sensory Neuropathy Variable Reflexes Cerebellar Disease Paraneoplastic Syndromes Intoxication Alcohol Mercury Lithium Barbiturates Gasoline Solvents Glue Infection HIV TB Increased Reflexes Cervical Spondylosis Spinal Cord Tumor Metastasis Multiple Myeloma Primary CNS Lesions Cervical Motor Nerve Exam Nerve Root Muscles Position C5 Biceps Arms supinate C6 Wrist Extensors Stop C7 Triceps Block C8 Finger flexors Fists up T1 Interossei Spread fingers Hypotension Orthostasis Cardiovascular drugs Arrythmia Anemia Type II Pre syncope Hypoglycemia Hypocapnia Neurotransmitter interactions Causes of Pre-syncope We do it! (i.e. drugs) Vasoactive Opioids, tramadol, etc. Antidepressant Antianxiety Anticholinergic It happens Aging autonomic nervous system Situations Anxiety Arrhythmia

4 Type I Vertigo Hyperventilation Test Anatomy Vestibular organ Vestibular nerve Vestibular nucleus Classifying Vertigo Lasting Days or Longer Vestibular Neuritis Lasting Days or Longer Lasting minutes to Hours Lasting Seconds to Minutes Cerebellar Stroke Postural Instability Brain Stem Stroke Neighborhood signs Lasting Minutes to Hours Lasting Seconds TIA = Stroke Ménière s disease Partial Seizure MS Migraine Perilymphatic Fistula Benign Paroxysmal Positional Vertigo BPPV

5 Epley Maneuver for BPPV Affecting the Right Ear A. Position head 60 below toward affected side B. Turn toward opposite side C. Turn face down D. Sit upright Pearls for Treating Vertigo When do you use drugs to treat BPPV? Don t Antivert (meclizine) is not the antidote for vertigo! What do you do for a vertigo patient who does not have BPPV? Get a consult. Almost everything other than BPPV is bad. Type 4 True Dizziness Classifying True Dizziness Somatoform Disorder Affective Disorders Malingering The existential essence of dizziness Regular visits SSRI Psychotherapy CBT Incurable TYPES OF DIZZINESS TYPE 1 VERTIGO I. Vertigo I. Lasting seconds to minutes Pre-syncope BPPV I Disequilibrium I Treat with Epley maneuver IV. True dizziness IV. Avoid drugs

6 TYPE 2 PRE-SYNCOPE TYPE 3 DYSEQUILIBRIUM I. Cardiovascular I. Proprioception disorder Often cause not determined Check reflexes I Always consider drug effect 1) Increased cord compression 2) Decreased peripheral neuropathy I Postural abnormality - cerebellum TYPE 4 TRUE DIZZINESS CLINICAL PEARL I. Somatoform disorder I. Always ask open ended initial question Affective Disorders Be quiet and listen I Malingering I Never say the word vertigo until you are sure CLINICAL PEARL DIZZY = VERTIGO VERTIGO = ANTIVERT DEFICIENCY Grateful Acknowledgement Mike Foody Professor Bob Droual, Modesto Junior College Jim Wolf