An Introduction to Dizziness and Vertigo
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1 An Introduction to Dizziness and Vertigo Tamara Mijovic MD CM FRCSC Clinical Assistant Professor Department of Otolaryngology Head and Neck Surgery Otology, Neurotology & Skull Base Surgery McGill University Dec 6 th 2016
2 Disclosure No conflicts of interest
3 Objectives 1) Understand the functional anatomy of spatial orientation and balance. 2) Establish the differential diagnosis of dizziness and distinguish central vs peripheral causes of vertigo 3) Highlight the key features on history taking and physical exam when assessing patients with dizziness or vertigo.
4 Functional anatomy of spatial orientation and balance SENSORS Vision Central nervous system Vestibular system (inner ear) 5 Organs per side Proprioception Joints Muscles
5 OUTPUTS 3. Orientation 1. Stabilize vision (Vestibulocular reflex) 2. Maintain posture (Vestibulospinal reflex Vestibulocolic reflex)
6 DDx: dizziness Central nervous system Lightheaded: Blood pressure and flow to the brain (Hypotension, arrhythmias, carotid stenosis) Vertigo: central Stroke (Vertebro-basilar) Vertebro-basilar insufficiency Multiple sclerosis Tumors of posterior fossa Migraines Psychogenic: Anxiety, Panic attacks Periods of high stress Vision and Ocular Motor function Diplopia Trauma, diabetes, neuropathies, cataracts Vestibular system (inner ear) Vertigo peripheral BPPV Ménière s disease Vestibular neuronitis Labyrinthitis Superior canal dehiscence Vestibular schwannoma Proprioception Cervical arthritis Cervical disk disease Diabetic neuropathy Aging!
7 DDx treatments Central nervous system Polypharmacy: R/A meds R/O Postural hypotension Compression stockings MRI head Doppler of the carotids and vertebral Migraine prophylaxis Neurology Psychogenic: Support, psychotherapy, meds Vision and Ocular Motor function Optometrist Ophtho Well lit environment Vestibular system (inner ear) Vertigo peripheral Vestibular physio Otolaryngologist Proprioception Physio for mobilization exercises Occupational therapy fall prevention Exercise routine Proper footwear
8 Presbystasis = dizziness and balance Central nervous system Polypharmacy: R/A meds R/O Postural hypotension Compression stockings MRI head Doppler of the carotids and vertebral Migraine prophylaxis problems in the elderly Vision and Ocular Motor function Optometrist Ophtho Well lit environment Vestibular system (inner ear) Vertigo peripheral Vestibular physio Otolaryngologist Psychogenic: Support Psychotherapy Meds Proprioception Physio for mobilization exercises Occupational therapy fall prevention Exercise routine Proper footwear
9 Clinical Assessment HISTORY THIS IS KEY MOST OF THE DIAGNOSIS COMES FROM HISTORY
10 A very broad symptom Dizziness? Lightheaded Disequilibrium Vertigo Diplopia Motion sickness
11 Vertigo Subjective sensation: Movement! 70%: Spinning and rotatory 20-25%: Falling, floating, linear movements, ROM Sensation of movement Spinning, tilting, pulling, rocking, floating
12 History Seconds Minutes Hours Days Always there AM/PM Vision Social history: what is going on in their life now?
13 Sec-Min BPPV Superior canal dehiscence Postural hypotension Psychogenic TIA Meniere Disease Migraines TIA / Stroke Min- Hours Days -Vestibular neuronitis -Labyrinthitis -Chronic hypoperfusion -Tumour -MS -Migrainous hypersensitivity Variable: Meds, VBI, Cervical problems, vision prob
14 History Vision Social history: what is going on in their life now?
15 Physical Examination The Basic assessment in Primary Setting General: Vitals and blood pressure: R/O Orthostatic hypotension Ears: Otoscopy and Tuning Fork (512 Hz) Eyes: Spontaneous nystagmus Ocular motor assessment Neurologic CN Cerebellar (coordination, RAM, fine motor) Functional balance: Romberg and Gait Vestibular: Dix-Hallpike Manoeuver
16 Conclusion Spatial orientation and balance are multisensory functions A thorough history and multisystem assessment is needed
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Dizziness. Vertigo. These 2 terms are often used interchangeably
Vincent Wu, MD; Michael M. Beyea, MD, PhD; Matthew T.W. Simpson, MD, MSc, CD, CCFP; Jason A. Beyea, MD, PhD, FRCSC Department of Otolaryngology (Drs. Wu and JA Beyea) and Department of Family Medicine