I m dizzy-what can I expect at my doctor visit? Dennis M. Moore, M.D. Lutheral General
Dizziness and Balance is a broad area encompassing multiple fields: primary care (internal medicine, pediatrics), otolaryngology (ENT), neurology, physical therapy, rehab medicine, psychology and psychiatry Most people with dizziness start at their primary care physician s office (generally most appropriate) or sometimes the emergency department and are then referred to other specialists as needed Some patients will self refer to specialists There are now physicians who call themselves Dizzy Docs (Drs. Tim Hain and Marcello Cherchi), physicians dedicated to focusing solely on dizziness and balance disorders (I refer patients to them quite frequently)
Specific disorders Inner Ear: Ex. BPPV, Meniere s Disease, Perilymph fistula, Superior canal dehiscence syndrome, labyrinthitis, autoimmune Neurologic: Ex. Migraine, Stroke, Parkinson s disease, Peripheral Neuropathy Vestibular Nerves: Ex. Acoustic Neuroma, Vestibular Neuritis Medical: Ex. Hypertension, Vascular, Cardiac, Medication Side Effects
Generally, the history of the problem directs the examination; therefore, the exam is usually targeted to the situation at hand No gold standard examination Most comprehensive vestibular exam usually occurs with the sub-specialty dizziness physicians
Prior to your visit: Ask the doctor s office about the routine What to bring: Reports and disks of scans, hearing tests, vestibular tests results, blood test results Should you take your meclizine or other dizzy meds? Should someone accompany you, a driver perhaps?
Day of your visit: Arrive early, may have to complete a questionnaire or forms What to wear: modest clothing, no miniskirts or stillettos, minimize makeup May have a bad hairday if doctor uses goggles in exam, don t make appointment on same day as prom, court date or academy awards Bring any assist devices you use: cane, walker. Bring Meds!!!!!!!!!!!!
History important from listening to interrogation What can I expect? Any known cause? (e.g. trauma, infection, medication reaction, etc.) Time course? seconds minutes hours days Pattern? spontaneous positional w/movement What helps? Meclizine? Holding still? Laying down? What makes it worse? Movement? Positions? Stress? Associated symptoms? Hearing loss? Ear fullness? Tinnitus? HA?
Examination: Subsets Otoscopy/ear exam other ENT/neuro exam? Cranial Nerve Exam Oculomotor Exam, incl. pursuit and saccades Spontaneous nystagmus Gaze evoked nystagmus VOR: Head Thrust VOR: Visual Fixation Suppression
Examination: Subsets VOR: Headshake Test Positional Tests: Hallpike, Static Balance: Walking Gait Romberg Test Fukuda Stepping Test Special Tests: Pressure Fistula Test Valsalva, Tullio s Vibration over mastoid
organ sense stimulus ear hearing sound eye vision light skin touch pressure mouth/throat taste chemical nose smell chemical ear equilibrium head motion
VOR - Vestibulo-ocular reflex - generates eye movements that enable clear vision while the head is in motion. the best studied and most understood VSR - Vestibulo-spinal reflex - generates compensatory body movement to maintain head and postural stability, thereby preventing falls.
Disclaimer The following video segments were not intended to insult anyone s intelligence. However, they are low budget and, in fact, were barred from YouTube (actually, they referred me to a new site called YouStupid). For best viewing, please use your imagination and wish me luck!
Basic Ear Exam
Cranial Nerve Exam
Eye Movements: visual pursuit, saccades
Spontaneous and Gaze Nystagmus w/ vision
Spontaneous and Gaze Nystagmus- IR goggles
Spontaneous and Gaze Nystagmus- eye movements
The VOR iiiii iiii i L R
Vestibulo-ocular Reflex, chair rotations
Vestibulo-ocular Reflex, chair rotations (eye movements)
Visual Fixation Suppression of VOR
Visual Fixation Suppression of VOR (eyes)
Rapid Head Thrust Test
Head Thrust Test
Romberg Test
Hallpike Maneuvers for the diagnosis of BPPV
Dix-Hallpike Test
Frenzel Goggles