S Diagnostic approach to evaluation. S Treatment modalities. S Effectiveness of treatment modalities. S Symptoms are nonspecific

6/5/2015 Objectives Dizziness S Diagnostic approach to evaluation S Treatment modalities Leslie Griffin MD MPH Assistant Professor University of T...
Author: Marvin Dean
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6/5/2015

Objectives

Dizziness

S Diagnostic approach to evaluation S Treatment modalities

Leslie Griffin MD MPH Assistant Professor University of Tennessee Family Medicine

S Effectiveness of treatment modalities S Brief look at the differences in evaluating the

elderly patient

S

Significance

Difficulties

S Approximately 5% of primary care visits

S Symptoms are nonspecific

S Nearly 3% of all emergency room visits

S Differential is broad S Final diagnosis not obtained in 20% cases.

Categories

Step one rule out other causes

S Vertigo

45-54%

S Caffeine

S Disequilibrium

16%

S Nicotine

S Presyncope

14%

S Alcohol

S Lightheadedness

10%

S Hypoglycemia S Head trauma and whiplash injuries.

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Commonly associated medications

Rule out: Migraines

S Cardiac S Alpha blockers, beta blockers, ACE inhibitors,

clonidine, dipyridamole, diuretics, hydralazine, methyldopa, nitrates, reserpine S CNS

S Episodic vertigo with signs of migraine S Photophobia, phonophobia, aura S During at lease 2 episodes of vertigo

S Antipsychotics, opioids, Parkinsonian drugs, skeletal

muscle relaxants, TCAs S Urologic S Phosphodiesterase type 5 inhibitors, urinary

anticholinergics

Step 2: Description

S Vertigo: Spinners- false sense of motion S Disequilibrium: off-balance S Presyncope: feeling of losing consciousness S Lightheadedness: Woozy- a more vague

disconnected feeling

Timing S Vertigo is never continuous for more that a few

weeks S Permanent vestibular lesion S CNS system adapts S Frequent episodic dizziness can be vestibular S Constant dizziness lasting months generally

psychogenic.

Vertigo

Benign Paroxysmal Positional Vertigo

S Benign Paroxysmal Positional Vertigo S Vestibular Neuritis S Meniere’s Disease S Labyrinthitis

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Benign paroxysmal positional vertigo

Diagnosis: BPPV

S Brief, self limited episodes of vertigo S Provoked by typical position changes S No hearing loss

Treatment: BPPV

Epley Maneuver

S Epley maneuver: approximately 5 times more

likely to have objective and subjective improvement S Objective: OR=5.67 95% CI (2.21-14.56) S Subjective: OR=4.92 95% CI (1.84-13.16)

Vertigo: Vestibular Neuritis S Meclizine S Commonly used despite no RCT support S Vestibular suppression can lead to brainstem compensation

S Viral infection of vestibular nerve

and actually prolong symptoms

S Vestibular rehabilitation therapy (VRT) S exercise-based program designed to promote central nervous

system compensation for inner ear deficits.

S No direct evidence S Benzodiazepine S Not significant difference between treatment and placebo

group.

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Presentation: Vestibular Neuritis

Diagnosis: Vestibular Neuritis

S Persistent vertigo S Severe vertigo S Without hearing loss S Typically post viral S URI S Generally self limited S 2-3 days.

Treatment options: Vestibular Neuritis S For prolonged symptoms S Vestibular rehabilitation therapy (VRT) S exercise-based program designed to promote

central nervous system compensation for inner ear deficits. S Steroids S 100mg methylprednisolone po daily then taper to 10 mg over 3 weeks S Methylprednisolone more effective than valacyclovir S RCT

Vertigo: Meniere’s Disease S increased endolymphatic fluid in the inner ear

Vestibular Rehab Therapy S Goal: S gaze and gait stabilization via compensation S Involve head movement to stimulate and

retrain the vestibular system S Neural plasticity S Changes in neural pathways in response to

new stimuli

Presentation Meniere’s

S Episodic spontaneous vertigo S 20 minutes to 2 hours S Ear fullness S Tinnitus S Hearing loss S Any age S 40-60 most common S Chronic disease

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Treatments: Meniere’s

S

Medications S For symptomatic relief of dizziness S Meclinzine, diazepam, glycopyrrolate, lorazepam

S

Salt restriction and diuretics S No RCT supporting

S

Injections: 80% resolution S Gentamicin 82% resolution S Increased risk permanent hearing loss by damage to microcillia S Dexamethasone 80% resolution

S

Endolymphatic sac surgery

Presentation: Labyrinthitis S Positional vertigo + Hearing loss S Vertigo resolves in days to weeks S Return of hearing more variable S Viral more common in adults S 30-60 y/o S Typically occur post URI S Bacterial more common in patients with cholesteatoma

Vertigo: Labyrinthitis

S Inflammation by viral or bacterial infection

Treatment: Labyrinthitis S Acute Phase: S Symptomatic S Meclizine, antiemetics S Treat underlying cause S Chronic Phase: S Vestibular rehabilitation therapy (VRT) S exercise-based program designed to promote

central nervous system compensation for inner ear deficits.

Disequilibrium

S Off balance or wobbly

Presyncope

S Feeling of losing consciousness

S Parkinson S Peripheral neuropathy S Stroke S Poor vision S Medications S Benzodiazepines and TCA in elderly

S Orthostatic hypotension S Medication review S hypotensives

S Hydration

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Presyncope:

S Severe orthostatic hypotension S Pharmacotherapy: S Midorine S alpha 1 agonist S Fludrocortisone S

mineralocorticoids increase Na and water retention

S Pseudoephedrine, Paxil, Desmopressin

Presyncope: Cardiovascular

S Arrhythmias S Supraventricular Tachycardia S Myocardial infarction S Carotid stenosis S Cardiac medications S Particularly in elderly

Lightheadedness S Symptoms more vague S Disconnected feeling S More likely psychiatric in origin S Anxiety S 25-28% S Hyperventilation Syndrome S Depression

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