Vertigo PDF

Vertigo Dizziness can be classified into four groups: •vertigo (spinning sensation) •disequilibrium (feeling of imbalance) •light-headedness (sensation of giddiness)3 •presyncope (sensation of feeling faint). Describe What You Are Experiencing? a) This question really addresses the character of...

Vertigo Dizziness can be classified into four groups: •vertigo (spinning sensation) •disequilibrium (feeling of imbalance) •light-headedness (sensation of giddiness)3 •presyncope (sensation of feeling faint). Describe What You Are Experiencing? a) This question really addresses the character of the dizziness the patient is experiencing b) It is helpful to stratify patients into two different categories of dizziness: Vertigo and Non vertigo dizziness c) It is important to establish this dichotomy as vertigo is often due to • a disorder in the vestibular system, • whereas non vertigo may be related to myriad causes including cardiovascular, ocular, or systemic diseases. d) Begin with open ended questions and allow the patient to respond instead of being biased during history taking vertigo - sensation of movement, often rotary, indicating disorder of the vestibular system Vertigo classification Central Vestibular symptoms originating from pathology in the cerebellum or brain stem Peripheral symptoms arising in the inner ear or from the vestibular nerve are classified as peripheral. Other questions in history Tinnitus/loss of hearing? Nausea/vomiting? Previous viral illness- vestibular neuronitis triggered by a change in the position of the head Weakness of limbs/numbness? brainstem characteristics, including diplopia, autonomic symptoms, nausea, dysarthria, dysphagia, or focal weakness. Gait ataxia Headache-migraine headaches Visual disturbances? Medication on? Risk factors for vascular disease, smoking, diabetes, obesity, hypertension and hypercholesterolaemia Duration • Episodic vertigo that lasts for days with nausea and no other ear or CNS symptoms is usually due to vestibular neuritis, especially following viral illness • Episodic vertigo that lasts for seconds and is associated with head or body position changes is probably due to benign paroxysmal positional vertigo (BPPV) • Vertigo that lasts for hours is probably caused by Ménière disease (if associated with hydropic ear symptoms) • Vertigo of sudden onset that lasts for minutes can be due to migraine or brain or vascular disease, especially if cerebrovascular risk factors are present general examination should emphasize assessment of vital signs, • supine and standing blood-pressure measurements, • and evaluation of the cardiovascular system • CNS-motor/sensory/gait/ Romberg’s/cerebellar • Examine ear • Eye-nystagmus • Examine neck for flexibility Most common differential diagnoses of vertigo Differential diagnosis Onset and duration of each attack of vertigo Provoking factors Special features Physical exam findings Labyrinthitis Few seconds to minutes Change in the head position Tinnitus Hearing loss present Vestibular neuronitis Seconds to minutes Recent upper respiratory tract infection Imbalance, while nystagmus is horizontal or rotational, the direction of the fast component is away from the side of the lesion Absence of hearing loss Benign paroxysmal positional vertigo Seconds Change in the head position Positional Positive Dix−Hallpike Ménière’s disease Hours Spontaneous Hearing loss and tinnitus Hearing assessment for sensorineural hearing loss Ataxia is defined as “an inability to coordinate voluntary muscular movements. Poor muscle control that causes clumsy voluntary movement Cerebellar peduncles. Three fiber bundles carry the input and output of the cerebellum. The inferior cerebellar peduncle (also called the restiform body) primarily contains afferent fibers from the medulla, as well as efferents to the vestibular nuclei. The middle cerebellar peduncle (also called the brachium pontis) primarily contains afferents from the pontine nuclei. The superior cerebellar peduncle (also called the brachium conjunctivum) primarily contains efferent fibers from the cerebellar nuclei, as well as some afferents from the spinocerebellar tract. Cerebellar Examination The cerebellar examination is performed in patients with neurological signs or symptoms of cerebellar pathology e.g dizziness, loss of balance or poor co-ordination Signs of cerebellar disease, from head to foot Scanning speech Causes enunciation of individual syllables: “the British parliament” becomes “the Brit-tish Par-la-ment.” Nystagmus Fast phase toward side of cerebellar lesion. Finger to nose & finger to finger test Ask patient to fully extend arm then touch nose or ask them to touch their nose then fully extend to touch your finger. Y increase the difficulty of this test by adding resistance to the patient's movements or move your finger to different locations. Abnormality of this is called dysmetria. Rapid alternating movements Ask patient to place one hand over the next and have them flip one hand back and forth as fast as possible (alternative you can ask the patient to quickly tap their foot on the floor as fast as possible) if abnormal, this is called dysdiadochokinesia. Rebound phenomenon (of Stewart & Holmes) Have the patient pull on your hand and when they do, slip your hand out of their grasp. Normally the antagonists musc will contract and stop their arm from moving in the desired direction. A positive sign is seen in a spastic limb where the exaggerated "rebound" occurs with movement in the opposite direction. However in cerebellar disease this response is completely absent causing to limb to continue moving in the desired direction. (Be careful that you protect the patient from the unarrested movement causing them to strike themselves.) Heel to shin test Have patient run their heel down the contralateral shin (this is equivalent the finger to nose test). Abnormal exam occur when they are unable to keep their foot on the shin. Hypotonia “Pendular” knee jerk, leg keeps swinging after knee jerk more than 4 times (4 or less is normal). Speech-staccato speech Nystagmus Rebound phenomenon Pendular knee jerk There are many causes of cerebellar ataxia including, among others • Autoimmunity to Purkinje cells or other neural cells in the cerebellum • CNS vasculitis, • multiple sclerosis, • infection, • bleeding, • infarction, • tumors, • direct injury, • toxins (e.g., alcohol), • and genetic disorders. Causes of sensory ataxia • Peripheral nerve: Peripheral neuropathy (especially Diabetic, Alcoholic and Nutritional), Peripheral neuritis. • Dorsal Column Medial Lemniscal Pathway: Tabes dorsalis. • Posterior column: Subacute combined degeneration of the cord, Demyelination changes of the posterior column. The Sensory Examination Pain: Test pain using a sharp object. ... Light touch: Using your fingertips or a wisp of cotton, lightly stroke the skin and determine if the patient feels this symmetrically in all areas tested. ... Temperature: ... Position sense: ... Vibration: ... Discriminitive sense: What is the function of the posterior column? Dorsal column–medial lemniscus pathway The dorsal column–medial lemniscus pathway (DCML) (also known as the posterior column-medial lemniscus pathway, PCML) is a sensory pathway of the central nervous system that conveys sensations of fine touch, vibration, two-point discrimination, and proprioception (body position) from the skin and joints. Friedrich’s ataxia • Commonest type • Starts in childhood 8-15 yrs • Initially lower limbs with gait problems; later involves all limbs • Loss of knee and ankle reflex • Sensory loss- joint position and vibration • Weakness of legs and less often of arms ( either UMN or LMN types) • Extensor plantar response • Kyphoscoliosis- chronic lung disease • Cardiomyopathy • Visual problems – optic atrophy,nystagmus, tremor, hearing loss History • Often, patients presenting with dizziness are unable to describe the sensation and can be vague, particularly if it is the initial presentation. When will you suspect central cause? • Central causes are suspected if the patient presents with associated neurological symptoms such as weakness, dysarthria, sensory changes, ataxia or confusion. • Risk factors for vascular disease, smoking, diabetes, obesity, hypertension and hypercholesterolaemia • Peripheral pathology is associated with symptoms of nausea, vomiting and hearing loss • can be triggered by a change in the position of the head, recent upper respiratory tract infection (URTI), stress or trauma. • Medications, including frusemide, salicylates and antihypertensive agents, can affect the vestibular system, which in turn causes vertigo. with hearing loss • Vertigo is seen in labyrithitis and Ménière’s disease with hearing loss • whereas hearing loss is not seen in benign paroxysmal positional vertigo (BPPV) and vestibular neuronitis (VN)