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DizzinessCAUSES

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MANAGEMENTDR.MOHAMMADHODANDLO.FRCS,KSUF,SAUDIBOARDENTConsultantSecurityForcesHospitalRiyadh,SaudiArabiaVertigodefinedasanillusionofmovementinwhichthesubjectfeelingiseitherthatheismovinginspaceorthattheouterworldismovingaroundhim.PhysiologyofBalanceThreesystemsinvolveinbalance:VisualProprioceptiveVestibularVestibularSystemConsistof5sensoryorgans3semicircularcanals:Lateral,Posteriorandsuperior(crista–ampularis)Otolithorgans–Utricleandsaccule(macula)SemicircularcanalsresponsibleforangularaccelerationOtolithicorgans–responsibleforlinearaccelerationCristaampularisandmaculaconsistofvestibularhaircellsembeddedintogelatinommasscontainsotolithThereare23000haircellsinthetreecristaeand40000haircellsinthetwomaculeEachsensoryhaircellsbearing50–100thinsterociliaandsinglethickandlongkinociliumEachafferentneuronhasbaselinefiringrateDeflectionofstereociliatowardkinociliumresultinanincreaseinthefiringrateofafferentneuronandviceversaInformationisintegratedwiththatfromvisualandproprioceptivesystemresultinginmaintainanceofbalancethrough:Vestibulo-ocularreflexVestibulospinal(cervical)reflexVestibuloocularreflexFunctionofVORistogenerateeyemovementswhichisequalinamplitudebutoppositeindirectiontoheadmovementscausingtheminordertostabilizetheimageformedontheretinaduringheadmovementsApproachtoDizzyPatientHistory:QualityofSymptoms Patientsusuallyexpresswidevarietyofsymptomsasdizziness:

1) Vertigo–usuallyrotatorymovement.Itusuallysuggest

peripheralvestibulardisorder. 2) Disequilibriumorimbalance–pt.Usuallycomplainof

unsteadinessrelatedtoambulation-Peripheralnervous

systemorcerebellardisorder. 3) Presyncope–feelingoffaintnessorimpendinglossof

consciousness-cardiovasculardisorder. 4) Lightheadness:nonspecificsensationofunsteadinessor

floating-variablecausesincludingHypoglycemia,

Hyperventilation,anemiadrugsandevenvestibular. 5) Uncomfortablesenseofshiftingorbobbingofviewedobject

(oscillopsia)=>bilateralvestibulardamageHistory:DurationofSymptomsSuddenonsetorintermittentsymptomsusuallyindicateperipheralcauseConstantandprogressivelyworseningsymptomsindicatedcentralcauseDurationofindividualAttachVertigolastingseconds:BenignParoxysmalpositionalvertigo(BPPV)VertebrobasilarinsufficiencyLabyrinthinefistulaVertigolastminutestohoursMenieresDiseaseSecondaryendolymphatichydropsPostmiddleearsurgeryDecompansationofpreviousvestibularlesionDurationofindividualAttachcont’d.Vertigolastfordays:VestibularneuronitisPost–labyrinthectomyHeadinjuryLabyrinthitisVascularlesionCPAtumoursAssociatedSymptomsHearingloss,earfullness,tinnituseardischargeindicateperipheralvestibularpathologyBlurredvision,diplopia,dysarthria,incontinence,motororsensorydeficit,convulsionorlossofconciousnessallindicateCNSpathologyNuseaorvomiting->indicateseverityandmorecommonwithperipheralcausesExacerbatingfactorsHeadmovement ->BPPVClosingtheeye ->peripheralvestibular

pathologyLoudnoise ->PerilymphfistulaAnxietyattack ->PsychologicalDrughistory–ototoxicmedicatione.g.aminoglycosidechemotherapyAntihypertensiveAnticonvulsantsAlcoholGENERALMEDICALHISTORYSystemicillnesssuchasDMVasculardis. -Hypertension -H/OC.V.A.

-Subclavianstealsyn.Cardiacdis. -Rheumaticheart(Aorticstenosis)

-I.H.D.

-ArrhythmiaInfectiondis. -Syphilis,Viral,BacterialHaemotologicalDiseasesuchPolycythemia,anemiaStabilizingsensoryorgandisorder

e.g.ReferactionoccularerrorsPeripheralnervedis.Jointdis.PsychiatricproplemDepressionPanicdisorderAnxietyEXAMINATIONOtologicalexamination(tuningfork)forhearingassessmentincludingfistulatestCranialnerveexaminationBloodpressureandpulseRomberg’stest(balancetest)CerebullarfunctiontestNeckexaminationforcarotidarterydiseaseandrangeofmotionNystagmus–theonlyobjectivemanifestationofvertigoNystagmusItisdefinedasinvoluntaryrepetitivemovementofeyes,havingslowandfastphaseSpontaneousnystagmusseenwheneyesareinrestingpositionGazeevokednystagmusInducednystagmusbyheadshakingtestorcalorictestPositionalnystagmusbyHallpikemaneuverPositionalnystagmus BPPV CentraltypeLatentperiod 2–20sec noneAdaptation disappearsin50sec persistsFatiguability disappearsonrepetition persistsVertigo alwayspresent typicallyabsentDirectionofnystagmus toundermostear variableIncidence relativelycommon relatively uncommonInvestigationScreeningbloodtest:

IncludeCBC-diff,ESR,TFT,lipidprofile,syphilisscreeningandserologyforautoimmunediseaseifindicated.P.T.A.todetectanyhearinglossABRifasymmetricalhearinglosspresentCT/MRIindicatedifthereisunexplainedneurologicalfindingorretrocochlearhearinglossECGwithrhythmstripSpecialVertibularInvestigationElectronystagmographyENGusetorecordeyemovementandthisispossiblebecauseofelectricpotentialdifferencebetweenRetina(-ve)andcornea(+ve)Calorictest

ItistheonlytestinwhichbothlateralSCCfunctioncanbeexaminedseparatelyChiartest

VORcomparingeyevelocitytoheadvelocity

(ie–chair)->anyasymmetryofresponseindicatevestibularsystdefect.DynamicPosturography

Itassessequilibriumaswhole,testisnotdiagnosticf