Referred for severe « dizzy spells »

PRESENT ILLNESS:

• First episode March 1997 (1h) and June 1997 (2h45)

• Daily DIZZY SPELLS, completely incapacitating,

since fall 97

• Stopped working 3 1/2 years ago

• 2 operations on the left ear in 1998

Male 40 years old, OttawaCase 1" Linesman " (Hydro Ontario)

Past history: Negative Rx: None

Functional inquiry: Negative

- No neurological symptoms

- Anxiety ++: fear of MS

Physical: BP 130/84 HR 72

- ENT: Decreased hearing left ear

- Lungs: Normal

- Heart: S1-S2 normal; no murmur

- Neuro: Normal

Male 40 years old, OttawaCase 1

Diagnosis: ???

Type I: Vertigo (Vestibular - Central Nervous System)

Type II: Presyncope (Cardiovascular)

Type III: Walking disequilibrium (Neuromuscular)

Type IV: Light headedness (Plus non specific symptoms)

(Hyperventilation)

" DIZZINESS " evaluation

History

Type 1: VERTIGO

(temporary disequilibrium, rotating movement)

(Vestibular – Central nervous system)

“Dizziness”

VESTIBULAR

Nystagmus

CENTRAL NERVOUSSYSTEM

Symptoms - Signs:

Diplopia - Dysarthria

Bilateral Loss of vision

Hemiparesis - Hypoesthesia – Ataxia – Cranial nerves

Vertigo

Duration

2 days-2 weeks

10 min - 20 hrs.

10 min – 20 hrs.

< 1 minute

Syndrome

Labyrinthitis (Vest.N.)

Recurrent neuronitis

Meniere’s disease

Positional vertigo

Periodicity

0

+ recurrent

++ recurrent

+++ recurrent

Other

0

0

Tinnitus Hearing ∆ Position

Peripherical vestibular vertigo

Dix Hallpike

Dix Hallpike

" Objective ": confirms the diagnosis

" Subjective ": suggests the diagnosis

Positive

Does not rule out the diagnosis!

Négative

Dix Hallpike

NEGATIVE

POSITIVE

History

Epley’s manoeuver

Inform the Patient

Day 1: vertical position - sleeping, head elevatedNormal activities afterward

Recurrence rate: 15% (Mobile otoliths)

Provoke vertigo in left -right decubitus (Identifies involved ear)

Recurrence

Repeat posterior canal manoeuvre (Patient himself)

Horizontal canal?: specific manoeuvre

Positional vertigo:Inform the Patient

Recurrence

1) Wrong diagnosis

2) Wrong ear: cervical arthrosis

3) Wrong position: position “C”

4) Wrong “timing”: >1 1/2 min in each position

5) Wrong canal: horizontal canal? (other manoeuvre)

“Yes we can!” President Obama

Epley’s manoeuvre: FAILURE?

““YES WE CAN…!YES WE CAN…! President Obama

“Clinical practice guideline: Benign paroxysmal positional vertigo”RECOMMANDATIONS:

Otolaryngology-Head and neck Surgery; November 2008: 139: S47-S81

1) BPV diagnoses is certain: BPV clinical history + Dix-Hall Pike (+)

2) “Clinicians should not obtain radiographic imaging, vestibular testing, or either in a patient diagnosed with BPV.”

3) “Clinicians should not routinely treat BPV with vestibular suppressant medications such as antihistamines or benzodiazepines.” (no Serc)

4) “Clinicians should treat patients with posterior canal BPV with particle repositioning maneuver.” (Epley)

5) Clinicians should revaluate the patient one month after repositioning maneuver.

ER 14/09/02: Presented 2 “dizzy spells” in the morning while attending a conference

Presents with episodes of sudden “fatigue” or “weakness” lasting 5 minutes for 10 years. Frequency 4 to 6 a year.Has been treated for “hypoglycemia”.

Does not drive his car outside Montreal, fearing a spell while driving! PAST HISTORY: Bilroth II 0 Rx 0 Alcohol

FUNCTIONAL INQUIRY: NEGATIVE (Neuro.- Cardio - Vascular)

PHYSICAL: BP 140/82 HR 72 reg. OTHERWISE: NORMAL (Cardiovascular)

Male 51 years oldCase 4

System

• Cardiovascular

(90%)

•Neuro (epilepsy)

•Metabolic

Presyncope = cardiovascular syncope

Onset

Sudden

Sudden

Slow

Recovery

Sudden

Slow

Slow

Presyncope

Syncope

Mechanical: Aortic Stenosis - Left atrium Myxoma

Electric: Bradycardia, tachycadia (supra. or ventricular)

AV block, prolonged sinus pauses...

Reflex: Vagal - " cardiac reflex " - micturition - etc.

Presyncope

« MER »

• History (sens. 95% - spec. 45%)

• Physical

• ECG

OpinionOpinion Specific diagnosis

Normal heart/Sick heart

Presyncope

Initial evaluation

• Electric: > 70%LV Dysfonction: ventricular tachycardia

• Reflex: 70%

SickHeart

NormalHeart

Presyncope

• Past History - Medication

• Onset: Advanced age

• Position: Lying down

• Concomitant Symptoms:

– Chest pains

– Palpitations

• Past history

• Onset: Young age

• Position: Standing

• Activity: Micturition - cough - etc.

• Stimulus: Pain - Discomfort

• Concomitant Symptoms:

– Nausea - Vomiting

– Yawning - Fatigue +++

CardiacSick Heart

ReflexNormal Heart

History

• BP Lying - Standing: orthostatic hypotention

• BP < 90 mmHg or ∆ BP systolic: > 20 mmHg standing position

• Carotid sinus massage

• Aortic murmur

• Heart failure signs:• jugular veins - pulmonary rales

• S3(+) - Legs oedema

Physical

• Sinus bradycardia (diagnostic if < 40) - sinus pause > 3

seconds

• Bifascicular bundle branch block

• Second degree AV block (Mobitz I)

• Prolonged QT (> 500 milliseconds)

• WPW

• Brugada’s syndrome

• Supraventricular or ventricular tachycardia

• Myocardial infarction (old or new)

Electrocardiogram

• Hospit - Ambul. Monitoring

• Echo - Treadmill• Loop Recorder

• EPS

• Ambulatory Monitoring

• Carotid Sinus Massage

• Loop Recorder

• Tilt Table Test

SickHeart

NormalHeart

Specific Evaluation

First evaluation: 21-08-2001

“Dizzy spells”: 2 types •Vertigo < 1 min changing position, with nausea - vomiting

• (Left lateral decubitus) - recurrent since a car accident in 1993

Dix Hallpike (+) left: Epley left ear

•Presyncope - syncope (Sudden onset - recovery). Began at

age 16 always in standing position, more often with stimulus

(dysmenorrhea and sometimes with nausea induced by BPV)

Woman 48 years oldCase 3

Woman 48 years old (continued)

Case 3

Diagnosis: ???

Second evaluation: 12-12-2001

Severe disabling “dizzy spells”

• Weakness – Light headedness - " spins in the head "• Concentration difficulty

• Palpitations - Shortness of breath - " Lasts all day " followed by intense fatigue feeling

• Since 08/ 01 no “vertigo” while changing position - no syncope

Past history - Functional inquiry - Physical : NORMAL

• Identification by the patient of the cause of his symptoms

• Explanation of “respiratory alcalosis”

• Recognition of stopping the symptoms by breath holding

• Elaboration of strategies for stress management

“Break vicious circle”

Provoke patient’s hyperventilation

History

« Dizziness, Syncope »« Dizziness, Syncope »

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