Vertigo is a subtype of dizziness in which a patient inappropriately experiences the perception of motion (usually a spinning motion) due to dysfunction of the vestibular system.
3. O Dizziness one of the most common
complaints in the primary care setting
O 3rd most common complaint after chest pain
and fatigue
O 20%, general population, aged 18-
65yrs, reported dizziness within previous
month*
O Incidence increases with age**
*Yardley I,Owen N, Nazareth I, Luxon L. Br J Gen Prac. 1998;.
**Kroenke K, Mangelsdorf D. Am J Med. 1989
Epidemiology
4. Epidemiology
O Over one year 18% of 65+ complained to
a physician or had loss of usual activities
due to dizziness
O 30% prevalence in community survey
O Most common complaint over age 75
O Risk factor for functional decline
www.entmdclinic.webs.com
5. The number of patients presenting with dizziness
to primary care professionals increases with age
0.2
0.7
1.8
1.8
2.4
2
3.4
4
6.7
0 1 2 3 4 5 6 7
0–14
15–24
25–34
35–44
45–54
55–64
65–74
75–84
85+
Ageofpatients
% primary care visits with dizziness as a presenting complaint
Sloane PD. J Fam Pract 1989;29:33–8.
US survey of 2879 physicians
6. Sloane PD.. J Fam Pract 1989
Proportion Seen by Different Disciplines
GP / FM
44%
General
Internist
23%
Other Internal Med
Specialist
6%
Otolaryngologists
6%
Cardiologists
6%
Other
4%
General Surgeons
4%
Neurologists
4%
Surgical Sub-Specialists
(OB/GYN)
3%
Physicians/Specialists
7. Sloane PD, dallara J, Roach C, Bailey KE, Mitchell M, McNUtt R.. J Am Board Fam Pract. 1994
*Desmond AL.,2004
3 of 140( 2%) patients referred for otologic diagnosis*
Treatment Strategies done by MDs
Treatment Strategy
0%
Office Lab Test
14%
Advanced Testing
(CT, MRI)
5%
Referral to Specialist
4%
Medication
25%
Observation
29%
Reassurance
17%
Behavioural
Recommendations
6%
Treatment Strategy
16. DIZZINESS VERTIGO
O Lightheadedness
O Heart/vascular
problem
O stroke
O Inner ear disorder
O Viral infx
O Changes in head
position
www.entmdclinic.webs.com
21. Vertigo
O Due to an imbalance in vestibular
system, arising from inner or middle
ear, brainstem or cerebellum
O Common causes include benign
paroxysmal positional
vertigo, cerebrovascular dx, and acute
labyrinthitis and vestibular neuronitis
www.entmdclinic.webs.com
22. Presyncopal lightheadedness
O Due to diffuse cerebral ischemia
typically arising from vascular or cardiac
causes
O Common causes include vasovagal
episodes, postural hypotension, cardiac
dx (such as arrhythmia, CHF, low
output), and carotid sinus sensitivity
www.entmdclinic.webs.com
23. Dysequilibrium
O Perceived as body rather than head
sensation arising from motor control
system
(vision, vestibulospinal, proprioceptive, se
nsory, cerebellar or motor function)
O Common causes include stroke, sensory
deficits, severe vestibular loss, peripheral
neuropathy, and cerebellar disease
www.entmdclinic.webs.com
24. Other causes of dizziness
O These are vaguely described and may be
associated with anxiety and other
psychological disorders
O Less common cause of dizziness in older
than younger persons
www.entmdclinic.webs.com
25. Multiple Causes
O Subtyping may be useful in only about half
the cases
O Older persons often describe several
subtypes
O Most have dysequilibrium along with some
other type of dizziness - vertigo or
presyncope
www.entmdclinic.webs.com
27. Common Problems in Aging
O Greater sway during platform studies with
known loss of hair in semicircular
canals, utricle, and saccule of vestibular
system
O Progressive decline in baroreflex
sensitivity
O Resting cerebral blood flow close to
threshold for cerebral ischemia
www.entmdclinic.webs.com
28. Key Dizziness Syndromes
O Postural dizziness
O Positional vertigo
O Labyrinthitis
O Vestibular neuronitis
O Meniere’s disease
O Vertebrobasilar TIAs
O Stroke
O Cervical dizziness
O Physical deconditioning
O Drug induced
O Multiple sensory
impairments
O Psychological
www.entmdclinic.webs.com
31. VESTIBULOOCULAR REFLEX
(VOR)
O Enables the preservation of visual acuity
and stable visual environment during
locomotion
O Nystagmus can be the result of any
disorder causing a malfunction in the VOR
38. Posture and Gait Test:
A test of somatosensation and
propioception.
Not a test of vestibular input.
39. Tandem Romberg
test
Standing on
Foam, FT
Pass
Fail
• AbN Vest
• AbN
Somatosensory(SS)
• AbN visual
• All 3 N
20
sec
Eyes
Open
Eyes
Closed
Pas
s
• Vest N
• SS N
Fail
• One of two AbN
30
sec
Standing on foam, FTFallAbN
Vest
49. TREATMENT OF DIZZINESS
SPECIFIC MANAGEMENT DEPENDS
ON THE DIAGNOSIS THAT IS
CAUSING THE VERTIGO.
GENERAL MANAGEMENT OF
DIZZINESS INCLUDES
PHARMACOTHERAPY.
53. Vasodilators
O Disturbed labyrinthine vascularity
O Re-establishes blood flow in ischemic
areas of inner ear
a. Nicotinic acid
b. Histamine
c. Betahistine
54. Acute versus Chronic Vertigo
• Acute: With well-defined isolated spells of vertigo;
with distinct onset and offset; resolves in two
weeks*
• Chronic: persistent or chronic sensation;
recurrent
Goebel JA. Management options for acute versus chronic vertigo 2000
*Kroenke K, Lucas CA, Rosenberg ML, Scherokman B, Herbers JE, Wehrle
PA, Boggi JO. Ann Intern Med 1992
55. Treatment for Acute Dizziness
• Use centrally-acting vestibular suppressants to
reduce vertigo and nausea
• Suppress activity of both vestibular nucleus and
reticular activating system(RAS)
• Examples
1. Meclizine 25 mg TID +/- Promethazine 25-
50mg TID
2. Diazepam 2-5mg TID; if severe, 5-10mg IM
3. Droperidol 2.5mg IM
4. Prochlorperazine 25 mg per rectum
• Must be discontinued as soon as possible when the
acute event subsides
56. START BETAHISTINE AS SOON AS POSSIBLE
TO FACILITATE CENTRAL COMPENSATION
Treatment for Acute Dizziness
58. What is Central
Compensation?
Loss or reduction in function of one
organ/ system
Other sensory organ
substitutes for loss of
function
(sensory substitution)
Tonic rebalancing of
sensory inputs
Habituation
(motor learning)
Through cerebellar/ brainstem neural
circuits- adaptive
plasticity/reprogramming
Sensory conflictDizziness
59. Medical Treatment of Chronic
(persistent) Dizziness
• Enhance central compensation : Betahistine- used
for Meniere’s disease
• Clinical use of most drugs began long before the
development of neuroscience; clinical efficacy and
their dosages have been established empirically*
• Animal studies showed its role in facilitating central
compensation
Bhansali SA. 2001
60. Mechanisms of Action:
Betahistine hydrochloride
Increase in cochlear blood flow (H3
pre-synaptic heteroreceptor
antagonism)
Decrease resting discharge in
labyrinthine hair cells
(H3 antagonist and H1 agonist
action)
Inhibition of firing activity of
vestibular nuclei (H3 receptor
antagonist)
Vestibular
compensation
61. Pharmacologic Effects of
Betahistine:
Peripheral endorgan
• Increase cochlear blood
flow
• Decrease in resting
electrical discharge
through presynaptic H3
receptor antagonism
Central organs
• HA release in VN results
in excitation of neuronal
activity
• Effect adaptive
reprogramming of VOR to
stabilize gaze, and VSR to
control posture
62. Recent Placebo and Active Control
Trials of Betahistine
Reference Method Diagnosis Treatment
and
duration
Result
Albers et. al
2003
N=52
Double-blind,
randomized,
multi-center
Recurrent
Vestibular
vertigo
Betahistine
Flunnarizine
8wks
Betahistine significantly better in
DHI, physical and functional
scores
Mira e.al.
2003
N=144
Double-blind,
multicenter,ran
domized,
parallel
Meniere’s
disease or
paroxysmal
positional
vertigo of
possible
vascular origin
Betahistine
16 tid
Placebo
3 mos
Betahistine significantly reduced
frequency, intensity and duration
of vertigo
Della Pepa
C.et.al.
Meta-analysis
(7 RCT,-
n=367)
Vertiginous
syndromee-
BPPV,vascular
Betahisitne
Placebo
3-8wks
Betahistine relieved vertigo 3x
versus placebo
63. Adverse Effects
O Generally rare
O Headache
O Skin reactions
O Heart burn/ nausea
Lacour M, Van de Heyning PH, Novotny M,Tighilet b. Betahistine in the treatment of Meniere’s
disease. Neuropsychiatry disease and treatment. 2007;3(4):429-440
Mira E, Guidetti G, Fattori GB,Malaninno M, MaialinoL,MoraR, Ottobonis S, et.al.Betahistine
hydrochloride in the treatment of peripheral vestibula vertigo. Euro Arch
Otorhinolaryngol2003;260;73-77
Sudden attacks of vertigo are more commonly due to benign disorders of the inner ear, and while bothersome, they can be less worrisome. Viral infections of the inner ear can interfere with normal signaling, causing a sudden attack of vertigo that can last for over 24 hours. Usually, patients will have a history of recent runny nose, cough or fever. On the other hand, short episodic attacks associated with changes in head position are suggestive of a condition called benign paroxysmal positional vertigo. While symptoms can be debilitating, the condition can be easily treated by a physician through series of specific physical maneuvers to reposition the components of the inner ear.Dizziness or lightheadedness, on the other hand, could be indicative of a heart or vascular problem. While stroke is a rare cause of dizziness, over 50 percent of patients diagnosed with stroke report dizziness. Early diagnosis of stroke is vital in order to administer key medications that can prevent permanent damage. In order to maximize the effectiveness of the medication, it should be administered within 90 minutes of symptom onset. Additional stroke red flags include:- Trouble with speaking or understanding- Numbness or weakness on one side of your body or face- Blurred or double visionFurthermore, if a stroke occurs in the balance center of your brain, sudden vertigo can also occur.Read more: http://www.foxnews.com/health/2012/06/13/distinguishing-between-vertigo-and-dizziness/#ixzz2UhFLCrgL