父母教养方式量表(EMBU)CreateTim.ppt

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1、VERTIGOVERTIGOAYESHA SHAIKHAYESHA SHAIKHPGY2PGY2EMORY FAMILY MEDICINE EMORY FAMILY MEDICINE CASE31,female doctor,otherwise healthy,post partum week 5.First episode,sudden feeling of room spinning,while entering patient data in computer,during Family Medicine Clinic One fine day last year same time!D

2、IZZINESSVertigoLightheadednessPre syncopeDys-equilibriumVERTIGOFALSE SENSE OF MOTION,usually rotational.2 TYPES1-CENTERAL VESTIBULAR CAUSES(Brain stem or cerebellum)2-PERIPHERAL VESTIBULAR CAUSES(Labyrinth or vestibular nerve)CAUSES OF VERTIGOCENTRALCerebellopontine angle tumorCerebrovascular diseas

3、eMigraineMultiple sclerosisPERIPHERALAcute labrynthitisVestibular neuritisBPPVCholestotomaMeniers diseaseOstosclerosisPerilymphatic fistulaCauses.DrugsAlcoholAminoglycosidesAnticonvulsants AntidepressantsAntihypertensivesBarbituratesCocaine(Slowly progressive Unilateral/Bilateral)HistoryTimingsDurat

4、ionProvoking,aggreviating factorsAssociated symptomsRisk factors for Cardiovascular diseaseQ:When you have dizzy spells,do you feel lightheaded or do you see the world spin around you?Q:Duration of Vertigo and associated symptoms?(differentiate peripheral vs central causes)Typical Duration of Sympto

5、ms for Different Causes of VertigoDuration of episode Suggested diagnosisA few seconds Peripheral cause:unilateral loss of vestibular function;late stages of acute vestibular neuronitis;late stages of Mnires disease Several secondsto a few minutes Benign paroxysmal positional vertigo;perilymphatic f

6、istulaSeveral minutes to one hour Posterior transient ischemic attack;perilymphatic fistulaHours Mnires disease;perilymphatic fistula from trauma or surgery;migraine;acoustic neuromaDays Early acute vestibular neuronitis*;stroke;migraine;multiple sclerosisWeeks Psychogenic(constant vertigo lasting w

7、eeks without improvement)*-Vertigo with early acute vestibular neuritis can last as briefly as two days or as long as one week or more.Information from references 3,6,and 12.Provoking Factors for Different Causes of VertigoProvoking factor Suggested diagnosisChanges in head position Acute labyrinthi

8、tis;benign positional paroxysmal vertigo;cerebellopontine angle tumor;multiple sclerosis;perilymphatic fistulaSpontaneous episodes Acute vestibular neuronitis;cerebrovascular disease(stroke or transient ischemic attack);(i.e.,no consistent Mnires disease;migraine;multiple sclerosisprovoking factors)

9、Recent upper respiratory viral illness Acute vestibular neuronitisStress Psychiatric or psychological causes;migraineImmunosuppression(e.g.,immunosuppressive Herpes zoster oticus medications,advanced age,stress)Changes in ear pressure,Perilymphatic fistula head trauma,excessive straining,loud noises

10、Information from references 1,3,5,12,and 13.Associated Symptoms for Different Causes of VertigoSymptom Suggested diagnosisAural fullness Acoustic neuroma;Mnires diseaseEar or mastoid pain Acoustic neuroma;acute middle ear disease(e.g.,otitis media,herpes zoster oticus)Facial weakness Acoustic neurom

11、a;herpes zoster oticusFocal neurologic Cerebellopontine angle tumor;cerebrovascular disease;findings)multiple sclerosis(especially findings not explained by single neurologic lesionHeadache Acoustic neuroma;migraineHearing loss Mnires disease;perilymphatic fistula;acoustic neuroma;cholesteatoma;otos

12、clerosis;transient ischemic attack or stroke involving anterior inferior cerebellar artery,herpes zoster oticusImbalance Acute vestibular neuronitis(usually moderate);cerebellopontine angle tumor (usually severe)Nystagmus Peripheral or central vertigoPhonophobia,photophobia MigraineTinnitus Acute la

13、byrinthitis;acoustic neuroma;Mnires diseaseInformation from references 1,6,and 12 through 14.Table 5Causes of Vertigo Associated with Hearing Loss Diagnosis Characteristics of hearing lossAcoustic neuroma Progressive,unilateral,sensorineuralCholesteatoma Progressive,unilateral,conductiveHerpes zoste

14、r oticus(i.e.,Ramsay Hun syndrome)Subacute to acute onset,unilateralMnires diseases Sensorineural,initially fluctuating,initially affecting lower frequencies;later in course:progressive,affecting higher frequenciesOtosclerosis Progressive,conductivePerilymphatic fistula Progressive,unilateralTransie

15、nt ischemic attack orstroke involving anterior inferior cerebellarartery or internal auditory artery Sudden onset,unilateralInformation from references 9,12,and 13.Distinguishing Characteristics of Peripheral vs.Central Causes of VertigoFeature Peripheral vertigo Central vertigoNystagmus Combined ho

16、rizontal and torsional;Purely vertical,horizontal,or torsional inhibited by fixation of eyes onto object;not inhibited by fixation of eyes onto object;fades after a few days;does not change may last weeks to months direction with gaze to either side ;may change direction with gaze Imbalance Mild to

17、moderate;able to walk Severe;unable to stand still or walkNausea May be severe Varies,vomitingHearing loss,tinnitus Common RareNonauditory Rare Commonneurologic symptomsLatency followingprovocative diagnostic Longer(up to 20 seconds)Shorter(up to 5 seconds)maneuver)Information from references 14 and

18、 15.Physical ExamSpecial attention to head and neckCardiovascular and neurologic symptomsProvocative diagnostic testsPhysical ExamVertical nystagmus is 80%sensitive for central lesions.Horizontal nystagmus for peripheral lesions.Rhomberg sign:sensitivity 19%only for peripheral causes.Dix-Hallpike ma

19、neuver PPV 83%,NPV 52%.Clues to Distinguish Between Peripheral and Central VertigoClues Peripheral vertigo Central vertigoFindings on Latency of symptoms None Dix-Hallpike and nystagmus 2 to 40 secondsmaneuver Severity of vertigo Severe Mild Duration of nystagmus Usually1 minute Fatigability*Yes No

20、Habituation Yes NoOther findings Postural instability Able to walk;Falls while walking;unidirectional instability severe instabilityHearing loss or tinnitus Can be present Usually absentOther neurologic Symptoms Absent Usually present*-Response remits spontaneously as position is maintained.-Attenua

21、tion of response as position repeatedly is assumed.Information from references 3 and 4.Diagnosis HistoryPhysical Exam:Orthostatic vital signs,and Otoscopic examination,Neurologic Exam:Dix-Hallpike Maneuver(central vs Peripheral)Complete Audiometric Testing for suspected Meniers disease No LAB testin

22、g!Brain imaging:MRI with contrast for acute vertigo and Sensorineural hearing loss,MRA for vertebrobasilar circulationDisorderDurationAuditory symptomsPrevalencePeripheral or central vertigoBenign paroxysmal positional vertigoSecondsNoCommonPeripheralPerilymphatic fistula(head trauma,barotrauma)Seco

23、ndsYesUncommonPeripheralVascular Ischemia,TIASeconds to hoursUsualy notUncommonCentral or peripheralMenieres diseaseHoursyescommonperipheralSyphillisHoursyesUncommoncentralVertiginous migraineHoursNoCommonCentralLabyrinthitisDaysYescommonperipheralVascular Ischemia:StrokeDaysUsually notUncommonCentr

24、al or peripheralVestibular neuronitisDaysNoCommonPeripheralAnxiety disorderVariableUsually notCommonUnspecifiedAcoustic neuromamonthsyesUncommonPeripheralMultiple sclerosisMonthsnouncommoncentralVestibular ototoxicitymonthsyesuncommonperipheralGeneral Treatment PrinciplesMedication for Acute Vertigo

25、 that lasts for few hours to several daysMedications have various combinations of acetylecholine,dopamineand histamine receptor antagonism.Benzodiazepines enhance GABA action(GABA is inhibitory neurotransmitter in vestibular system)Strength of Recommendation Key clinical recommendation The canalith

26、repositioning procedure(Epley maneuver)is recommended in patients with benign paroxysmal positional vertigo.A The modified Epley maneuver also is effective in patients with benign paroxysmal positional vertigo.B Vestibular suppressant medication is recommended for symptom relief in patients with acu

27、te vestibular neuronitis.CVestibular exercises are recommended for more rapid and complete vestibular compensation in patients with acute vestibular neuronitis.BTreatment with a low-salt diet and diuretics is recommended for patients with Mnires disease and vertigo.BEffective treatments for vertigin

28、ous migraine include migraine prophylaxis(e.g.,tricyclic antidepressants,beta blockers,calcium channel blockers),migraine-abortive medications(e.g.,sumatriptan Imitrex),and vestibular rehabilitation exercises BSelective serotonin reuptake inhibitors can relieve vertigo in patients with anxiety disor

29、ders.Because of side effects,slow titration is recommended.B A=consistent,good-quality patient-oriented evidence;B=inconsistent or limited-quality patient-oriented evidence;C=consensus,disease-oriented evidence,usual practice,opinion,or case series.See page 1046 for more information.MedicationsMecli

30、zine*(Antivert)12.5 to 50 mg orally every 4 to 8 hourDimenhydrinate*(Dramamine)25 to 100 mg orally,IM,or IV every 4 to 8 hoursDiazepam(Valium)2 to 10 mg orally or IV every 4 to 8 hoursLorazepam(Ativan)0.5 to 2 mg orally,IM,or IV every 4 to 8 hoursMetoclopramide(Reglan)5 to 10 mg orally every 6 hours

31、 5 to 10 mg by slow IV every 6 hoursProchlorperazine(Compazine)5 to 10 mg orally or IM every 6 to 8 hours 25 mg rectally every 12 hours 5 to 10 mg by slow IV over 2 minutesPromethazine(Phenergan)12.5 to 25 mg orally,IM,or rectally every 4 to 12 hoursVestibular Rehabilitation ExercisesThese exercises

32、 train the brain to use alternative visual and proprioceptive clues to maintain balance and gait.Improve postural control during the first month after acute unilateral vestibular lesions resulting from vestibular neuronitis.Treatment of Specific Disorders 1-BPPV (Usually posterior canal Calcium Debr

33、is)MEDS.?Head Rotation Maneuvers Eply ManeuverContraindication:Severe carotid stenosis,unstable heart disease,severe neck diseaseSuccess rate:80%after one treatment,100%with repeated treatments.Recurrence rates:15%/year,20%20 months,and 37%60 months.Treatment of specific Disorders 2-Vestibular Neuro

34、nitis (Acute Prolonged Vertigo)Symptom relief using vestibular suppressant medications,followed by vestibular exercises.Vestibular compensations occurs more rapidly and more completely if the patient begins twice-daily vestibular rehabilitation exercises soon after symptom control with medications.T

35、reatment of specific disorders 3-Meniers Disease (Distension of Endolymphatic compartment due to impaired endolymphatic filtration and excretion)Low salt diet(1-2 gm/day)Diuretics(combo HCTZ and Triamterene)Surgery in rare cases-ablation of vestibular hair cells)4-Vascular Ischemia (Sudden onset of

36、vertigo with additional symptoms eg diplopia,ataxia,dysphagia,dysarthria)TIA/Stroke:BP control,Cholesterol Lowering,smoking cessation,inhibition of platelet function,anticoagulationVestibualr suppressant medications plus minimal head maneuver on first day,then initiate rehabilitationVestibular stent

37、s for symptomatic critical vertebral artery stenosis.6-Migraine Headaches Treat Migraine!Reduce or eliminate Aspartame,chocolate,caffeine and alcohol,Lifestyle changes,Vestibular rehabilitation exercises.Meds:BDZ,TCA,BB,SSRI,CCB,Antiemetics.7-Psychiatric Disorders(Anxiety,Panic disorders more common

38、 than depression;Hyperventilation is the cause.)Vesibular supressants and Benzodiazepines-transient to inadequate relief.SSRI show better relief.Cognitive behaviour therapy may be helpful.Physiologic VertigoMotion sickness:incongruence in the sensory input from the vestibular,visual,and somatosensor

39、y systems.Visual system does not sense the movement.Bring systems back in congruence!Eg watch horizon when on a boat.also scopolamine patch behind ear 4 hours before boating.DisorderDurationAuditory symptomsPrevalencePeripheral or central vertigoBenign paroxysmal positional vertigoSecondsNoCommonPer

40、ipheralPerilymphatic fistula(head trauma,barotrauma)SecondsYesUncommonPeripheralVascular Ischemia,TIASeconds to hoursUsualy notUncommonCentral or peripheralMenieres diseaseHoursyesCommonPeripheralSyphillisHoursyesUncommoncentralVertiginous migraineHoursNoCommonCentralLabyrinthitisDaysYesCommonPeriph

41、eralVascular Ischemia:StrokeDaysUsually notUncommonCentral or peripheralVestibular neuronitisDaysNoCommonPeripheralAnxiety disorderVariableUsually notCommonUnspecifiedAcoustic neuromamonthsyesUncommonPeripheralMultiple sclerosisMonthsnouncommoncentralVestibular ototoxicitymonthsyesuncommonperipheral

42、Dix-Hallpike ManeuverEpley ManeuverInternet resources for patient educationTHANKS!ReferencesLabuguen R.Initial Evaluation of Vertigo.American Family Physician.January 15,2006.Swartz R,Longwell P.Treatment of Vertigo.American Family Physician.March 15,2005.OdLaI6F3C0y)v%s#pXlUiRfNcK8H5E2A+x(u$rZnWkTh

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