오심과 어지럼증으로 내원한 환자의 진료

오심과 어지럼증으로 내원한 환자의 진료

이비인후과적 관점

Jae Yong Byun

Department of ORL-HNS, Kyunghee University, Seoul, Korea

Sense of

Head acceleration

& gravity

Biological

signal Motor reflex

for equilibrium & vision

Cortex

Cerebellum

Reticular formation Extrapyramidal system

Balance

Clinical Scenario

• 47 female

• Chief complaints : Dizziness BP 145/80

gather your thoughts before interview.

Start Interview and P/Ex

for making a hypothesis about the site and type of lesion

Patient presents with dizziness

What sensation does the patient describe

False sense of motion or spinning sensation

Off-balance or wobbly

Feeling of losing consciousness or

blacking out

Vague symptoms, possibly feeling disconnected with

the environment

Vertigo (50%)

Disequilibrium

(25%) Presyncope

(15%)

Lightheadedness (10%)

Senile change, Parkinson etc

Cardiogenic? Psychogenic?

Flawed but helpful What do you

mean by dizzy?

Approach for distinguishing vertigo from other type of dizziness

• Constant or episodic

• Associated symptoms- ear, neurology

• Gradual vs sudden onset

• Aggravating/provoking symptoms

• Duration and frequency of attacks if episodic

• Triggers

• Time course -- vertigo is never continuous

• Provoking factors -- spontaneously or with positional changes

• Aggravating factors -- all vertigo is made worse by moving the head If head motion does not worsen the feeling - probably another type of dizziness

Distinguishing vertigo from other types of dizziness

• Provoking factors

 Certain vertigo occur spontaneously, while others( PLF) are precipitated by maneuvers that change head position or middle ear pressure ( coughing, sneezing, or Valsalva maneuvers)

 Positional vertigo and postural presyncope are both are associated with dizziness upon standing

 Determine whether dizziness can be provoked by maneuvers that change head position without lowering BP or decreasing cerebral blood flow

 Such maneuvers include lying down, rolling over in bed, and bending the neck back to look up

Vertigo

• Predominant symptom of vestibular dysfunction

_ Peripheral vertigo (60%)

 Central vertigo(20%)

 Others(20%)

Characteristic Peripheral Central

Severity Severe Mild

onset Sudden Gradual

duration Sec - day Weeks to Months

Positional Yes No

Fatigable Yes No

Ass Sx Auditory Neurologic and Visual

imbalance Mild (can walk) Severe( unable to stand or walk)

Approach for distinguishing pph vertigo from central

vertigo

Head Impulse Test

Characteristic Peripheral Central

Severity Severe Mild

onset Sudden Gradual

duration Sec - day Weeks to Months

Positional Yes No

Fatigable Yes No

Ass Sx Auditory Neurologic and Visual

imbalance Mild (can walk) Severe( unable to stand or walk)

Nystagmus Fixation suppression No suppression

Nystagmus Direction Vertical or horizontal,

direction may change with head position

Unidirectional, Horizontal or rotatory

Head impulse test positive negative

Approach for distinguishing pph vertigo from central

vertigo

dizziness (+)

- aggravating factor: position change - relieving factor: rest

- associated symptom: HD(-), tinnitus(-), ear fullness(-)

• P/Ex :

Both TM : intact spontaneous N(-):

Dix-Hallpike test(+): Lt ear down시

duration: 1분 이내 fatigability

reversibility

Return to Clinical scenario-2

PERIPHERAL VESTIBULAR DYSFUNCTION

• Benign Paroxysmal Positional Vertigo (50%)

• Labyrinthitis (vestibular neuronitis) (10%)

• Meniere’s Disease (10%)

• Trauma

• Tumors (Acoustic Neuroma)

BENIGN PAROXYSMAL POSITIONAL VERTIGO

• Vertigo with head movements

• Brief episodes lasting < 1 minute; nausea

• Usually no tinnitus or hearing impairment

• Spontaneous nystagmus is not present

• Usually self-limited; can persist for weeks

• Provoked by specific head movements

• Typically have no other neurological complaint

• Any type of dizziness may worsen with position change but disorders such as benign positional vertigo only occur after position change

Dix-Hallpike test

(Lt PSCC BPPV)

Epley maneuver

Right beating H. nyst Left beating

H. nyst

ampullofugal ampullopetal

Geotrophic Horizontal Nystagmus

Stronger nystagmus in head lateral to lesion side : Ewald’s 2^nd law

Lateral canal BPPV( canalo)

lateral canal Ipsi – MR

Contra - LR Contra – MR Ipsi - LR

Meniere’s Disease

• Sudden and recurrent (paroxysmal) attack of severe vertigo (4

leading cause)

• Low-tone hearing loss

• Low-tone tinnitis

• Sense of fullness in the ear

• Vertigo lasts for hours to a day then burn out

• Hearing loss may progress

Medical managements algorithm

Acute Management ( first 48hr)

Vertigo Hearing loss

Vestibular suppressant - Diazepam, Meclizine Anti-Nausea

- Promethazine

Correction of dehydration & electrolyte

Steroid Taper

response Recurr

No-response IT-steroid

Reassess

Chronic Therapy

Vertigo(-) Vertigo(+)

Diuretics Vertigo(+)

IT-GENTA, ELS ,IT-steroid, VNS Consider stop Diuretics after 3Mo

Vertigo(-) Continue life style modification

Reduces stress, Low salt, Limitted caffein, Tobacco, Alcohol

Vestibular Neuronitis

• Commonly occurs on first awakening

• Nausea is marked and almost universal

• 57% evidence or recent viral infection

• horizontal or rotatory nystagmus for few days

• Attacks become sequentially shorter and if not then consider another diagnosis

• Vertigo symptoms usually resolve over a few days as vestibular compensation occurs

• Symptomatic treatment for first few days only

Neurotransmitter on Vestibular pathway

Dramamin, Meclizine Diazepam, Lorazepam,

Baclofen

Medical treatment- acute stage

SUMMARY

Thank you

• Elucidate by history and confirm by physical

• Majority of pts have vertigo, followed by nonspecific dizziness and disequilibrium

• Most causes are benign and self-limited

• Serious causes suspected by unilateral hearing loss, abnormal neurological exam, or evidence of a central as opposed to peripheral cause of vertigo