what is the permanent impact of loss of the vestibular...
Transcript of what is the permanent impact of loss of the vestibular...
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what is the permanent impact of loss of the vestibular sense ?
for balance, vision and spatial orientation)
loss of speed
- poor dynamic vision (daily life)
- fear to fall and falls
loss of automatisation
- severe cognitive load:
anticipation constantly required to prevent falls
impaired double tasking
fatigue
- visual dependence: intolerance to optokinetic stimuli
no more shopping or parties
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how do we assess
complaints, syndromes in the history ?
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new insight in history taking of dizziness
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vestibular disorders“history taking: hints and pitfalls”
Herman Kingma
Department of ORL, Head Vestibular Clinic, Maastricht University Medical Centre, The Netherlands
Faculty of Physics, Tomsk Research State University, Russian Federation
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what’s the diagnosis?
patient complaining of “dizziness”
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acute vertigo: misconceptions (n=28)
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misconceptions: background
Acute Vestibular Syndrome (AVS) at emergency department
• 81% of cases: nystagmus inconsistent with diagnosis
• misconception misdiagnosis
• 40.000-70.000/year potentially 10.000-30.000 deaths/year
causes:
• too much emphasis on “type” of vertigo
• <50% shows classical neurological signs
• sensitivity CT of posterior fossa: +/-16%
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History taking: Steps – Questions?
Step 1: Timing
Step 2: Triggers
Step 3: Describe dizziness
Step 4: Is chronic involved?
Step 5: Subjective = Objective?
yes
Acute Episodic Chronic Episodic + Chronic
DISCO HAT
SO STONED
HADS + DHI
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misconceptions: prevention
focus on Timing and Triggers not on “Type”
TiTrATE
• Timing
• Triggers
• And Targeted Examination
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misconceptions: prevention
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timing and triggers
timing trigger syndrome diagnosis benign diagnosis dangerous
episodic trigger t-EVS BPPV
orthostasis
CPPV/Tumor
internal bleeding
vascular stenosis
vertebral artery
spontaneous s-EVS Meniere’s
Migraine
SCDS
paroxysms
vasovagal
panic
arrhythmia/MI
TIA
pulmonary embolus
hypoglycemia
acute postexposure t-AVS perilymphatic fistula skull base fracture
vertebral dissection
drugs (genta, AED)
carbon monoxide, etc.
spontaneous s-AVS neuritis
labyrinthitis
CVA/Vertebral
Wernicke’s/encephalitis
other internal / neuro
chronic context e.g. Vestibular hypofunction
spontaneous e.g. Cerebellar degeneration
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Timing and Triggers
3 syndromes + 1:
Acute Episodic Chronic
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Timing and Triggers
3 syndromes + 1:
Acute Episodic Chronic Episodic + Chronic
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Timing and Triggers
3 syndromes + 1:
Acute Episodic Chronic Episodic + Chronic
PANIC!!!
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History taking: Steps
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History taking: Steps
Takes time Saves time
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History taking: Steps
Step 1: Timing?
Acute Episodic Chronic
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History taking: Steps
Step 1: Timing?
Step 2: Triggers
Acute Episodic Chronic
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History taking: Steps
Triggers can be obvious:
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History taking: Steps
Step 1: Timing
Step 2: Triggers
Acute Episodic Chronic
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History taking: Steps
Step 1: Timing
Step 2: Triggers
Step 3: Describe dizziness
Acute Episodic Chronic
SO STONED
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History taking: SO STONED
• Symptoms: vertigo, instability, dizziness, etc.
• Occurence: how often?
• Since: when?
• Triggers: head movement, no trigger, etc.
• Otological: hearing, tinnitus, etc.
• Neurological: migraine, loss of conciousness, etc.
• Evolution: how did it evolve?
• Duration: how long does the dizziness last?
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History taking: SO STONED
WATCH OUT!!!
1. Deadly D’s:
• Dysarthria
• Diplopia
• Dysphagia
• Dysphonia
• Dysmetria
• Dysesthesia
2. Headache: 3xS
• Sudden
• Severe
• Sustained
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History taking: Steps
Step 1: Timing
Step 2: Triggers
Step 3: Describe dizziness
Acute Episodic Chronic
SO STONED
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History taking: Steps
Step 1: Timing
Step 2: Triggers
Step 3: Describe dizziness
Step 4: Is chronic involved?
yes
Acute Episodic Chronic Episodic + Chronic
DISCO HAT
SO STONED
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History taking: DISCO HAT
• Darkness
• Imbalance
• Supermarket effect / visual vertigo / optokinetic
• Cognitive functions
• Oscillopsia
• Head movements (fast)
• Autonomic functions
• Tiredness
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History taking: DISCO HAT
• Darkness
• Imbalance
• Supermarket effect / visual vertigo / optokinetic
• Cognitive functions
• Oscillopsia
• Head movements (fast)
• Autonomic functions
• Tiredness
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History taking: DISCO HAT
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History taking: DISCO HAT
• Darkness
• Imbalance
• Supermarket effect / visual vertigo / optokinetic
• Cognitive functions
• Oscillopsia
• Head movements (fast)
• Autonomic functions
• Tiredness
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History taking: DISCO HAT
Oscillopsia:
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History taking: DISCO HAT
• Darkness
• Imbalance
• Supermarket effect / visual vertigo / optokinetic
• Cognitive functions
• Oscillopsia
• Head movements (fast)
• Autonomic functions
• Tiredness
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History taking: DISCO HAT
Head Impulse Test:
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History taking: DISCO HAT
• Darkness
• Imbalance
• Supermarket effect / visual vertigo / optokinetic
• Cognitive functions
• Oscillopsia
• Head movements (fast)
• Autonomic functions
• Tiredness
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THE OTHER SIDE DOES NOT TAKE OVER!
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History taking: Steps
Step 1: Timing
Step 2: Triggers
Step 3: Describe dizziness
Step 4: Is chronic involved?
yes
Acute Episodic Chronic Episodic + Chronic
DISCO HAT
SO STONED
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History taking: Steps
Step 1: Timing
Step 2: Triggers
Step 3: Describe dizziness
Step 4: Is chronic involved?
Step 5: Subjective = Objective?
yes
Acute Episodic Chronic Episodic + Chronic
DISCO HAT
SO STONED
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History taking: Steps
Step 1: Timing
Step 2: Triggers
Step 3: Describe dizziness
Step 4: Is chronic involved?
Step 5: Subjective = Objective?
yes
Acute Episodic Chronic Episodic + Chronic
DISCO HAT
SO STONED
HADS + DHI
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History taking: Psychology
Psychological factors
Vestibular disorder
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History taking: Psychology
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History taking: Psychology
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History taking: Pitfalls
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Pitfalls: Episodic vertigo
Cases:
• 3 patients, same story: >1 week “dizzy”
• Examination: Vestibular hypofunction right
What is the first diagnosis that you think of?
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Pitfalls: Episodic vertigo
Patient 1: “Actually I was dizzy for 3 days and it took a week to get better”
Patient 2: “Actually I was dizzy for 5 hours but I was unstable for a week”
Patient 3: “Actually I was dizzy with each headmovement for 2 weeks, like turning in bed”
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Pitfalls: Episodic vertigo
Patient 1: “Actually I was dizzy for 3 days and it took a week to get better” Neuritis
Patient 2: “Actually I was dizzy for 5 hours but I was unstable for a week” Ménière’s
Patient 3: “Actually I was dizzy with each headmovement for 2 weeks, like turning in bed” BPPV
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Pitfalls: Episodic vertigo
• Patients not always report the whole story: SO STONED
- Ask for exact duration
- Ask for triggers
• Absence of hearing loss, tinnitus, migraine, headache
• Attack is not always reported
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Pitfalls: Chronic dizziness
• The other side does not take over: DISCO HAT
• Vertigo is not always present
• Patients can experience a false continuous dizziness
• Fysiological complaints overlap psychological ones
- Psychological co-morbidity
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Example
Since 2 years multiple spontaneous attacks of vertigo.
The average attack includes:- Sudden sensation of vertigo- Hearing loss on the left, aural pressure and tinnitus (high
pitching sound)- No flashes, no photo- or phonophobia, no headache, no aura’s,
no migraines in the past- No other neurological signsDuration: 5 minutes – 2 hoursFrequency: 2-5x each month
In between attacks:- Darkness no effect, imbalance yes, supermarket effect yes, no
problems with concentration or memory, no oscillopsia, instablewith fast head movements, no orthostatic hypotension, more tired
Diagnosis: Meniere’s syndrome left with unilateral hypofunction
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Example
Since 2 years multiple spontaneous attacks of vertigo.
The average attack includes:- Sudden sensation of vertigo- Hearing loss on the left, aural pressure and tinnitus (high
pitching sound)- No flashes, no photo- or phonophobia, no headache, no aura’s,
no migraines in the past- No other neurological signsDuration: 5 minutes – 2 hoursFrequency: 2-5x each month
In between attacks:- Darkness no effect, imbalance yes, supermarket effect yes, no
problems with concentration or memory, no oscillopsia, instablewith fast head movements, no orthostatic hypotension, more tired
Diagnosis: Meniere’s syndrome left with unilateral hypofunction
SO STO
NED
DISC
O H
AT
Timing & Triggers
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Conclusions
• Abandon classical approach of “type of dizziness” • Timing & Triggers
• SO STONED
• DISCO HAT
• Classify dizziness: 4 syndromes
• Recognize pitfalls:• No vertigo necessary
• Other side does not take over
• Psychological co-morbidity
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History taking: Steps – Questions?
Step 1: Timing
Step 2: Triggers
Step 3: Describe dizziness
Step 4: Is chronic involved?
Step 5: Subjective = Objective?
yes
Acute Episodic Chronic Episodic + Chronic
DISCO HAT
SO STONED
HADS + DHI