The Dizzy Patient 4x4 Method

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The Dizzy Patient4x4 Method

• Dr Ahmad Alamadi FRCS
• Consultant, HOD
• Al Baraha Hospital

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Vestibular Physiology

• Orientation of our body in space is the primary
  function of the vestibular system. This is
  achieved by integration of signals from
  vestibular, visual and proprioceptive receptors
  at the level of brain stem.
• Information regarding the movement of the head
  relative to the body is largely provided by
  paired vestibular sensory endorgans

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Vestibular Sensory Endorgans
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Cristae Otolithic organ
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Information Relay
Peripheral Vestibular System EYES Proprioceptive Receptors
Central Vestibular Nuclei
Vestibulocerebellar tracts (VCT) Vestibulospinal (VST)
Vestibulo-Ocular reflex (VOR)
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VOR

• Keeps a stable retinal image during head movement
• As the head moves in one direction there should
  be an equal and opposite conjugate movement of
  the eyes (sometime known as the dolls eye
  maneuver)

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VOR Defect

• Bilateral Defect (for example from systemic
  aminoglycoside toxicity) the patient will
  complain of imbalance and a blurring of vision
  with head movement better known as oscillopsia
• Unilateral defect the equilibrium of the
  push-pull forces between the inner ears is
  altered. This result in a drift of the eyes away
  from side of lesion followed by a quick central
  nervous system (CNS) mediated saccade in a
  repetitive to and fro fashion better known as
  nystagmus.

Nystagmus is the cardinal sign of a central or
peripheral vestibular disorder
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History Steps

1. Organic Vs Psychogenic
2. Vestibular Vs Non vestibular
3. Peripheral Vs Central
4. Which Peripheral Vestibular Disorder

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Organic Vs Psychogenic
Features Organic vestibular Psychogenic
Duration Usually well defined i.e. seconds, minutes or hours (never a flash) Variable from a flash to days Not well defined
Frequency Except for benign paroxysmal positional vertigo (BPPV), rarely more than once a day Constant or many times a day
Head Movement Intensifies symptoms Symptoms usually unaffected
Ataxia during spell Usually prominent Insignificant
Effect of Hyperventilation Not like the attack Often reproduces symptoms accurately
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Vestibular Vs Non vestibular

• True Vertigo (hallucination of movement relative
  to self) Vs Non specific Dizziness
• Note patient with non specific dizziness need to
  be investigated for cardiac and neurological
  causes.
• Patients with true vertigo have a vestibular
  disease which can be central or peripheral

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Peripheral Vs Central

• Ask for associated symptoms i.e. discharge,
  tinnitus, aural fullness and hearing loss
• Ask for focal neurological complaints i.e.
  diplopia, dysphagia, dysarthria, paresis,
  parasthesia or incontinence and LOC.

• Inner ear disorders should never be associated
• with a loss of consciousness

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Which Peripheral Vestibular Disorder

• Benign paroxysmal positional vertigo (BPPV)
• seconds several attacks /day positional
• Meniere's disease
• minutes to hours tinnitus fluctuating
  hearing loss aural fullness
• Recurrent Vestibulopathy
• minutes to hours
• Vestibular Neuronitis (acute viral labyrinthitis)
  
• Hours to days

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Examination Steps

1. Otological examination
2. Neurological examination
3. Special clinical vestibular tests
4. Important Diagnostic Tests

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Otological examination

• Otoscopy
• Hearing assessment (Weber and Rinne tests)
• Fistula Test

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Neurological examination

• Cranial Nerves
• Cerebellar Tests
• Oculomotor Tests
• Smooth pursuit, saccades, visual fixation
  and vergence
• Balance Tests
• proprioception, Rombergs and tandem gait
  tests (both eyes open and closed).

• When Smooth Pursuit is Normal it would be
• unlikely for a central disorder to be present

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Special clinical vestibular tests

• The Halmagyi maneuver
• The head shake test
• The oscillopsia test
• VOR suppression test

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Important Diagnostic Tests

• Dix-Hallpike Positional Test
• Hyperventilation Test

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Conclusion

• 4 steps in History
• x 99 Diagnosis
• 4 steps in Examination

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• Thank You