2. Referred for severe « dizzy spells » PRESENT ILLNESS: First episode March 1997 (1h) and June 1997 (2h45) Daily DIZZY SPELLS, completely incapacitating, since fall 97 Stopped working 3 1/2 years ago 2 operations on the left ear in 1998 Male 40 years old, Ottawa Case 1 " Linesman " (Hydro Ontario)

3. Past history: Negative Rx: None Functional inquiry: Negative - No neurological symptoms - Anxiety ++: fear of MS Physical:BP 130/84 HR 72 - ENT: Decreased hearing left ear - Lungs: Normal - Heart: S1-S2 normal; no murmur - Neuro: Normal Male 40 years old, Ottawa Case 1 Diagnosis: ???

4. Type I: Vertigo (Vestibular - Central Nervous System) Type II: Presyncope (Cardiovascular) Type III: Walking disequilibrium (Neuromuscular) Type IV: Light headedness (Plus non specific symptoms) (Hyperventilation) " DIZZINESS " evaluation

5. History Type 1: VERTIGO (temporary disequilibrium, rotating movement) (Vestibular – Central nervous system) “ Dizziness ”

6. VESTIBULAR Nystagmus CENTRAL NERVOUS SYSTEM Symptoms - Signs: Diplopia - Dysarthria Bilateral Loss of vision Hemiparesis - Hypoesthesia – Ataxia – Cranial nerves Vertigo

7. Duration 2 days-2 weeks 10 min - 20 hrs. 10 min – 20 hrs. < 1 minute Syndrome Labyrinthitis (Vest.N.) Recurrent neuronitis Meniere’s disease Positional vertigo Periodicity 0 + recurrent ++ recurrent +++ recurrent Other 0 Tinnitus  Hearing ∆ Position Peripherical vestibular vertigo

9. Dix Hallpike

11. " Objective ": confirms the diagnosis " Subjective ": suggests the diagnosis Positive Does not rule out the diagnosis! Négative Dix Hallpike NEGATIVE POSITIVE History

12. Epley’s manoeuver

13. Inform the Patient Day 1: vertical position - sleeping, head elevated Normal activities afterward Recurrence rate: 15% (Mobile otoliths) Provoke vertigo in left -right decubitus (Identifies involved ear) Recurrence Repeat posterior canal manoeuvre (Patient himself) Horizontal canal?: specific manoeuvre Positional vertigo: Inform the Patient Recurrence

14. 1) Wrong diagnosis 2) Wrong ear: cervical arthrosis 3) Wrong position: position “C” 4) Wrong “timing”: >1 1/2 min in each position 5) Wrong canal: horizontal canal? (other manoeuvre) “Yes we can !” President Obama Epley’s manoeuvre: FAILURE? “YES WE CAN…! “YES WE CAN…! President Obama

15. “Clinical practice guideline: Benign paroxysmal positional vertigo” RECOMMANDATIONS: Otolaryngology-Head and neck Surgery; November 2008: 139: S47-S81 1) BPV diagnoses is certain: BPV clinical history + Dix-Hall Pike (+) 2) “Clinicians should not obtain radiographic imaging, vestibular testing, or either in a patient diagnosed with BPV.” 3) “Clinicians should not routinely treat BPV with vestibular suppressant medications such as antihistamines or benzodiazepines.” (no Serc) 4) “Clinicians should treat patients with posterior canal BPV with particle repositioning maneuver.” (Epley) 5) Clinicians should revaluate the patient one month after repositioning maneuver.

16. ER 14/09/02: Presented 2 “dizzy spells” in the morning while attending a conference Presents with episodes of sudden “fatigue” or “weakness” lasting 5 minutes for 10 years. Frequency 4 to 6 a year. Has been treated for “hypoglycemia”. Does not drive his car outside Montreal, fearing a spell while driving! PAST HISTORY: Bilroth II 0 Rx 0 Alcohol FUNCTIONAL INQUIRY: NEGATIVE (Neuro.- Cardio - Vascular) PHYSICAL: BP 140/82 HR 72 reg. OTHERWISE: NORMAL (Cardiovascular) Male 51 years oldCase 4

17. System Cardiovascular (90%) Neuro (epilepsy) Metabolic Presyncope = cardiovascular syncope Onset Sudden Slow Recovery Sudden Slow Presyncope Syncope

18. M echanical:Aortic Stenosis - Left atrium Myxoma E lectric: Bradycardia, tachycadia (supra. or ventricular) AV block, prolonged sinus pauses... R eflex: Vagal - " cardiac reflex " - micturition - etc. Presyncope « MER »

19. History (sens. 95% - spec. 45%) Physical ECG Opinion Specific diagnosis Normal heart/Sick heart Presyncope Initial evaluation

20. Electric: > 70% LV Dysfonction: ventricular tachycardia Reflex: 70% Sick Heart Normal Heart Presyncope

21. Past History - Medication Onset: Advanced age Position: Lying down Concomitant Symptoms: – Chest pains – Palpitations Past history Onset: Young age Position: Standing Activity: Micturition - cough - etc. Stimulus: Pain - Discomfort Concomitant Symptoms: – Nausea - Vomiting – Yawning - Fatigue +++ Cardiac Sick Heart Reflex Normal Heart History

22. BP Lying - Standing: orthostatic hypotention BP 20 mmHg standing position Carotid sinus massage Aortic murmur Heart failure signs: jugular veins - pulmonary rales S3(+) - Legs oedema Physical

23. Sinus bradycardia (diagnostic if 3 seconds Bifascicular bundle branch block Second degree AV block (Mobitz I) Prolonged QT (> 500 milliseconds) WPW Brugada’s syndrome Supraventricular or ventricular tachycardia Myocardial infarction (old or new) Electrocardiogram

24. Hospit - Ambul. Monitoring Echo - Treadmill Loop Recorder EPS Ambulatory Monitoring Carotid Sinus Massage Loop Recorder Tilt Table Test Sick Heart Normal Heart Specific Evaluation

26. First evaluation: 21-08-2001 “Dizzy spells”: 2 types Vertigo < 1 min changing position, with nausea - vomiting (Left lateral decubitus) - recurrent since a car accident in 1993 Dix Hallpike (+) left: Epley left ear Presyncope - syncope (Sudden onset - recovery). Began at age 16 always in standing position, more often with stimulus (dysmenorrhea and sometimes with nausea induced by BPV) Woman 48 years oldCase 3

27. Woman 48 years old (continued) Case 3 Diagnosis: ??? Second evaluation: 12-12-2001 Severe disabling “dizzy spells” Weakness – Light headedness - " spins in the head " Concentration difficulty Palpitations - Shortness of breath - " Lasts all day " followed by intense fatigue feeling Since 08/ 01 no “vertigo” while changing position - no syncope Past history - Functional inquiry - Physical : NORMAL

28. Identification by the patient of the cause of his symptoms Explanation of “respiratory alcalosis” Recognition of stopping the symptoms by breath holding Elaboration of strategies for stress management “Break vicious circle” Provoke patient’s hyperventilation

30. History « Dizziness, Syncope » « Dizziness, Syncope » WWW.LEMIEUXBEDARD.COM/EMC WWW.LEMIEUXBEDARD.COM/EMC