Lightheadedness (Dizziness) And Dizziness (Vertigo)

Dizziness is a vague term use Patients often to describe various related emotions: powerlessness (feeling of impending syncope) drowsiness feeling of insecurity or imbalance A vague behaved or benebeltes ( “swimmy-headed”) feeling. A rotation feeling as dizziness is called a freak sensation of movement of one’s self or the environment. Typical is the perception of a (whirling or swirling) rotary motion, although some patients feel simply pulled to one side only. Dizziness is not a diagnosis, it is rather the description of a sensation. Both feelings may be accompanied by nausea and vomiting, or equilibrium and / or gait disturbances. Since these feelings are hard to describe in words, patients often use “dizziness”, “Vertigo” and other terms interchangeably and inconsistently. Different patients with the same underlying disorder can describe the symptoms vary widely. One and the same patient can even give different descriptions of the same dizzy If at a practice visit, depending on how the question is asked. Because of this discrepancy and although dizziness (vertigo) is a well-defined subset of lightheadedness (dizziness) seems to be prefer many doctors to examine both symptoms together. However they are described, drowsiness and dizziness can be very distracting and even make them unable to act, especially if they are accompanied by nausea and vomiting. The symptoms cause particular problems in people who engage in demanding or dangerous activities such as driving or flying or operate heavy machinery. By dizziness approximately 5-6% of all doctor visits are arranged. Dizziness may occur at any age but is more common with increasing age; it affects about 40% of people over 40 years at any time. Dizziness may be temporary or chronic. Chronic dizziness, defined as> 1 month continuously, is common in the elderly. Pathophysiology The vestibular apparatus is the most important neurological system, which is involved in balance. This system comprises: a. The vestibular apparatus of the inner ear to VIII cranial nerve (vestibulocochlear nerve), the signals from the vestibular apparatus of the central components of the system directs the vestibular nuclei in the brainstem and cerebellum diseases of the inner ear and VIII cranial nerve be regarded as peripheral disturbances.. Those of the vestibular nuclei and their pathways in the brain stem and cerebellum are considered central disorders. The sense of balance also includes visual input from the eyes and proprioceptive input from the peripheral nerves (via the spinal cord). The cerebral cortex receives the output signal from the bottom center and the integrated information to generate a motion perception. Vestibular apparatus, the perception of stability, movement and orientation to gravity has its origins in the vestibular apparatus. This consists of: three semicircular canals two otolith organs (utricle and saccule) When the rotational movements endolymph device in the oriented to the movement plane archway in flow. From the direction of flow, it depends on whether the set in motion endolymph has an inhibiting or stimulating effect on the hair cells of the Bogengangepithels or their nerve impulses. In the saccule and utricle similar hair cells in a matrix of calcium carbonate crystals (otolith) are embedded. When the otolith bend under the influence of gravity, stimulates or inhibits the discharge of neural signals of their hair cells. Etiology There are numerous structural (trauma, tumors, degeneration), vascular, infectious, toxic (including drug-related), and idiopathic causes (see Table: Causes of dizziness and vertigo), but only a small percentage of cases is caused by a serious disorder. The most common causes of dizziness with Schwind same meeting, a component of the peripheral vestibular system: Benign paroxysmal positional vertigo Meniere’s disease vestibular neuronitis labyrinthitis Less is often the cause is a central vestibular disorder (most common migraine), a disorder with a global effect on cerebral function, psychiatric disorder or a disorder that affects the visual or proprioceptive input. Sometimes no cause can be discerned. The most common causes of dizziness without vertigo are less clearly defined, but they are not otologic usually highly probable medication side effects multifactorial or idiopathic non-euro Logical interference with a global effect on cerebral function sometimes manifest as dizziness and rarely as a fraud. These disorders typically involve an inadequate supply substrate (eg. For example, with O2, glucose) due to hypotension, hypoxia, anemia, or hypoglycemia. In severe cases, some of these diseases can manifest as syncope. In addition, certain hormonal changes (eg. As in thyroid diseases, menstruation, pregnancy) a feeling of lightheadedness (dizziness) can cause. Numerous CNS active drugs can cause a feeling of dizziness (dizziness), regardless of a toxic effect on the organ of equilibrium. Occasionally drowsiness and dizziness feeling may also be psychogenic. Patients with panic disorder, hyperventilation syndrome, anxiety or depression can present with vertigo. Dizziness elderly patients are often multiple factors – such as by drug side effects or aged declining sensory functions (limited vision, balance, proprioceptive disorders). Two of the most common specific causes are diseases of the inner ear: benign paroxysmal positional vertigo and Meniere’s disease. Causes of drowsiness and dizziness cause suspect results Diagnostic procedure diseases of the peripheral Vestibularsystemsa, b benign paroxysmal positional vertigo, short (<1 min) vertigo attacks triggered by a rotation of the head in a certain direction nystagmus has a latency of 1-10 s, is gravity fatigued and torsional and shows the impact direction towards the lowermost ear Frenzel glasses is required to prevent view fixation hearing and neurological examination intact Dix-Hallpike- Maneuvers to assess characteristic positional nystagmus Meniere's disease Repeated episodes of unilateral Tinnitus and fullness in the ear audiogram gadolinium MRI to rule out other causes of vestibular neuronitis (viral cause suspected) Sudden, incapacitation leading, severe dizziness without hearing loss or other findings Takes up to 1 week, with gradual weakening of the symptoms can be positional vertigo lead Clinical evaluation gadolinium MRI labyrinthitis (viral or bacterial) Hearing loss, tinnitus CT of the temporal bone in suspected purulent infection gadolinium MRI in unilateral hearing loss and tinnitus otitis media (acute or chronic, occasionally with cholesteatoma) earache, eye-catching ear examination, including discharge for chronic otitis infection in the history Clinical evaluation CT in cholesteatoma in order to exclude a fistula in the archway trauma (eg. B. tympanic membrane, labyrinthine contusion, perilymphatic fistula, fracture of the temporal bone, postkommotionelles syndrome) trauma of history obviously Other findings depending on the location and extent of injury CT depending on the cause and finding acoustic neuroma Slowly progressive unilateral hearing loss, tinnitus, dizziness, loss of balance Rarely numbness in the face and / or weakness audiogram gadolinium MRI, should significant asymmetry in hearing or unilateral tinnitus is ototoxic Medikamentec Recently initiated treatment with aminoglycosides, in usually with bilateral hearing loss and loss of balance function Clinical evaluation Vestibular investigation by electronystagmography and swivel chair tests herpes zoster oticus (Ramsay Hunt syndrome) geniculate ganglion also affected, which is why facial weakness and loss of taste often occur with hearing loss Vertigo possible but not typical blisters on pinna and in the ear canal Clinical evaluation Chronic sickness (mal de debarquement) Persistent symptoms after acute sickness Clinical evaluation Central disorders of Vestibularsystemsd brainstem hemorrhage or infarction Sudden onset involvement of the cochlear artery may cause ear symptoms Immediate imaging If available gadolinium MRI, otherwise CT cerebellar hemorrhage or infarction Sudden onset with ataxia and other cerebellar findings, common Headache Immediate imaging deteriorates rapidly if available gadolinium MRI, CT otherwise migraine Episodic, recurrent dizziness, unilater usually without ale auditory symptoms (which may have tinnitus, which usually bilaterally is) Possibly headache but often migraine in personal or family history of photophobia, phonophobia, visual or other auras possible helpful in diagnosis Usually, clinical examination, but with imaging to rule out other causes for migraine prophylaxis trial multiple sclerosis Various motor and sensory deficits with CNS remission and recurrent exacerbations (relapses). Gadolinium-enhanced MRI of the brain and spinal cord dissection of the vertebral artery Often head and neck pain magnetic resonance angiography vertebrobasilar insufficiency Sporadic short episodes, sometimes Global with drop attacks, blurred vision, confusion magnetic resonance angiography disorder of CNS ctio anemia (numerous causes) pallor, weakness, sometimes heme-positive stool blood CNS active Medikamentef (not ototoxic) Recently introduced medication or dose increase; several drugs, especially in an elderly patient symptoms Occasionally, regardless of movement or, drug levels (certain anticonvulsants) sample-by-step withdrawal hypoglycemia (usually by antidiabetic caused) dose escalation Occasionally sweating glucose test Recently performed on the fingertip (if possible in the presence of symptoms) hypotension (caused by heart disease, antihypertensives, blood loss, dehydration or orthostatic hypotension syndromes incl. orthostatic tachycardia syndrome and other Dysautonomien) symptoms when standing up, sometimes with vagal stimulation (z. B. urination), but not be i head movements or possibly (of cause lying manifestation z. As blood loss, diarrhea) dominated Orthostatic vital signs, occasionally with Kipptischversuch, ECG Other tests depend on the suspected cause hypoxemia (numerous causes) tachypnea Frequently lung disease are at pulse oximetry Other Ursachene pregnancy may unrecognized pregnancy test Psychiatric (z. B. panic attacks, hyperventilation syndrome , anxiety, depression) Symptoms of chronic short, recurrent Whatever movement or position, but can occur with stress or anger Normal neurological and ENT medical examination findings initially may be diagnosed with peripheral vestibular dysfunction in patients and a response to the appropriate treatment remains from Clinical evaluation Syphilis Chronic symptoms with bilateral hearing loss, fluctuating, with episodic vertigo syphilis serology thyroid dysfunction weight change heat or cold intolerance tests of thyroid function aThe symptoms are continuously usually more paroxysmal, severe and episodic style instead. Ear symptoms (eg. As tinnitus, sensation of fullness, hearing loss) normally indicate a peripheral disorder. Loss of consciousness is not due to the associated peripheral vestibular pathology with vertigo. bPeriphere vestibular disorders are listed in rough order of their frequency of occurrence. cZahlreiche drugs, including aminoglycosides, chloroquine, quinine and furosemide. Many other drugs are ototoxic, but have more influence on the cochlea to the vestibular apparatus. dOhrsymptome are rarely available, but disturbances of gait / balance are common. Nystagmus is not inhibited by views fixation. eDiese causes should not otic symptoms (eg. as hearing loss, tinnitus) or focal neurological deficits (sometimes occur with hypoglycemia on) cause. Vertiginous symptoms are rare, but have been reported. Fez are numerous medications, including most anxiolytic, anticonvulsant, antidepressants, neuroleptics and sedatives. Drugs used to treat dizziness are also included. Clarification history The history of the disease process should cover the perceived sensations of the patient. An open question is this most appropriate (eg. As "People use the word 'dizziness' different. Can you please be as specific as possible to describe what you feel?"). Short, specific questions, then if the feeling of weakness, dizziness, loss of balance or dizziness is able to bring some clarity, but persistent efforts to categorize the patient's feelings are unnecessary. Other elements are valuable and unique: the severity of the first episode severity and features of subsequent episodes constant or episodic symptoms frequency and duration at episodic symptoms release and alleviation factors (that is triggered by a change in head or body position) Associated ear symptoms (such as hearing loss, bloating. in the ear, tinnitus) severity and related impairment of the patient Provides for a single, sudden, acute event before, or dizziness is chronic and relapsing? Was the first episode of the heaviest (vestibular crisis)? How long the episodes, and what seems to trigger them and worse? The patient should be specifically asked to provide certain head movements, for problems when standing up, anxiety or stress and menstruation. Important Accompanying symptoms include headache, hearing loss, tinnitus, nausea and vomiting, visual disturbances, focal weakness and difficulty walking. The severity of the impact on the patient's life should be estimated: Is the patient like? If the patient is reluctant to take the car or leave the house? If the patient workdays missed? The review of organ systems should search for causative disorders, including symptoms of infections of the upper respiratory tract (inner ear disorders), chest pain and / or palpitations (heart disease), dyspnea (lung disease), dark stools (anemia caused by gastrointestinal bleeding), weight change or heat or cold intolerance (thyroid disease). The history should briefly past head injuries (usually due to the history obviously), note migraine, diabetes, heart or lung disease as well as drug and alcohol abuse. Besides identifying all currently applied drugs a drug history should be recent changes in assets and / or dosages ermitteln.Körperliche investigation The investigation begins with an assessment of vital signs, including fever, rapid or irregular pulse and blood pressure in supine and standing, taking on the descent blood pressure when standing up (orthostatic hypotension) and the provocation of symptoms is important while standing. When standing provoked symptoms, orthostatic symptoms should be of those that are triggered by head movement when returning to the horizontal position, differentiated, until the symptoms disappear and then the head is turned. ENT medical and neurological examinations are essential. In the supine position, the eyes are aimed at the occurrence, direction and duration of spontaneous nystagmus checked (for a complete description of the test for nystagmus nystagmus). Direction and duration of nystagmus and the development of dizziness are noted. A coarse hearing test is performed at the bedside, the ear canal is examined for discharge and foreign bodies and the tympanic membrane is examined for signs of infection or perforation. The cerebellar function is checked by the assessment of the aisle, also be finger-nose test and Romberg's test performed (diagnostic access in neurological patients). The Unterberger- (or Fukuda) Step Test (diagnosis) can be performed by a specialist to assist in the detection of a unilateral vestibular lesion. The rest of the neurological examination is carried out, including the examination of the other cranial nerves. Nystagmus A nystagmus is a rhythmic eye movement, which can have various causes. Vestibular disorders can cause nystagmus due to the connection between the vestibular system and the eye muscles. A vestibular nystagmus not only helps to identify problems with balance, but sometimes when delineate a central from a peripheral vertigo. A vestibular nystagmus is due to the influx of vestibular nerve impulses a slow movement phase and a fast corrective phase of movement that causes a movement in the opposite direction. The direction of nystagmus is defined by the direction of the fast movement, because it is easier to see. There are rotational, vertical or horizontal Nystagmi, which may occur when changing the viewing direction or in certain head movements spontaneously. The inspection to a nystagmus is initially in a supine position of the patient and without eye focusing (a view fixation can be prevented by a lens power of +30 diopters or a Frenzel glasses). The patient is then rotated slowly, first in left, then their right side. Attention is paid to the direction and duration of nystagmus. If so no nystagmus can be seen, the Dix-Hallpike- is (or Barany-) carried out maneuver. In this maneuver, the patient is sitting upright on a stretcher in such a way that his head protruding lying over the end. Did he put down with the help rapidly horizontal, the head should be overstretched and 45 ° backwards rotated 45 degrees to the left. Attention is paid to the direction and duration of nystagmus and the development of a hoax. After righting the patient's maneuver is repeated, this time with head rotation to the right. If a particular situation or test phase has led to the nystagmus, should be repeated check if it weakens. While having a nystagmus due to a peripheral nerve dysfunction is a latency period of 3-10 s and quickly disappears again, a nystagmus in CNS disorders without latency and mitigate without occurs. An induced nystagmus inhibited as soon as the patient focuses on an object with the eyes when prompted, is the nystagmus based on a peripheral disorder. Since Frenzel glasses prevent visual fixation, they must be removed in order to assess the visual fixation. With intact vestibular nystagmus can be triggered by a caloric irritation of the ear canal. The failure of this attempt or arises regarding the Nystagmusdauer one side difference> 20-25%, a lesion on the side of the weaker reaction is suspected. Quantification of caloric reaction is best done by a formal (computer-aided) electronystagmography. The ability of the vestibular system to respond to a peripheral stimulation can be assessed at the bedside. It should be ensured that with a known perforated eardrum or a chronic infection does not occur to flush the ears in patients. In supine position with the head elevated 30 ° both ears of the patient are washed successively with 3 ml of ice water. Instead of cold can also use 240 ml of warm water (40-44 ° C), care should be taken not to scald the patient with too hot water. Cold water causes a contralateral, warm Wassen out a homolateral nystagmus. As a reminder the English abbreviation COWS you can remember (to the Cold and Warm Opposite to the Same). Warning The following findings are particularly important: the head or neck pain ataxia loss of consciousness focal neurological deficits severity, continuous symptoms for> 1 h interpretation of the findings Classically, took place the differential diagnosis based on the exact nature of the main complaints (ie by distinguishing between drowsiness, nonspecific dizziness and vertigo ). However, the inconsistency of the patient’s descriptions and the low specificity of symptoms make this process appear to be unreliable. A better approach puts more emphasis on the beginning and the timing of the symptoms on the triggers and their associated symptoms and findings, especially otological and neurological. Some constellations have very suspicious (see Table: Causes of dizziness and vertigo), especially those that help to differentiate peripheral from central vestibular disorders. Peripheral: ear symptoms (. For example, tinnitus, sensation of fullness, hearing loss) normally indicate a peripheral disorder. They are typically associated with dizziness and not generalized dizziness (unless this is caused by uncompensated peripheral vestibular weakness). The symptoms show paroxysmal usually severe and episodic character; persistent dizziness due to peripheral vertigo is rare. Loss of consciousness is not associated with dizziness as a result of peripheral vestibular pathology. Central: ear symptoms are rarely present, but gait and balance disorders are widespread. Nystagmus is prohibited not gaze fixation. Tests In patients with a sudden, sustained attack should be made pulse oximetry and a finger glucose testing. In women, a pregnancy test should be performed. Most doctors also cause an ECG. Other tests are in accordance with the findings made (see Table: Causes of dizziness and vertigo), but generally is a gadolinium MRI indicated for patients with acute symptoms that have headaches, neurological abnormalities or other findings that suggest a CNS etiology to let. In patients with chronic symptoms a multiple sclerosis or other CNS lesions should be sought with CT or MRI for signs of a stroke. Flashy or doubtful results of the investigations on the bed (Bedside tests of hearing and Vestibularisfunktionen) should lead to a more accurate audiometric and elektronystagmographischen examination of the patient. ECG, Holter monitoring for arrhythmia, echocardiography and stress testing can be performed to evaluate heart function. Laboratory tests are rarely helpful, except in patients with chronic dizziness and bilateral hearing loss, where a syphilis serology is indicated. Treatment Treatment depends on the cause and includes settling, reduction or change of causative drugs. If a Vestibularisfunktionsstörung is present, suspected of that they vestibular the result of Meniere’s disease, neuronitis or labyrinthitis is, this can be most effectively (with diazepam 2-5 mg PO every 6-8 h, controlled in severe dizziness increase in dose) or antihistamines / anticholinergics (z. B. meclizine suppress 3 times 25-50 mg / day po). Since they make you tired, these funds are intended for limited use in certain patients. Nausea can (i.m. 4 times 10 mg or 25 mg 2 times rectal) with prochlorperazine be treated. Vertigo, which is associated with a benign paroxysmal positional vertigo, is (repositioning of the otolith), carried out by a skilled practitioner treated with the pley maneuver. Meniere’s disease is best treated by an ENT physician experienced in the management of this chronic disease. Initial treatment measure is a low-salt diet and the administration of a potassium-sparing diuretic. (Such as secondary to vestibular neuronitis) it can often be useful when prescribed them a rehabilitation treatment from an experienced physiotherapist for patients with persistent or recurrent dizziness due to a one-sided imbalance. Most patients succeeds quite well, only elders prepares it in some more trouble. Physical therapy can also provide important safety information for older or disabled patients in particular. Basics of Geriatrics With age function responsible for the sense of balance organs less well. For example, seeing falls in low light ever more difficult, inner ear structures deteriorate, proprioception is less sensitive, and the mechanisms that control blood pressure, are less responsive (z. B. in terms of attitude changes, postprandial requirements). Older people are also more likely to cardiac or cerebrovascular diseases to S

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