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Ok, so hello everyone. Uh my name is and I'm the ent lead for the Mind, The Bleak um surgical specialty series for final year students. Um And today we've got Doctor Aisha Abdulhamid, who's one of the consultant ent uh doctors at Oxford University Hospitals. And she's gonna be speaking to us today about assessment of dizziness and vertigo and it's a really high yield topic for finals. So thank you all so much for joining and we really hope you enjoy the session. Thank you so much Veronica. Um I hope you all enjoy this session. Uh Dizziness is often a very complex topic. In fact, um most ent surgeons, if they see a referral in their clinic of dizziness, they get worried and start panicking and um try and pass it on to one of their balance specialists. Um So it's great that you're attending this session out of hours. I'm just going to share my slides and hopefully we can get started. Perfect. So I'm hoping that you can see my screen. So I'm just gonna give you a brief overview on dizziness and kind of talk about some of the main conditions that we see in ent. But actually you, if you were to ever go to a Balance Clinic, dizziness Vertigo Clinic, you'll get lots of different diagnoses. And that's because as I said, it's a difficult topic and um sometimes it's not clear what the diagnosis is and therefore some of the conditions are going to be related, some are going to be neurological related, some possibly ophthalmology. There are loads of different differentials, um and you'll get them all into your clinic because it's so hard to try and unpick what the problem is. So we're going to cover dizziness, vertigo, balance problems, whatever you want to call it, we'll try and unpick it and go through it. And some of the main conditions that I'm going to talk about is benign, proximal positional vertigo BPPV, which you've probably heard of and men as disease. So I just want to go through the ear just in brief again just to try and orientate you. So you've got your outer ear. It's very uncommon that po conditions in the outer ear will cause dizziness. You've got your middle ear, which is anything beyond the eardrum. But before the inner ear, which is where the stapes the third bone um of hearing attaches to the inner ear. Ok. So this area is all your inner ear, you've got your eustachian tube and then you've got your cochlear, which is your hearing organ and then you've got your balance organs, your semicircular canals, and then your sacral and utricle, which are also part of your balance organs. Ok. So sometimes actually pathology within the middle ear can have an impact on the inner ear, which can also have an impact on dizziness. Ok. So there's just some of the things that can occur in the ear that can cause you problems. Ok. So balance isn't balance issues isn't necessarily vertigo. The term vertigo is used um for as an ent is when patients describe the feeling that the room is spinning or that they're spinning. So that's vertigo, but patients don't know that they will tell you I've been diagnosed with vertigo, which is not a diagnosis that's a symptom or they will describe all other different problems um as vertigo or sometimes they describe off balance or, or sort of balance issues as vertigo, vertigo is off balance. Um for you to stay balanced, you need different inputs to the brain to give you balance. So you've got your vision, your eyes, your balance systems. So the organs that we saw semicircular canals and then proprioception. So soma sensory to give all of all those three input into the brain and that will give you balance, that will tell you where you are in your environment. OK? You don't need to know or think about where you're standing, you, you, you know you're standing on a hard surface, a soft surface, all of that. You don't need hard, too much thinking day to day because all of that is kind of a reflex. Ok, it's a balance reflex. So sometimes when we take away one of the three. So for example, if we take away somebody's vision, they will feel off balance, or if their proprioception is poor, they're going to feel off balance. And of course, if they have problems within the balance organs themselves that can again give you balance problems, but not necessarily vertigo, which is the sensation that you're spinning or the room is spinning. So if you've got this important reflex, which again, kind of inputs into all of this previous slide that we've talked about the vestibular ocular reflex. This is a really important reflex because for example, you turn your head in one direction, you want your eyes to move the other direction to try and stabilize on an image. OK? For example, if you're running and your head is constantly bouncing, usually your vision does not bounce dramatically because of your vestibulo ocular reflex. OK. So it's not just turning your head side to side, it's also up and down. OK? And you can look at your screen um that you're watching now turn your head quite rapidly, but you've still got a relatively stable image. OK. And that again is because the head is turning and you're getting that, that reflex. So the balance organs, it can sense where you're turning your head because of the, these little ampules, basically these little hairs in the um balance organs, you turn your head, it tells you a head that these hairs have moved to a certain direction that will then fire going to the brain that will then go to the eye. So again, you see how basically things aren't working in isolation, they're working as a a system um to give you all of these lists of little bits of information. So if you have a problem with the eyes, again, a problem with the balance organs, you can see how um you will have problems. OK. So this is a mind back created by one of my colleagues, um Angus Waddle at Great Western and, and I find this really, really useful because it really gets you to think about all of the other factors and not just focus on the ear. So think about the other different things because often, you know, especially if you're in a specific subspecialty, you're probably most comfortable with that areas that it is. But we do obviously have to think about the other things because as I said, it might be difficult for the, the GP or the A&E doctor whoever is referring into your clinic to figure out what the problem is. Most people, as I said, don't enjoy dizziness. So when they come to you, even if you're the ent person, you need to try and help that patient and figure out what the problem is, even if it's not related to your subspecialty, rather than just saying. Well, it's not an ear problem. I'll send you back uh to whoever referred you. OK. So we talked about the vision. So ask them if they've got any visual problems, they need glasses. Um Is, is it a problem that's happening just in the dark? Some patients will tell you that just in the dark they, they have, they have significant problems and then that's triggering. Oh, is it maybe something else that's causing? For example, proprioceptions when they've lost one balance or one system for their balance is something weaker and that's why they're struggling. Ok. Um Load vitamin b12. Um alcohol, obviously, diabetes can have an impact on proprioception and and the sensation in the feet is we'll talk about a little bit in more detail later on. Um and then uh it's not uncommon that as we age, we can get things like small vessel disease, cerebral atrophy and that can also have a general impact on balance because your brain function isn't working as well as it should do. Of course, there's cardiac issues. So sometimes uh lightheadedness is described as vertigo or balance problems. So you should think about postural drop, uh syncope palpitations, all of that can have an impact. Um We see patients that hyperventilate um can also have balance issues and sometimes they might have had uh specific insult to their balance organ, for example, BPPV or labyrinthitis and that resolves. But later on because of that anxiety their symptoms persist. So again, that you need to investigate these causes and neurological problems and vascular problems like such as stroke, they're big, big issues that you really need to also and think about, um especially if the patient presents acutely to A&E you want to try and think is this labyrinthitis, which is obviously a horrible condition, but a benign condition versus a stroke, um which needs to be treated much more seriously. Ok. And then medication in general can have an impact a lot of the patients. Um Sometimes when they have general dizziness.