Clinical Evaluation of the Vertiginous Patient

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Clinical Evaluation of the Vertiginous Patient

• John C. Li, M.D.

Li_at_Dr-Li.net http//Dr-Li.net
John Li MD PA, 210 Jupiter Lakes Blvd
5105 Jupiter, FL 33458
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Goals and Objectives

• Dizziness and vertigo is a very complex topic
• Recognize and Understand
• Physiology
• Signs and symptoms of various causes of dizziness
  
• proper exam and tests needed for evaluation and
  diagnosis
• Be able to educate patients using analogies
• Recognize emergencies
• Know when to refer

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Course Mandates

• Learn proper technique for evaluation of
  dizziness
• Learn to pare down differential diagnosis by
  physical findings as well as symptoms
• Learn canalith repositioning techniques

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Definitions

• Vertigo is an abnormal sensation of movement when
  there is no movement actually occurring --
  usually spinning sensation

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Diagnosis

• Diagnosis of dizziness, tinnitus and vertigo can
  be one of the most difficult of medical tasks.
• Source of imbalance can range
• Dehydration
• Brain tumor.
• Correct diagnosis
• Thorough history,
• Physical
• Tests

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Balance System Physiology
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Contradiction Vertigo
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Twin Engine Analogy
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Why Is It So Complicated?
B
C
D
E
A
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So Many Differential Dx

• Salt or water imbalance, Labyrinthitis, Meniere's
  disease, Thyroid hormone disease, Low Blood
  Pressure, Sarcoidosis Autoimmune disease (Lupus,
  Rheumatoid arthritis), Stroke, Hi Cholesterol or
  triglyceride, Diabetes, Acoustic neuroma (brain
  tumor), Syphilis / Lymes disease, Migraines,
  Superior canal dehiscence, BPPV, Vestibular
  neuritis, Cervical vertigo, Sinusitus, Head
  Trauma, Concussion..etc

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So Many Treatments

• Dietary Management, Compazine, Antivert,
  Droperidol, Valium, Dyazide, Neptazine,
  Prednisone, Tumor excision, Labyrinthectomy,
  Streptomycin Perfusion, Vestibular Nerve Section,
  Vascular Loop Decompression, Endolymphatic Sac
  Decompression, Endolymphatic Sac Shunt, Cody
  Tack, Cochleosacculotomy, Canal Occlusion,
  Canalith Repositioning Procedure, Vestibular
  Rehabilitation, Accupuncture, Biofeedback, etc.

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Simplify

• We could teach you all the different physical
  findings, different tests, different
  treatments.
• Instead, we need orderly, way of thinking
• Know the key players
• Learn the physiology
• Systematic algorithm
• Work backwards

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Diagnoses Simplified

• Inner ear related (peripheral)
• Other (non-inner ear)

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Diagnoses

• Inner ear related (peripheral)
• Other (non-inner ear)
• Central nervous system related (CNS)
• Brain tumor
• Migraine
• Stroke
• Systemic related
• Cardiac / Syncope
• Endocrine
• Drugs
• Psychiatric panic attacks

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Vertigo Dx. You Want to Know

• Ménières disease / Endolymphatic Hydrops
• Benign positional vertigo
• Labyrinthitis / Vestibular Neuritis (15)
• Chronic vestibular weakness
• Fistula /Superior Canal Dehiscence
• Migraine

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Menieres Syndrome
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Definition

• Menieres syndrome and endolymphatic hydrops both
  refer to a condition of excess pressure
  accumulation in the inner ear.

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4 Main Features

• Attacks of vertigo
• Fluctuating hearing loss
• Tinnitus or ringing in the ears (usually low
  tone roaring)
• Aural fullness (pressure sensation in the ears)

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Physiology Hydrops

• There are two fluids that fill the chambers of
  the inner ear. Too much endolymph pressure will
  stretch these nerve-filled membranes

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Increased Pressure May Be Caused by Several
Disorders

• Inner ear inflammation or infection or Trauma
• Autoimmune disease (Lupus, Rheumatoid dz)
• Syphilis
• Allergy
• Metabolic / Endocrine
• High Cholesterol or Triglycerides
• Thyroid disease
• Diabetes
• Idiopathic

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Workup of Menieres

• History Physical
• Otoscopy Normal
• Imaging Normal
• CT / MRI / MRA / MRV
• Blood Tests Normal
• Audiology
• Hearing Audiogram Low freq SNHL
• Tympanogram Normal
• Ecog Abormal Increased SP/AP ratio
• VNG Abormal -- RVR

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Standard Treatment Options

• Dietary Management
• Medical Treatment
• Antivert
• Dyazide
• Steroids
• Meniett
• Surgical Treatment

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Dr. Lis Analogy

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Dietary Management i.e. Avoid

• Foods with high sodium content.
• Caffeine and tobacco
• Chocolate, excessive sweets-candy, etc.
• Foods with high cholesterol or triglyceride
  content
• Foods with high carbohydrate content

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Medical Treatment of Symptoms

• The goal of these medications are to mask the
  vertigo.
• Antivert 1 tablet every 8 hours or as needed.
• Droperidol 1-2 drops under the tongue.
• Compazine 1 rectal suppository for nausea (use
  when too sick for pills)

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Medical Treatment of Pressure Build Up

• Dyazide l water pill a day in the mornings.

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Steroids

• Taper as directed
• Very useful in acute processes
• Anti-inflammatory

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Surgical Treatment

• Non-Destructive Surgery
• Tympanostomy tube / Meniettes
• Transtympanic Steroids
• Endolymphatic Sac Decompression
• Ablative (Destructive) Surgery
• Transtympanic Aminoglycosides
• Vestibular Nerve Section
• Labyrinthectomy

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Vestibular Rehabilitation

• Balance retraining is important for many reasons
• Improved preparedness for impending attacks
• Improved tolerances of attacks
• Rehab after Destructive Surgery

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BENIGN PAROXYSMAL POSITIONAL VERTIGO
PICTURE

• John Li, M.D.

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Introduction
PICTURE 2

• BPPV most common single dx of vertigo
• Underestimated
• Misdiagnosed
• Concomitant pathology

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What is BPPV?

• Definition Vertigo (a phantom sensation of
  motion) elicited by specific changes in head
  position.
• Caused by placing the affected ear downward.
  (Classical BPPV)
• Associated with characteristic eye movements
  (classical nystagmus)

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Dizziness Characteristics

• Thrown into a spin There is a lag period.
• The symptoms start very violently
• Dissipate within 20 or 30 seconds.
• This sensation reverses upon sitting erect again.

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Classical Nystagmus

• Parallels the symptoms.
• Predominantly rotatory nystagmus , fast phase
  toward ground
• Latency (5 sec)
• Limited duration (lt20 sec)

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Canalith Theory
Canalith Theory
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Diagnosis
History Physical
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Laboratory tests
PICTURE

• Audiogram -- May be normal.
• Electronystagmography --
• Caloric test not always useful

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The Hallpike Maneuver
PICTURE

• Standard clinical test for BPPV.
• Pathognomonic
• A negative test is meaningless

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Treatment Options

• Watch and Wait vs.
• "The Canalith Repositioning Procedure"

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CRP video
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What Are The Positions?

• Start. Sitting, head turned 45 degrees towards
  ipsilateral side.
• Position 1. Supine, 20-30 degrees head hanging
  tilt, head turned 45 degrees towards ipsilateral
  side.
• Position 2. Supine, 45 degrees head hanging
  tilt, head turned 45 degrees towards
  contralateral side.

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CRP Positions (Left BPPV)
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What Are The Positions?(3-5)

• Position 3 Lying on side with contralateral
  shoulder down, head turned 45 degrees below
  horizon towards contralateral side.
• Position 4 Sitting, head turned at least 90
  degrees towards contralateral side.
• Position 5 Straight ahead, head tilted forward.

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CRP PositionsLeft BPPV
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The 360o Maneuver
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Pearl BPPV

• Association between BPPV and Menieres!
• If one exists then possibly the other exists

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Vestibular Neuritis / Labyrinthitis

• Vestibular Neuronitis, Labyrinthitis
• Viral infection / inflammation of the nerve /
  labyrinth.
• Think along the lines of Bells Palsy
• Watch out for Ramsey Hunt Syndrome

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Anatomical Differentiation
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Differences

• Vestibular Neuritis
• Dizziness, Vertigo
• Nausea, Vomiting

• Labyrinthitis
• Very sick
• Dizziness, Vertigo
• Nausea, Vomiting
• Ear Pressure /Full
• Hearing loss
• Tinnitus
• May be bacterial

• Cochlear Neuritis
• Ear Pressure /Full
• Hearing loss
• Tinnitus

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Findings

• Vestibular Neuritis
• Abnl neuroto exam
• Unilateral Vesibular weakness on ENG

• Labyrinthitis
• Very sick
• Abnl neuroto exam
• Unilat Vesibular weakness on ENG
• Abnl hearing
• Abnl Audio

• Cochlear Neuritis
• Abnl hearing
• Abnl Audio

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Vestibular Neuritis RX

• Steroids
• Antivirals
• (Antibiotics)
• Vestibular rehab

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Chronic Uncompensated Vestibular Loss

• Unilateral and bilateral vestibular loss can
  become permanent.
• Natural compensation
• Many factors contribute to poor compensation
• Age
• Physical condition
• CNS status

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RX

• Vestibular Rehab

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Migraine

• CNS cause
• Traveling wave of depression
• Vasospasm of feeding vessels
• Can Mimic Menieres
• Associated with Menieres
• Similar triggers (Chocolate, caffeine, red wine)
• No diagnostic tests exist for migraine-associated
  vertigo

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Definite Migrainous Vertigo

• Episodic vestibular symptoms of at least moderate
  severity
• Migraine according to the IHS criteria
• At least one of the following migrainous symptoms
  during at least 2 vertiginous attacks migrainous
  headache, photophobia, phonophobia, visual or
  other auras
• Other causes ruled out by appropriate
  investigations

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Migraine Treatment

• Reduction of risk factors Avoidance therapy No
  BCPs
• Medications
• Calcium Channel blockers
• Topiramate (Topamax)
• Tricyclic antidepressants
• Beta-adrenergic blockers
• Ergot alkaloids and derivatives
• Anticonvulsants
• NO Surgery

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Zebras

• Diagnoses that are do occur, but not too often.
• Be aware of these
• Superior Canal Dehiscence
• Fistula
• Acoustic neuroma
• Cervical Vertigo

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Fistula

• Barotrauma
• Diving / Strain
• Leakage of fluid
• Loss of vestibular function
• Exacerbation by pressure changes (bearing down)
• Hearing loss CHL / SN

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Superior Canal Dehiscence
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Superior Canal Dehiscence

• Loss of bone over SC
• Similar sx as fistula
• Pressure Sensitive vertigo
• Conductive Hearing Loss
• Autophony

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Acoustic Neuroma

• Rare 1 100,000
• Unilateral SNHL
• Dizzy, but usually not Vertigo
• Great Masquerader
• Medico-legal issues
• ABR or MRI scan

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Cervical Vertigo

• Controversial
• History of Neck trauma or spine problems
• Vestibulospinal tract
• off balance dizzy
• Usually NOT Spinning

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Office Examination of the Dizzy Patient

• Dix-Hallpike Maneuver
• Pneumatic Otoscopy
• Romberg Test
• Fukuda Stepping Test
• Gait Test

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Dix-Hallpike Maneuver
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Pneumatic Otoscopy

• Henneberts sign/symptom nystagmus and vertigo
  with /- pressure
• Normally No nystagmus
• May be positive in fistula, SCC dehiscence
  syndrome, Menieres disease

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Romberg Test

• Patient asked to stand with feet together and
  eyes closed
• Increased sway with eyes closed suggests inner
  ear problem
• Equal sway with eyes open and closed suggests CNS
  problem
• Fall or step is positive test

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Fukuda Stepping Test

• Patients are asked to step with eyes closed and
  hands out in front
• 100 steps.
• Turn by more than degrees is abnormal
• Turn usually occurs to the side of the lesion
• Forward motion is often normal

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Tandem Gait Test

• Patients are asked to walk heel to toe in a
  straight line or in a circle
• Complex function evaluates many aspects of
  balance
• Poor performance seen in CNS cerebellar lesions,
  but can be seen in many disorders
• Poor sensitivity and specificity

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Diagnostic Testing Tools

• Audiology assess Peripheral Vestibular System
• Hearing Audiogram, otoacoustic emissions
• Tympanogram
• Electrophysiologic Ecog, ABR, VEMP
• ENG / VNG
• Rotary Chair
• Posturography
• Imaging assess CNS
• CT / MRI / MRA / MRV
• Blood Tests assess Systemic

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Caloric Testing

• Established and widely accepted method of
  vestibular testing
• Most sensitive test of unilateral vestibular
  weakness
• Cold and warm water/air flushed into EAC
• COWS (cold opposite, warm same) direction of
  the nystagmus

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Putting It Together

• Keep in mind the various diagnoses, and
  categories of diagnoses
• Use History to develop your DDX
• Rule out Dangerous stuff!
• Peripheral vs. Central
• Use more specific Hx to refine the DDX
• Use Physical to confirm the DDX
• Use Testing to nail down DX

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Algorithm

• Prioritize / Categorize
• Is this life threatening?
• Yes Triage to ER
• No Continue workup

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How Patient Looks

• Ask yourself Is the patient sick? Is it lethal?
  
• Think Emergency diagnoses
• Neuro Symptoms, Weakness, mental status changes?
  Stroke, Aneurysm, Brain Bleed
• Pinpoint pupils? Drugs Overdose - Tox screen
• Chest pain? Shortness of breath MI EKG
• Consider Syncope workup.

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Very Sick Patient

• General guideline
• IF only Vertigo, nausea, vomiting
• WITHOUT Cardiac SX, SOB, Neuro deficits,
  blackout, grey-out, Visual disturbanceetc
• WITH auditory symptoms only
• THINK inner ear, otherwise GO TO ER

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5 Distinguishing Questions

• Whirling vertigo vs. lightheadedness?
• Episodic versus constant?
• Short duration versus long duration?
• Provocable versus spontaneous?
• What sets it off?
• Associated symptoms?

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Whirling vs. Lightheaded

• True whirling vertigo
• Generally inner ear-related / peripheral
  vestibular
• Although could be CNS involvement of the
  vestibular nuclei
• Migraine

• Lightheadedness
• Generally non-otologic, CNS
• Although chronic vestibular mismatch can cause
  this.

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Episodic vs. Constant

• Episodic Attacks
• Usually ear related, acute peripheral vestibular
• BPPV, Ménières
• Could occasionally be CNS related
• Migraine, TIA

• Constant, Chronic
• Usually CNS or Systemic
• Tumor
• Stroke
• Could be chronic peripheral vestibular
• Uncompensated vestibular loss
• Labyrinthitis / Neuritis

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Timing Duration

• Transient seconds to minutes
• TIA, Vascular event or BPPV
• 20 minutes to several hours
• Ménières disease
• Continuous dizziness for days weeks
• Vestibular neuritis, labyrinthitis,
• Continuous dizziness for months
• Uncompensated vestibular problem or chronic CNS
  problem

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Provocation

• Movement induced
• Benign positional vertigo (by far)
• Rarely
• Unstable peripheral vestibular problem
• CNS arachnoid cyst
• Dietary triggers
• Ménières disease
• Migraine

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Associated Symptoms

• Hearing flux? Tinnitus? (think inner ear)
• Ear pressure and fullness? (think inner ear)
• Visual symptoms? (think CNS)
• Headaches? (think CNS)
• Exertional? (think Cardiopulmonary)

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Vote

• Peripheral
• Whirling vertigo
• Episodic
• Duration 20 min-hours
• Sudden Onset
• Flux Hearing Loss
• Ear Pressure / fullness
• Tinnitus

• CNS or Vascular etc.
• Lightheaded
• Constant
• Seconds OR days - months
• Insidious onset

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Physical Exam To Hone In

• Dix-Hallpike Maneuver
• Pneumatic Otoscopy
• Romberg Test
• Fukuda Stepping Test
• Gait Test

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Diagnosis Specific Findings

• Positional changes
• BPPV or Postural Hypotension
• Dix Hallpike BPPV
• Diet provoked
• Menieres vs. Migraine
• Flux HL, Pressure, Tinnitus, Vertigo
• Menieres

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Treatment

• Once diagnosis has been nailed down, go ahead and
  treat as appropriate.
• Ie CRP for BPPV.

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Treatment Tips

• Note that CRP is relatively safe and can be used
  when in doubt.
• Low Salt, Low Caffiene etc. diet is generally
  good for health, Migraines as well as Menieres
  dz.
• Antivert masks the problem. Use as last resort.
• Paring down medications is generally a good idea

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Conclusion

• Vertigo diagnosis and management can be confusing
  and daunting.
• If you put into categories, it brings clarity.
• Now you should be able to identify Menieres, BPPV
  and some other types of Vertigo.
• You should be able to come up with an algorithm
  for approach to diagnosis

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Statistics

• Nearly 13 of the adult population of the United
  States has migraine.
• 5 of men have migraine
• Women 10 at the onset of menstruation, and
  increasing to nearly 30 at the peak age of 35
  years. At menopause, rates of migraine abruptly
  decline in women back to roughly 10.
• Meniere's disease, 0.2 of the US population
• prevalence of Migraine in Menieres 50,
• 25 in the non-Meniere's population