Going For A Spin A Guide to the Balance System Martyn Leggett

Peripheral Vestibular System Semicircular Canals Otolith Organs – Utricle – Saccule Vestibular Nerves Vestibular Nuclei

History Symptom Tempo Circumstance Past History

Symptoms Clear – Relatively easy to categorize Vague – Frustrating – Often the key to Psychological Cause

Symptom Disequilibrium – Loss or Lack of Stability – Loss of Vestibulospinal, Proprioception, Visual, Psychological Lightheadedness/Presyncope – Reduced Blood flow to Brain Sensation Rocking/Swaying (Mal de Debarquement) – Problem with Vestibular adaptation, Anxiety

Symptom Motion Sickness – Visuovestibular mismatch Nausea/ Vomiting – Stimulation of Medulla Oscillopsia – Severe Bilateral Loss of Vestibulo-ocular Reflex

Symptom Floating, Swimming, Rocking, Spinning inside Head – Anxiety, Depression Vertical Diplopia – Skew eye deviation Vertigo (Rotatory, Linear, Tilt) – Hallucination of Movement – Imbalance of Tonic Neural Activity to Vestibular Cortex

Tempo Seconds to Minutes – BPPV – Microvascular Compression 30 min-24 hours – Hydrops – Migraine hours – Acute Vestibular Failure

Circumstance Precipitating Factors Occuring – Before – During – After Associated

Symptom Generation “One-off” Vestibular Event with Sequelae – Problems with Compensation Recurrent Vertigo Positional Vertigo Chronic Subjective Dizziness Syndrome – Psychological

Past History First Attack – Pathology Subsequent Attacks – Pathology – Decompensation

First Attack Acute Vestibular Loss – Most Severe Attack – May be only pathological event suffered Recurrent Vertigo – Not necessarily most severe attack “Have you ever had an attack which went on for days?”

Examination Physiology Pathophysiology Vestibulo-ocular reflex

Vestibulo-Ocular Reflex Maintains Steady Gaze during Head Movement Normal Activities – <550 ° /sec Responds up to – 6000 ° /sec Response Time – 5-7 msec

Nystagmus Cause – Tonic Imbalance Drift (Slow Phase) – Towards underactive side Correction (Fast Phase) – Away from underactive side Enhanced looking in direction of Fast Phase Enhanced in the absence of Ocular Fixation

Grades of Nystagmus First Degree – Looking in direction of Fast Phase Second Degree – Looking Straight ahead and in direction of Fast Phase Third Degree – All Three Positions

Clinical Examination Ocular Range of Movement Smooth Pursuit – Conjugate Movement – Jerky Movement Impaired Smooth Pursuit Nystagmus – Jerky Movement with Target Stationary

Clinical Examination Saccades – Abnormal- Cerebellar VOR Suppression Head Thrust – Horizontal

Clinical Examination Saccades – Abnormal- Cerebellar VOR Suppression Head Thrust – Horizontal Dynamic Visual Acuity

Clinical Examination Romberg – Vestibulo-spinal reflex – Proprioception Unterberger – Unreliable except within one week of Acute Dysfunction Dix-Hallpike

Anything Else Problem – Often Asymptomatic when seen – Abnormal Signs Disappeared Video Eye Movements when Symptomatic – 10 sec looking straight ahead – 10 sec looking to left – 10 sec looking to right Have They Nystagmus when Symptomatic?

Acute Vestibular Dysfunction Acute Tonic Imbalance – Acute Vertigo – Nystagmus – Nausea and Vomiting Recovery of Function Central Compensation – Static and Dynamic

Compensation Inhibition Prolonged use of Suppressant Medication Lack of Stimulation

Acute Vestibular Loss- Causes Trauma – Fractured Temporal Bone – Surgery

Acute Vestibular Loss- Causes Trauma – Fractured Temporal Bone – Surgery Labyrinthitis – Viral – Bacterial

Acute Vestibular Loss- Causes Trauma – Fractured Temporal Bone – Surgery Labyrinthitis – Viral – Bacterial Vestibular Neuronitis

Virus Particles isolated in Scarpa’s Ganglion Superior Vestibular Nerve – Superior Canal – Horizontal Canal Inferior Vestibular Nerve – Posterior Canal

Management Vestibular Suppressants – Reduces Tonic Asymmetry – hours Rehabilitation

Compensation Static Dynamic – Requires Stable input – Requires Stimulation Get off Suppressant Medication Start Exercises

Problems Incomplete Compensation Partial Decompensation Complete Decompensation

Decompensation Causes – Unusual Movement – Another Illness Management – Rehabilitation

Recurrent Vertigo Recurrent Pathological Events Recurrent Alteration of Tonic Activity Implies – Partial Damage – Recovery of Function Total Partial

Causes Migraine Meniere’s Vascular Loops Susac’s Syndrome Syphilis

Meniere’s Disease Episodic Vertigo – 20 min- 24 hours Fluctuating Low Tone Sensori-neural Hearing Loss Tinnitus Sensation Pressure in Ear

Stages Hearing returns to normal between Attacks Permanent Low Tone Loss – Worse during attack Permanent Loss – Doesn’t change

Diagnosis History Evidence of Canal Paresis Serial Audiometry

Variants Cochlear Hydrops – No Vestibular Symptoms Vestibular Hydrops – Probably Migraine Tumarkin Otolithic Crisis – Sudden Collapse

Management Medical Low salt Diet Cinnarizine in acute phase Betahistine – Dose: 8-16mg tds – High Dose: mg tds

Non-Response to Medical Treatment Revisit Diagnosis – Why couldn’t it be Migraine? Surgical Options

Surgical Chemical Labyrinthectomy – Gentamicin Delivery – Grommet – Transtympanic Injection – Tympanotomy Apply directly to Round Window Membrane

Surgical Options Endolymphatic Sac Decompression Vestibular Nerve Section

Migrainous Vertigo Migraine without Aura Migraine with Aura – Migraine with Prolonged Aura Basilar Migraine Migraine Aura without Headache Childhood Periodic Syndromes Migrainous Infarction

Basilar Migraine Two or more:- Vertigo, Tinnitus,Hearing Loss, Ataxia, Dysarthria, Diplopia, Paraesthesia, Paresis Headache Vertigo – 5-60 min

Migraine Aura without Headache Past History Classical Migraine Family History Migraine Response to Triptans

Undiagnosed Recurrent Vertigo 30% Develop Migraine or BPPV Some Migraine Bilateral Involvement Vestibular Migraine, Meniere’s, Epilepsy, MS BPPV All may have atypical presentations

Differential Meniere’s BPPV TIAs Vestibular Epilepsy Perilymph Fistula

Case Study 1 Early 50’s 2 months Recurrent Dizziness

History Symptom – Mostly lightheadedness – Severe episodes- Spinning Tempo – sec – Multiple Times a day

Symptoms Circumstance – Accompanying Palpitations – Causation Eating Solids

Examination ENT – Normal ECG – Normal

Test Feed Pre-Food – Heart Rate65 – BP132/70 Post Feed – Heart Rate – Rhythm Atrial Extrasystoles Flutter Rhythm Terminates with Increasing AV block

Case 2 52 yr old Female No Past History Dizziness Turned Suddenly Acute Rotatory Vertigo Nausea and Vomiting Given Cyclizine Referred to Hospital

Admission Severe Vertigo Severe Nausea and Vomiting No Nystagmus

Benign Paroxysmal Positional Vertigo

Causes Idiopathic Head Injury Vestibular Neuronitis Labyrinthitis Anterior Vestibular Artery Ischaemia

Idiopathic Highest Incidence – 6 th -7 th Decade >70 years – 25% patients presenting with “dizziness” had BPPV Referrals to Vestibular Clinic – 23% BPPV – Mean age 61

Idiopathic Undiagnosed – Increased Risk Falls – Impaired Daily Living General Medical Clinic – 9% Positive Dix-Hallpike Test but no balance complaints

Canal Involved Posterior – 76% Anterior – 13% Posterior or Anterior – 6% Horizontal 5%

Symptoms Vertigo Light-headedness Floating Sensation

Vertigo Lying Down Getting Up Rolling Over in Bed Looking Up

Light-Headedness Floating Sensation Hours Days

Forms Canalithiasis – Otoconia floating in Canal – Move to most dependent part of canal – Pull on Cupula ceases when Otoconia stop moving Cupulolithiasis – Otoconia stuck to Cupula – Gravitational Distortion of Cupula persists as long as position maintained – Some Vestibular Adaptation occurs

Dix-Hallpike Test Latent Period – 3-40 sec Nystagmus Fatigues Adaptation with repeat testing

Nystagmus Upbeat Torsional – Upper Pole beating towards undermost Ear

Treatment Particle Repositioning Manoeuvre – Epley Liberatory Manoeuvre – Semont Slam-Dunk Brandt-Daroff Exercises – Habituation

Treatment Canalithiasis – Epley Cupulolithiasis – Liberatory – Re-test – If now Canalithiasis – Epley

Other Nystagmus Not Posterior Canal BPPV Horizontal Jerk Nystagmus – Horizontal Canal BPPV

Horizontal Canal BPPV Roll Test Lie on Back- Head degrees up Turn quickly to Right or Left Observe for Nystagmus Move Head slowly back to Neutral Position Wait sec Repeat on opposite side

Results Effect turning to both sides Stimulating in one direction Inhibiting in opposite direction One side – More severe symptoms – More Pronounced Nystagmus – Longer duration of Nystagmus

Treatment Canalithiasis – Bar-B-Que Roll – Appiani Manoeuvre Cupulolithiasis – Casani Manoeuvre

Bar-B-Que Manoeuvre Turn head to affected side – Wait 15 seconds after symptoms stop Turn head 90 degrees to the Vertical – Wait as before Another 90 degrees – Wait Another 90 degrees – Wait

CHRONIC SUBJECTIVE DIZZINESS SYNDROME

Precise(ish) Symptoms True Vertigo Light Headed Presyncope Pressure Sensation Postural Imbalance Ataxia

Psychogenic Symptoms Chronic Heavy Head Light Headed Tightness in Head Floor Rising and Falling

CSD Symptoms >3 months – Non-vertigo dizziness – Light Headed – Heavy Headed – Feeling inside head spinning – Feeling Floor moving – Disassociation from Environment

CSD Symptoms Chronic Hypersensitivity – One’s own movement – Movement of Objects in Environment Exacerbation of Symptoms – Situation of Complex Visual Stimuli – Supermarket – Computer screen

Age and Sex Age – Adolescent to Old Age – Peak Sex – Female 2 - Male 1

Pathogenesis Psychological Problem – 93% General Anxiety Panic Attacks/ Phobia Minor Anxiety

Pathogenesis Few – Depression – Post Traumatic Stress Disorder – Hypochondriasis – Conversion Disorder

Relationship with Neuro-otological or Neurological Conditions Many had – Vestibular Neuronitis – Migraine – BPPV Acute Vestibular Problem Precipitates Acute Anxiety Requirement – Treat underlying Psychopathology

Otogenic CSD No Prior History of Anxiety Anxiety precipitated by Neuro-otologic Illness

Psychogenic CSD Dizziness develops during Anxiety attack

Interactive CSD Prior History of Anxiety CSD Develops or worsens after – Acute Vestibular Event – Transient Mild Rotatory Vertigo

Continuing Problem Psychological Process plays Principal Role in Sustaining – Symptoms – Functional Impairment

Key to Therapeutic Success Address Psychological Problems

Treatment Psycho-education Most Believe – Physical Disorder Need – Explanation of how Psychological Disease produces and sustains Physical Symptoms

Pharmacology SSRI Complete Remission50% Positive Effect70% Initial Increase in Symptoms – Benzodiazepines may help in first few weeks 20% intolerant

Other Treatments Cognitive Behaviour Therapy Vestibular Rehabilitation