Vertigo Paul Chatrath Consultant ENT/Head & Neck Surgeon Charing Cross Hospital (Imperial Healthcare NHS Trust) Honorary Senior Lecturer Anglia Ruskin University, Chelmsford Visiting Professor of Rhinology Canterbury Christ Church University, Kent 6 th September 2016

Objectives Dizziness / vertigo in general Dizziness / vertigo in general ENT causes for vertigo ENT causes for vertigo Meniere’s Meniere’s BPPV BPPV Labyrinthitis Labyrinthitis Other ENT causes of dizziness Other ENT causes of dizziness ‘red flags’ ‘red flags’

Case - Dizziness Please see this 40 year old female suffering with short lived episodes of vertigo Occurring almost daily Occurs whenever moves head in any direction

Clinical approach Vertigo vs dizziness Vertigo vs dizziness Vertigo Vertigo Rotatory Rotatory Suggests a peripheral vestibular or cerebellar problem Suggests a peripheral vestibular or cerebellar problem Dizziness / lightheadedness Dizziness / lightheadedness Non-specific Non-specific ‘whoozy’ ‘ lightheaded’ ‘unsteady’ ‘drunken’ ‘whoozy’ ‘ lightheaded’ ‘unsteady’ ‘drunken’ Suggests non-vestibular pathology Suggests non-vestibular pathology

Types of Dizziness Rotation (Spinning) Unsteadiness (Imbalance) Light headedness (faint feeling) If the patient has ever lost consciousness: it is not ENT!

Vertigo - causes Vestibular Viral labyrinthitis Viral labyrinthitis BPPV BPPV Meniere’s disease Meniere’s disease Acute Otitis Media Acute Otitis Media Trauma Trauma Cholesteatoma Cholesteatoma Drug induced Drug induced Postsurgical PostsurgicalCentral Migraine Migraine Vertebrobasilar ischaemia Vertebrobasilar ischaemia MS MS Tumours Tumours Cerebellopontine angle Acoustic neuroma Brainstem CVA CVAPsychogenic

Non-specific dizziness: Causes Cardiovascular Cardiovascular Arrhythmias Reduced cardiac output Carotid artery stenosis Arteriosclerosis Hypotension (postural) Proprioception Proprioception Arthritis (cervical and other) Metabolic Metabolic DM Hypothyroidism Hypercholesterolaemia Anaemia Peripheral neuropathy Peripheral neuropathy DM Renal or hepatic failure Alcohol Vasculitis Infections Leprosy, TB, syphilis Vitamin deficiencies B1, B6, B12 Genetic - Refsum’s disease Toxins Lead, metronizadole Psychogenic Psychogenic

Vertigo: Duration is key Brief (<1min) Brief (<1min) BPPV BPPV Psychogenic Psychogenic Hours Hours Meniere’s Meniere’s Migraine Migraine Days (>24hrs) Days (>24hrs) Viral labyrinthitis Viral labyrinthitis BPPV- specific head movement Psychogenic - any head movement Meniere’s- classic triad Migraine- classic headache

Nystagmus Movement of the eyes: Movement of the eyes: Rhythmic Rhythmic Oscillating Oscillating Synchronous Synchronous Involuntary Involuntary Two phases Two phases Slow phase (pathological) Fast phase (corrective) Direction described in terms of fast phase Direction described in terms of fast phase

X LNystagmus Eyes central Slow drift to right Rapid corrective flick to left = Left nystagmus L R Normal labyrinths Abnormal Right Labyrinth

Vertigo: Compensation Vestibular phenomenon Vestibular phenomenon Steady accommodation to the effects of vertigo Steady accommodation to the effects of vertigo Gradual resolution of symptoms over time Gradual resolution of symptoms over time Typically occurs 6-12 weeks after acute insult Typically occurs 6-12 weeks after acute insult Mechanisms Mechanisms Habituation Reduced output good side Increased output affected side Sensory substitution Increased reliance on eyes and musculoskeletal system

Vertigo: Compensation Impaired compensation due to: Impaired compensation due to: Poor visual acuity Poor visual acuity Musculoskeletal problems Musculoskeletal problems Reduced peripheral sensory input Reduced peripheral sensory input Ongoing vestibular pathology Ongoing vestibular pathology Medication (prolonged stemetil) Medication (prolonged stemetil) Rehabilitation: Rehabilitation: General fitness Vision, walking stick Physical programs Cawthorne-Cooksey Psychological support Specific exercises Eg. Brandt-Daroff exercises for BPPV

Vertigo: Vestibular v Central VestibularCentral Type of dizzinessVertigoVertigo / Dizzy Effect of head movementWorseEquivocal Tinnitus/hearing lossMay be presentAbsent CompensationOccursDoes not occur NystagmusHorizontalHorizontal or vertical + unilateral+ bilateral + away from affected ear

Vestibular rehabilitation: Cawthorne - Cooksey Head movements Head movements Balance tasks Balance tasks Coordination of eyes with head Coordination of eyes with head Total body movements Total body movements Eyes open & closed Eyes open & closed Noisy environments Noisy environments Causes early exacerbation of vertigo

Caution: Prochlorperazine Powerful vestibular sedative Powerful vestibular sedative Suppresses acute vertiginous symptoms Suppresses acute vertiginous symptomsBUT Also suppresses natural compensatory response Also suppresses natural compensatory response LT use:‘non-specific dizziness’persists LT use:‘non-specific dizziness’persists

Psychogenic Type of dizziness: any (nonspecific or vertigo) Type of dizziness: any (nonspecific or vertigo) Frequency: constant Frequency: constant Duration: Typically brief <1min Duration: Typically brief <1min Trigger: Stress, anxiety, crowds Trigger: Stress, anxiety, crowds Associated features: palpitations, sweating, tremor Associated features: palpitations, sweating, tremor Examination: Normal Examination: Normal

Labyrinthitis History History Vertigo Vertigo >24hrs >24hrs Vomiting Vomiting Constitutional symptoms Constitutional symptoms Usually following URTI Usually following URTI Examination Examination Nystagmus Nystagmus Fast phase away from affected ear Fast phase away from affected ear Pyrexia Pyrexia Treatment Treatment Bed rest Vestibular sedatives Fluids Cawthorne-Cooksey vestibular rehabilitation exercises Rule of threes - 3 days: v bad, 3 weeks, a lot better, 3 months resolved

Meniere’s Disease Key features: Key features: Vertigo Vertigo Hours Hours Tinnitus/hearing loss Tinnitus/hearing loss Before/during/after vertigo Before/during/after vertigo Other symptoms Other symptoms Pressure feeling Pressure feeling Nausea Nausea Natural history Natural history One episode One episode Episodic Episodic Increasing frequency Increasing frequency Salt restriction Salt restriction Diuretics - thiazides Diuretics - thiazides Vasodilators Vasodilators Betahistine, cinnarizine Evidence – no RCTs Evidence – no RCTs Cinnarizine > placebo Diuretics = placebo Serc of marginal benefit Salt restriction of marginal benefit

Intratympanic therapy: Steroids or Gentamicin

BPPV: Benign Paroxysmal Positional Vertigo Calcific debris in semicircular canals Calcific debris in semicircular canals Vertigo Vertigo Brief (<1min) Brief (<1min) On head turn in a particular direction On head turn in a particular direction Typically self-limiting Typically self-limiting Primary Primary Secondary Secondary Trauma (HI) Trauma (HI) Prolonged bed rest Prolonged bed rest Otological condition (up to 70%) Otological condition (up to 70%) Posterior SCC Posterior SCC In plane on lying in bed In plane on lying in bed Hallpike’s test Hallpike’s test Nystagmus on lying back to one side Nystagmus on lying back to one side

BPPV - Epley Epley, 1992

BPPV - Brandt & Daroff Brandt & Daroff, 1980

Migraine Clinical features Clinical features Family history Family history Motion intolerance Motion intolerance Vertigo occurs with classical headache either before or after Vertigo occurs with classical headache either before or after ENT/vestibular examination usually NAD ENT/vestibular examination usually NAD Lifestyle change Lifestyle change Exercise, diet, avoidance of stimulants Exercise, diet, avoidance of stimulants Medication: Medication: Abortive therapy eg. Sumatriptan Abortive therapy eg. Sumatriptan Prophylactic therapy eg. B blockers Prophylactic therapy eg. B blockers

Other ENT conditions causing dizziness Ear: Ear: Malignant OE Malignant OE Otitis media Otitis media Cholesteatoma Cholesteatoma Nose/Sinus Nose/Sinus Sinusitis Sinusitis Thyroid disturbance Thyroid disturbance

Dizziness/Vertigo: Indications for Urgent Referral Vertigo Vertigo Intense Intense Disabling Disabling Unremitting Unremitting Nystagmus Nystagmus Sudden SNHL Sudden SNHL Features to suggest malignant pathology Features to suggest malignant pathology Elderly with granulation in ear canal VIIn palsy Post-traumatic TM perforation + vertigo

Conclusion Must define the dizziness / vertigo Must define the dizziness / vertigo Rotatory or not Rotatory or not Frequency Frequency Triggers Triggers History is the most important factor History is the most important factor Duration Duration Vertigo Vertigo BPPV (cervical / psychogenic) Meniere’s (Migraine) Labyrinthitis (Drug / multifactorial) ENT causes for vertigo ENT causes for vertigo When to refer urgently When to refer urgently

Case Please see this 40 year old female suffering with short lived episodes of vertigo Occurring almost daily Occurs whenever moves head in any direction

Vertigo Paul Chatrath Consultant ENT/Head & Neck Surgeon Charing Cross Hospital (Imperial Healthcare NHS Trust) Honorary Senior Lecturer Anglia Ruskin University, Chelmsford Visiting Professor of Rhinology Canterbury Christ Church University, Kent 6 th September 2016