Clinical Evaluation of the VESTIBULAR

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

Definitions: Vertigo is an abnormal sensation of movement when there is no movement actually occurring -- usually spinning sensation 2

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

Balance System Physiology

Contradiction = Vertigo

Twin Engine Analogy

Why Is It So Complicated? B C D E A

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…

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.

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

Diagnoses Simplified Inner ear related (peripheral) Other (non-inner ear)

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

Vertigo Dx. You Want to Know Ménière’s disease / Endolymphatic Hydrops Benign positional vertigo Labyrinthitis / Vestibular Neuritis (15%) Chronic vestibular weakness Fistula /Superior Canal Dehiscence Migraine

Meniere’s Syndrome

Definition: Meniere’s syndrome and endolymphatic hydrops both refer to a condition of excess pressure accumulation in the inner ear.

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)

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

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 20

Workup of Meniere’s 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

Standard Treatment Options Dietary Management Medical Treatment Antivert Dyazide Steroids Meniett Surgical Treatment

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

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)

Medical Treatment of Pressure Build Up Dyazide: l “water pill” a day in the mornings.

Steroids: Taper as directed Very useful in acute processes Anti-inflammatory

Surgical Treatment: Non-Destructive Surgery Tympanostomy tube / Meniette’s Transtympanic Steroids Endolymphatic Sac Decompression Ablative (Destructive) Surgery Transtympanic Aminoglycosides Vestibular Nerve Section Labyrinthectomy

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

BENIGN PAROXYSMAL POSITIONAL VERTIGO PICTURE BENIGN PAROXYSMAL POSITIONAL VERTIGO 30

Introduction BPPV most common single dx of vertigo Underestimated PICTURE 2 Introduction BPPV most common single dx of vertigo Underestimated Misdiagnosed Concomitant pathology

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)

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.

“Classical Nystagmus” Parallels the symptoms. Predominantly rotatory nystagmus , fast phase toward ground Latency (~5 sec) Limited duration (<20 sec)

Canalith Theory Canalith Theory

Diagnosis History Physical

Laboratory tests Audiogram -- May be normal. Electronystagmography -- PICTURE Laboratory tests Audiogram -- May be normal. Electronystagmography -- Caloric test not always useful

The Hallpike Maneuver Standard clinical test for BPPV. Pathognomonic PICTURE The Hallpike Maneuver Standard clinical test for BPPV. Pathognomonic A negative test is meaningless

Treatment Options Watch and Wait vs. "The Canalith Repositioning Procedure"

CRP video 40

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.

CRP Positions (Left BPPV)

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.

CRP Positions Left BPPV

The 360o Maneuver

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

Vestibular Neuritis / Labyrinthitis Vestibular Neuronitis, Labyrinthitis Viral infection / inflammation of the nerve / labyrinth. Think along the lines of Bell’s Palsy Watch out for Ramsey Hunt Syndrome

Anatomical Differentiation

Differences Vestibular Neuritis Labyrinthitis Cochlear 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

Findings Vestibular Neuritis Labyrinthitis Cochlear 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 50

Vestibular Neuritis RX Steroids Antivirals (Antibiotics) Vestibular rehab

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

RX Vestibular Rehab

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

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

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

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

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

Superior Canal Dehiscence 60

Superior Canal Dehiscence Loss of bone over SC Similar sx as fistula Pressure Sensitive vertigo Conductive Hearing Loss Autophony

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

Cervical Vertigo Controversial History of Neck trauma or spine problems Vestibulospinal tract “off balance” “dizzy” Usually NOT Spinning

Office Examination of the Dizzy Patient Dix-Hallpike Maneuver Pneumatic Otoscopy Romberg Test Fukuda Stepping Test Gait Test

Dix-Hallpike Maneuver

Pneumatic Otoscopy Hennebert’s sign/symptom – nystagmus and vertigo with +/- pressure Normally: No nystagmus May be positive in: fistula, SCC dehiscence syndrome, Meniere’s disease

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

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

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

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 70

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

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

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

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.

Very Sick Patient General guideline: IF only Vertigo, nausea, vomiting WITHOUT: Cardiac SX, SOB, Neuro deficits, blackout, grey-out, Visual disturbance…etc… WITH: auditory symptoms only THINK inner ear, otherwise GO TO ER

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

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.

Episodic vs. Constant Episodic Attacks Constant, Chronic Usually ear related, acute peripheral vestibular BPPV, Ménière’s 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

Timing: Duration Transient seconds to minutes TIA, Vascular event or BPPV 20 minutes to several hours Ménière’s disease Continuous dizziness for days – weeks Vestibular neuritis, labyrinthitis, Continuous dizziness for months Uncompensated vestibular problem or chronic CNS problem

Provocation Movement induced: Dietary triggers: Benign positional vertigo (by far) Rarely Unstable peripheral vestibular problem CNS: arachnoid cyst Dietary triggers: Ménière’s disease Migraine 80

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)

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

Physical Exam To Hone In Dix-Hallpike Maneuver Pneumatic Otoscopy Romberg Test Fukuda Stepping Test Gait Test

Diagnosis Specific Findings Positional changes: BPPV or Postural Hypotension Dix Hallpike: BPPV Diet provoked: Meniere’s vs. Migraine Flux HL, Pressure, Tinnitus, Vertigo Meniere’s

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