Dizzy, my head is spinning! Raj Gulati GPwSI ENT FRCGP PG Dip ENT

Dizziness Affects at least 20% of population at some stage Kroenke 1993 75% of cases can be diagnosed and treated without the need for further investigations Hoffman 1999 History is crucial Differentiate vertigo from other causes of imbalance and labyrinthine from central causes of vertigo Broomfield 2008 8/1000 GP consults. 75% improve spontaneously & 13% referred. ¼ are migraine associated dizziness. •needs time to assess, NORMAL balance balance depends on input from eyesight (60%) proprioception of muscles (tension on the muscle spindles) & joints (esp ankles & neck) so no good if standing on a foam mattress & syphillis & the vestibular labyrinth. Describe your first attack?

10 key dizziness questions Broomfield SJ, Bruce IA et al 2008 Does the room spin? Types of dizziness Drachman 1998 Vertigo ‘illusion of movement’ Presyncope sensation of impending faint Dysequilibrium impaired balance & gait without Abn head sensation Lightheadedness Medical cause should be considered in absence of true vertigo Is the room spinning? Is it episodic

10 key dizziness questions Broomfield SJ, Bruce IA et al 2008 Is the spinning horizontal or vertical? Is it better with eyes open or closed? Labyrinthine pathology: Horizontal or rotational vertigo that lessens with fixation of gaze Central pathology: Purely vertical or doesn’t lessen with fixation of gaze Ask for coincident neurological symptoms Speech, altered consciousness, vision changes, sensory symptoms, involuntary motor activity, incontinence Ask for cardiac symptoms Chest pain, palpitations, pre-syncopal symptoms, passive slump to ground Did they come before the vertigo? if better with eyes open, more likely labyrinthe. If you fix your gaze you can overcome peripheral vertigo by overstimulating the visual pathways. Supermarkets are therefore a challenge as lots of visual stimuli, plus motion

10 key dizziness questions Broomfield SJ, Bruce IA et al 2008 How long does the vertigo last? BPPV (VBI) seconds Meniere’s syndrome minutes to hours Acute vestibular failure hours to days Migrainous vertigo hours to days Central weeks Time course of attack of vertigo Momentary think PV – unless other symptoms present Few minutes now settled think cardiovascular Recurrent with movement think PV – but be alert to silent MI

10 key dizziness questions Broomfield SJ, Bruce IA et al 2008 Is there a positional trigger? True vertigo will always be worse with head movement Halmagyi 2005 BPPV: seconds provoked by specific head position 6. Are deafness and tinnitus associated? Meniere’s disease: Prodromal aural fullness, tinnitus and hearing loss in direct association with the vertigo 7. Has there been a recent viral illness? ? Viral cause for AVF Any tinnitus directly associated with vertigo? ( fluctuating low pitch= more menieres/migraine or constant = acoustic neuroma or labrynthitis, no tinnitus or hearing loss – vestibular hydrops) Any vertigo directly associated with a pressure in the ear (menieres)? Vestibular hydrops is where episodes of vertigo but no loss of hearing or tinnitus. Cause of hydrops include syphillis/mumps/hypothyroid/allergy Any hearing loss directly associated with the vertigo (fluctuating SNHL =menieres, constant SNHL = acoustic neuroma/ labrynthitis)? In one particular ear? (BPV describe rolling over in particular direction causes vertigo)?

10 key dizziness questions Broomfield SJ, Bruce IA et al 2008 8. Are there any other symptoms? Aural fullness in Meniere’s. Headache, visual disturbance, aura & nausea in migrainous vertigo. Neurological symptoms in TIAs 9. Is there a history of migraine or are attacks clustered? Migrainous vertigo or Meniere’s syndrome attacks can be clustered 10. Is there an associated aura or are you left with a ‘hang-over’ feeling? Migrainous vertigo

Examination Examine the ears Assess nystagmus Examine cranial nerves Otoscopy Assess nystagmus Alexander’s law: ↑ amplitude with gaze in direction of fast phase in peripheral nystagmus Central type nystagmus is vertical or direction-changing Examine cranial nerves Assess cerebellar function Examination check TM, Cranial nerves esp nystagmus (airplane wing tilts to affected side & then wing quickly corrects), diplopia, corneal sensation (contact lenses can reduce the sensation thus ask to remove). check cerebellar signs eg past pointing open & closed eyes, heel/toes gait • . Menieres attacks are short & sharp. Expect to become depressed. • Advise no ladders, swimming, walking or driving in the dark. • Vestibular rehabilitation- The best is Gaze Stabilisation Exercises as this helps the vestibular-ocular reflex. Cawthorne-Cooksey (stresses the balance system to encourage brain compensation) and are good for chronic, anxious people, Brandt Darroff. Cochrane review 2008 says helps (CKS). Rehabilitation fails if there is a fluctuating deficit e.g migraine/ Menieres/ BPPV/ perilymphatic fistula or autoimmune inner ear disease. Fixed deficits from burnt out menieres , labarythitis and trauma seem to fair better. • Epleys manoeuvre ca cure BPV (80%) see below, but it is contraindicated in neck OA • Use of Cyclizine/ buccal stemetil –vestibular sedatives, but prolonged use can cause a delay in central compensation. Use for 48 hours & stop (as soon as you can cut it down, cut it down). Encourage patients to resume normal activities ASAP. Triptans do not help. Avoid the 5 “Cs” (caffeine, chocolate, cheese, Chinese food and C2HO5). Strip lights contain red light so consider eye wear to blot it out. Nortryptiline (weight gain). Propranolol (tiring with sports). Topiramate (stop if tingling in arms). Aspirin seems to be effective (75mg a day). • serc causes indigestion (analogy to grabbing a twig to keep you afloat) 16mg tds. Lo Salt (1.5g or less a day) reduce MSG, caffeine & alcohol/stress /allergy. Bendroflumethiazide 2.5mg-5mg with a banana. Grommets seem to help. Meniett device pulses air into the ear is FDA approved but very expensive. Last resort- Dexamethasone can help when injected into drum (vasodilates). • Neck collars are only useful in driving but prolonged use causes a reduction in central compensation. Also if people hold themselves in a particular posture e.g hip atalgia can develop lateral canal disease which needs a modified Epley- face down for 2 minutes once otoconia dislodged.

Examination 2 Head thrust test in acute vertigo Halmagyi 2005 Positive in AVF and Negative in Cerebellar infarction Balance tests Romberg’s and Unterberger’s tests Positional tests Dix-Hallpike test to diagnose BPPV Cardiovascular system Postural hypotension, bruits, AF Vestibular ocular reflex, Saccades, Smooth pursuit, Halmagyi Head thrust test- ask the patient to move head to side, keeping eyes straight and then move the head to the centre. Do a few times. Looking for saccadic movements of the eye. If the left vestibular apparatus is weak then saccades to the right (over corrects to catch up). Romberg’s (stand on foam as knocks out proprioception) & Unterberger’s (1930’s) – stand still, eyes closed, arms out, hands up, march on spot (50 steps) & patient moves to diseased ear (because eyes closed- removes eye input, removes proprioception so leaves just vestibule to help), the test needs to be atleast 40 degrees to be positive Lying & standing BP Carotid bruits Checking pulse

Dix Hallpike http://youtu.be/kEM9p4EX1jk Good Nystagmus at 0.54 Dix-Hallpikes is used to diagnose BPV (GP list of 1700, 2 cases per year). Patient sat up,then holding head, the patient is laid down with head over end of couch & watch for rotational (torsional) nystagmus ( initial latency & then atleast 20seconds as fatigues). It causes the otoconia (displaced particles from the utricle from a prior labrynthitis, “chalk crystals”) to move from the posterior semicircular canals back to the utricle

Investigations Pure tone audiogram Blood tests- only if indicated by history and examination Imaging Vestibulocochlear asymmetry or ? central

Management Reassurance and explanation Vestibular rehabilitation Psychological support Specific treatment if diagnosis clear • Menieres attacks are short & sharp. Expect to become depressed. • Advise no ladders, swimming, walking or driving in the dark. • Vestibular rehabilitation- The best is Gaze Stabilisation Exercises as this helps the vestibular-ocular reflex. Cawthorne-Cooksey (stresses the balance system to encourage brain compensation) and are good for chronic, anxious people, Brandt Darroff. Cochrane review 2008 says helps (CKS). Rehabilitation fails if there is a fluctuating deficit e.g migraine/ Menieres/ BPPV/ perilymphatic fistula or autoimmune inner ear disease. Fixed deficits from burnt out menieres , labarythitis and trauma seem to fair better.

Management BPPV Suggestive history + positive DH test → Epley manoeuvre Acute vestibular failure / labyrinthitis / vestibular neuronitis Vestibular sedatives only in the acute phase Vestibular rehabilitation may quicken central compensation Vestibular migraine Avoid dietary trigger factors. Medical treatment similar to standard migraine Use of Cyclizine/ buccal stemetil –vestibular sedatives, but prolonged use can cause a delay in central compensation. Use for 48 hours & stop (as soon as you can cut it down, cut it down). Encourage patients to resume normal activities ASAP. Avoid the 5 “Cs” (caffeine, chocolate, cheese, Chinese food and C2HO5). Strip lights contain red light so consider eye wear to blot it out. Nortryptiline (weight gain). Propranolol (tiring with sports). Topiramate (stop if tingling in arms). Aspirin seems to be effective (75mg a day). Neck collars are only useful in driving but prolonged use causes a reduction in central compensation. Also if people hold themselves in a particular posture e.g hip atalgia can develop lateral canal disease which needs a modified Epley- face down for 2 minutes once otoconia dislodged.

Meniere’s disease Incidence 15 per 100 000 in UK Both sexes equally affected First episode usually between 20 and 50 years of age Both ears affected in 50% of cases Hearing loss initially reversible Low tone sensorineural loss often develops over time Chronic disequilibrium and deafness/tinnitus Examination normal MR scan

Meniere’s Disease Management Dietary and lifestyle modification Psychological Vestibular sedatives Betahistine, bendrofluazide, propranolol Surgical management Grommet, intratympanic gentamycin, saccus decompression, vestibular nerve section, bony labyrinthectomy serc causes indigestion (analogy to grabbing a twig to keep you afloat) 16mg tds. Lo Salt (1.5g or less a day) reduce MSG, caffeine & alcohol/stress /allergy. Bendroflumethiazide 2.5mg-5mg with a banana. Grommets seem to help. Meniett device pulses air into the ear is FDA approved but very expensive. Last resort- Dexamethasone can help when injected into drum (vasodilates).

Vertigo- which pt to always refer? ? Central cause Persistent vertigo Suspected Meniere’s syndrome Asymmetrical vestibulocochlear symptoms The Best Policy A Team Approach General practice, elderly medicine, neurology, cardiology, otology Rehabilitation team: physiotherapy, cognitive behaviour therapy, occupational therapy, exercise therapy, activities in the community

Epleys manoeuvre can cure BPV (80%) see below, but it is contraindicated in neck OA

Various http://youtu.be/hq-IQWSrAtM Dix hallpike 0-0.17 Supine Roll test 0.17 to Lempert 0.49 Epley’s 1.42 Sermont 2.25 Gufoni 2.48 Brandt Daroff 3.29