“VERTIGO” November 12, 2011 Kansas Association of Osteopathic Medicine Primary Care Update G. Marcus Stephens, D.O.

Illustrative Case A 67 year-old man rolled over in bed early in the morning and suddenly developed severe nausea as well as the unpleasant sensation that the room was spinning around him. The spinning resolved within 30 seconds but recurred again in the opposite direction when he rolled back to his original position. This had never happened to him before. The patient denied tinnitus, hearing loss, recent viral illness, or head trauma.

Case continues The patient's past medical history was remarkable only for hypertension for which he took atenolol. Surgical history was unremarkable. He did not smoke, drank only occasionally, and denied illicit drug use. Family history was non-contributory. He had no known drug allergies.

Case continues VS: 37.2, 70, 140/85, 12, 98%. The head, eyes, ears, neck, and cardiac examinations were unremarkable. A detailed neurological examination, including mental status, cranial nerves, motor function, sensory function, and cerebellar function, was normal. A Dix- Hallpike (aka Nylan-Barany) test was performed and showed torsional nystagmus in the right head-hanging position, along with reproduction of the patient's symptoms.

Objectives What are the 4 major categories of dizziness? How is it worked up? How is it treated? What is vertigo? Review Inner Ear anatomy and physiology Understand BPPV. Learn the Dix- Hallpike Maneuver Learn Canalith Repositioning technique

“Dizziness” Common and Treatable Dx by history The physical exam is just confirmational. The dx does not yield to technology, some tests may lead astray. 38% of elderly have this complaint at any given time. As with many conditions, if you don’t know the dx at the end of the history, you will probably never know the dx. It does not lend itself well to technology, in fact some tests may lead you astray. The physical exam is just confirmatory.

Rules for taking a history. NEVER suggest any symptom, especially with dizziness, or any other sensorineurologic condition, e.g. headache, numbness, etc. You are interviewing the affected organ Family docs are usually the first to work up The first 30 seconds in the life of a dizzy complaint are the most important You say, “does the room spin” Pt says, “why yes, doctor, the room does spin. You, “Do you get double vision?” Pt, “Yes, I see double.” You, “Triple?” Pt Yes, triple You “ever been blind” Pt “Yes, I’ve been blind.” Paralyzed…yes, paralyzed. You “Does your stool glow in the dark?” Pt…”Yes, doctor, my stool does glow in the dark. You have created a neurologic monster…this will affect all subsequent interviews.

More rules The psychiatrists approach: “Feeling dizzy lately?” Then WAIT! Average time a doctor waits for an answer is 8 seconds. No questionnaires! I’m busy, how long should I wait…..til hell freezes over. It will save time in the long run.

Still more rules ‘Dizzy’ is a lay term Synonyms include woozy, lightheaded, drunk-feeling, unstable. Vertigo is becoming a lay term Listen for localizing symptoms, e.g.. Hearing loss, tinnitis, double vision, dysarthria, ataxia, 4-limb weakness (points to CNS rather than peripheral lesion) It turns out that there is no increased incidence of vertigo among patients who present complaining of vertigo. They get it from the Hitchcock movie Vertigo, or from internet sites, eg. “Doctor, I have a perilymphatic fistula.”

The four types of dizziness A landmark study done several years ago at Northwestern University on hundreds of patients complaining of dizziness found that the complaints could be categorized into 4 main types:

The Four Types Vertigo: an illusion or hallucination of motion Dysequilibrium: a gait disorder Near-syncope: a sensation of impending faint Ill-defined lightheadedness: a metaphor for anxiety

Vertigo An illusion or hallucination of motion The most common of the 4 types We’ve all experienced it, e.g. spinning on a stool Illusion: a misperception of a stimulus, accounts form most forms of vertigo Hallucination: a perception without a stimulus, e.g. vertiginous migraine, temporal lobe seizure

Near-syncope A sensation of impending faint. We’ve all experienced this, e.g. hyperventillating, standing up to fast after squatting, etc. Only about 50% do faint. Workup same as for syncope German study on medical students with EEG and Video monitoring: “looks like a seizure” Hyperventillating decreases CO2, causing cerebral vasoconstriction (generalized, not focal like a TIA). Worse with crouching and hyperventillating, then stand up and Valsalva, decreases venous return, decreases cardiac output with cerebral vasconstriction, lead to syncope

Dysequilibrium A gait disorder “I stagger” “I feel like I’m drunk” “I feel like I’m going to fall” “I feel unbalanced” About 50% do fall

Ill-defined lightheadedness Aka Type IV Dizziness A metaphor for anxiety “What do you mean, dizzy?” “I’m just dizzy. I’m dizzy all the time. Nothing really helps.” Try to use another word to describe how you feel… “Dizzy!”

Prevalence of Dizziness There is more dizziness than there are dizzy people There are roughly 1.5 dizzy complaints per dizzy person. About half of all dizziness is vertigo, the other half is about a third each of the other 3 types. Some may have a mixture of types…try to ascribe percentages, e.g. 75% vertigo, 25% type IV.

Physical Exam Always look in the ear Test hearing Look for nystagmus Positional exam Neuro exam Ear exam: just because patients expect it, everyone knows it must be an inner ear problem. Nystagmus: don’t do extremes of gaze Dix Hallpike: 2 slides later Neuro exam: look for dysarthria, aphasia, hemiparesis, hemianopsia, do reflexes and Babinski, and assess gait and visual fields

Inner Ear Let’s review the anatomy before we discuss the hearing tests and physical exam

Hearing Test Is there hearing loss? (Finger rubs) Is it sensorineural or conductive (Rinne test) If it’s sensorineural, is it cochlear or retrocochlear (speech discrimination) If it’s retrocochlear, do MRI If you can’t rember all this, do audiogram Rinne: 256 Hz tuning fork on mastoid and by ear, which is louder no. 1 or no. 2, should be no.2, air should be better than bone, if not, then hearing loss is sensorineural Don’t do Weber (Vay-burr) test, tuning fork in forehead, where do you hear it, they either point to the forehead, or to one ear, at which point you can’t remember what that means. Phone conversation assesses speech discrimination, which if reduced indicates a retrocochlear problem, probably an acoustic neuroma, so do an MRI of posterior fossa and acoustic canal

Dix Hallpike Test Aka Barany’s test Start seated Supine with neck extended 20 degrees Head rotated 45 degrees Watch for nystagmus and ask about vertigo Repeat on other side

Actual photo of Dix Hallpike

Central Peripheral cranial nerve findings Hemiparesis Facial weakness Diplopia Hypesthesia Horner’s sign Gait ataxia-may have no limb ataxia hearing loss (AICA exception) Able to walk Nystagmus horizonto-rotary Gaze-independent Reduced with visual fixation Dix-Hallpike differences

Dix Hallpike Peripheral Central Latency 2-40 seconds None Severity of Vertigo Severe Mild Duration <1 minute >1 minute Fatigability Yes No Habituation Postural Instability Can walk Falls, very unstable Hearing loss May be present Usually absent Other neuro sxs Absent Usually present Nystagmus Only one position In all positions Fatiguability meanse response remits spontaneously as position is maintained Habituation means attenuation of response as position is assumed repeatedly

BPPV Benign paroxysmal positional vertigo Usually in elderly Self-limited Responds poorly to antivertigo drugs Due to canaliths

Canaliths Canaliths are calcium carbonate debris that gets in the semicircular canals, usually the posterior canal

Epley Manuever Seated Supine with head rotated 45 degrees toward the involved side Rotate to opposite side Roll to lateral recumbent Nose down Sit up

Post-Epley Instructions Sleep upright 2 nights Cervical collar?? Avoid head back position No dentist, hair dresser Don’t drive home 2 pillows at night for a wk Watch eye drops, shaving Avoid BPPV position

Other causes of Vertigo Perilymphatic fistula Vestibular neuronitis Labyrinthitis Meniere’s Disease Traumatic Vertigo Acoustic Neuroma Crack in the oval window, often due to trauma, may be remote, eg woman fell off horse as a child, vertiginous for 6 weeks, years later got bronchitis, opened again, usually goes away, can be fixed with surgery Vn usually viral or postviral, like Bell palsy of 8th nerve, if hearing component labyrinthitis, tx w steroid boost, no evidence that antiviral helps, resolves in 6 wks. Meniere: probably autoimmune, can do antibody test, treat with steroids, antivertigo drugs, valium, lasix, hctz, decrease salt Trauma: contusion of inner ear, dx w MRI, takes 6-8 wks to go away, don’t confuse w post-concussion syndrome which is more type IV dizziness, usually w work comp or lawsuit Neuroma: retrocochlear hearing loss, mild tinnitus and mild vertigo, dx w MRI

Acoustic Neuroma

Non-vertiginous dizziness Near-syncope Usually due to impaired ability to vasoconstrict in the upright posture, e.g. hypovolemia, high ambient temperature, hyperventilation, alpha- blockers, ACEi, bp meds. Overactive baroreceptor response in elderly (treat w betablocker-blocks beta receptor and allows unopposed alpha action)

Non-vertiginous dizziness Dysequilibrium Gait disorders, e.g. Parkinsonism, Cervical spondylosis Myelopathy, e.g. B12 deficiency Always assess gait. Parkinson’s dz or syndrome Spondylosis: stiff neck and bad proprioception, worse in the shower, the Rhomberg machine, slippery, close eyes Myelopathy: poor proprioception

Non-vertiginous dizziness Type IV: Ill-defined lightheadedness “dizzy all the time” a metaphor for anxiety Replace the word dizzy with the word anxious Hyperventillation

DRUGS For BPPV if Epley fails For motion sickness (physiologic vertigo) Use anticholinergic drugs that cross the blood-brain barrier Works better prophylactically NASA experience Antihistamines (sedating) Benzodiazepines (Type IV) Astronauts were continuously vertiginous in early years, now use meclizine 25 mgq6h and ritalin 10mg q6h to combat soporiphic effect Phenergan: very anticholinergic phenothiazine, parenteral Scopolamine strong, but old people get delirious Treat 3 days before and during and 3 days aftermotion sickness

Nystagmus due to peripheral causes has all of the following featuresexcept: a.    Diminishes with fixation b.   Unidirectional fast component c.    Can be horizontal, rotary or vertical d.   Nystagmus increases with gaze in direction of fast component e.    Can be accentuated by head movement

Nystagmus due to peripheral causes has all of the following featuresexcept: a.    Diminishes with fixation b.   Unidirectional fast component c.    Can be horizontal, rotary or vertical d.   Nystagmus increases with gaze in direction of fast component e.    Can be accentuated by head movement

Nystagmus due to central causes has all of the following featuresexcept: a.    Does not change with gaze fixation b.   Can be unidirectional or bidirectional c.    Can be horizontal, rotary or vertical d.   Nystagmus increases with gaze in direction of fast component e.    Can be dramatically accentuated by head movement

Nystagmus due to central causes has all of the following featuresexcept: a.    Does not change with gaze fixation b.   Can be unidirectional or bidirectional c.    Can be horizontal, rotary or vertical d.   Nystagmus increases with gaze in direction of fast component e.    Can be dramatically accentuated by head movement

Epley Maneuver Demonstration Montani Semper Liberi