1. Clinical Evaluation of the VESTIBULAR

2. 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

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

4. 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

5. Balance System Physiology

6. Contradiction = Vertigo

7. Twin Engine Analogy

8. Why Is It So Complicated?B C D E A

9. 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…

10. 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.

11. 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

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

13. 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

14. 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

15. Meniere’s Syndrome

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

17. 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)

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

19. 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

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

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

22. 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

23. 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)

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

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

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

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

28. BENIGN PAROXYSMAL POSITIONAL VERTIGO
PICTURE
BENIGN PAROXYSMAL POSITIONAL VERTIGO 30

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

30. 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)

31. 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.

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

33. Canalith Theory
Canalith Theory

34. Diagnosis
History
Physical

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

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

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

38. CRP video 40

39. What Are The Positions?
Start. Sitting, head turned 45 degrees towards ipsilateral side.
Position 1. Supine, 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.

40. CRP Positions (Left BPPV)

41. 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.

42. CRP Positions Left BPPV

43. The 360o Maneuver

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

45. 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

46. Anatomical Differentiation

47. 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

48. 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

49. Vestibular Neuritis RX
Steroids
Antivirals
(Antibiotics)
Vestibular rehab

50. 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

51. RX
Vestibular Rehab

52. 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

53. 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

54. 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

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

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

57. Superior Canal Dehiscence60

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

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

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

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

62. Dix-Hallpike Maneuver

63. 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

64. 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

65. 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

66. 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

67. 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

68. 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

69. 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

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

71. 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.

72. 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

73. 5 Distinguishing Questions
Whirling vertigo vs. lightheadedness?
Episodic versus constant?
Short duration versus long duration?
Provocable versus spontaneous?
What sets it off?
Associated symptoms?

74. 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.

75. 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

76. 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

77. 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

78. 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)

79. 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

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

81. 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

82. 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