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DISTINGUISHING PERIPHERAL FROM CENTRAL DISORDERS David R. Friedland MD, PhD
A Practical Guide to Dizziness and Disequilibrium April 5, 2019
PERIPHERAL VS CENTRAL • Peripheral - Coming from the inner ear Over 50% of referrals to MCW ENT for dizziness Abnormal activation of the inner ear are not peripheral or ear‐ Abnormal inhibition / loss of function in the inner ear related (Friedland et al., Chronic weakness / loss of function in the inner ear JAMA Otolaryngology, • Central 2016) - Coming from the brain
Neurological disease
Brain trauma or insult
Psychological disorder
Functional condition
A Practical Guide to Dizziness and Disequilibrium April 5, 2019
WHAT TYPE OF EPISODE/DIZZINESS
• Acute • Recurrent • Chronic
A Practical Guide to Dizziness and Disequilibrium April 5, 2019
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ACUTE DIZZINESS
ACUTE DIZZINESS
The patient is experiencing, or just experienced, an • Stroke or no stroke? attack of dizziness while you are examining or talking to them.
The patient had a single well‐defined attack of dizziness.
A Practical Guide to Dizziness and Disequilibrium April 5, 2019
DISTINGUISHING PERIPHERAL FROM CENTRAL ACUTE VESTIBULAR DISORDERS
•HINTS (HI – N – TS) - Three tests to assess vestibular system •INFARCT (IN – FA – RCT) - Way to remember how to interpret the HINTS tests
A Practical Guide to Dizziness and Disequilibrium April 5, 2019
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HINTS Ear Related Issue • Positive head thrust • Head Impulse • Unidirectional - Positive in peripheral horizontal nystagmus - Negative in central • No skew deviation • Nystagmus - Unidirectional in peripheral Stroke - Direction changing in central • Negative head thrust - Horizontal in peripheral • Direction changing or - Vertical in central vertical nystagmus • Test of Skew • Skew deviation - Absent in peripheral Kattah JC, Talkad AV, Wang DZ, Hsieh YH, - Present in central Newman-Toker DE. HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion- A Practicalweighted Guide to imaging. Dizziness Stroke. and 2009 Disequilibrium Nov;40(11):3504-10. April 5, 2019
HEAD IMPULSE TEST
HINTS • Head Impulse • Nystagmus • Test of Skew Loss of VOR on Left Side Zee and Minor, 2002
A Practical Guide to Dizziness and Disequilibrium April 5, 2019
NYSTAGMUS • Corrective mechanism HINTS - Rapidly bring eyes back to where they belong • Head Impulse • Named for the fast direction of • Nystagmus motion - Left / right; up / down • Test of Skew - Rotary: clockwise / counterclockwise
A Practical Guide to Dizziness and Disequilibrium April 5, 2019
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HORIZONTAL NYSTAGMUS: BEATS TOWARD STRONGER EAR
Turn the wheel quickly to correct for difference in HINTS tire pressure • Head Impulse FLAT • Nystagmus • Test of Skew
Car drifts
A Practical Guide to Dizziness and Disequilibrium April 5, 2019
NYSTAGMUS
HINTS • Head Impulse • Nystagmus • Test of Skew
A Practical Guide to Dizziness and Disequilibrium April 5, 2019
NYSTAGMUS
HINTS • Head Impulse • Nystagmus • Test of Skew
A Practical Guide to Dizziness and Disequilibrium April 5, 2019
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ALEXANDER’S LAW
Gaze in the direction of HINTS the fast phase of • Head Impulse nystagmus increases amplitude and • Nystagmus frequency • Test of Skew
A Practical Guide to Dizziness and Disequilibrium April 5, 2019
ALEXANDER’S LAW
HINTS • Head Impulse • Nystagmus • Test of Skew
A Practical Guide to Dizziness and Disequilibrium April 5, 2019
TEST OF SKEW • Alternate Cover Test - Focus on fixed point HINTS - Alternate covering one eye then the • Head Impulse other - Observe for refixation when uncover • Nystagmus eye - Abnormal skew represents brainstem • Test of Skew or cerebellar misinterpretation of otolith signals
A Practical Guide to Dizziness and Disequilibrium April 5, 2019
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TEST OF SKEW
HINTS • Head Impulse • Nystagmus • Test of Skew
A Practical Guide to Dizziness and Disequilibrium April 5, 2019
INFARCT HINTS •Impulse Normal • Head Impulse •Fast-phase Alternating •Refixation with Cover Test • Nystagmus • Test of Skew
A Practical Guide to Dizziness and Disequilibrium April 5, 2019
HINTS TEST: OVERVIEW HINTS • Head Impulse • Nystagmus • Test of Skew
A Practical Guide to Dizziness and Disequilibrium April 5, 2019
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RECURRENT DIZZINESS
RECURRENT DIZZINESS
The patient has • Repeated attacks/spells/episodes experienced more than one attack of dizziness. • Nature: what is it like? • Duration: how long does it last? Attacks have a beginning and end with no dizziness • Triggers: when does it occur? between attacks. • Associated symptoms • Associated conditions
A Practical Guide to Dizziness and Disequilibrium April 5, 2019
RECURRENT DIZZINESS: PERIPHERAL
• BPPV ~85% of ear
• Meniere’s disease related Friedland et al., JAMA dizziness Otolaryngol Head Neck Surg. ------2016;142(4):351-356 • Superior canal dehiscence; fistula - Sound or pressure induced dizziness; hear “eyes move” • Vestibular neuritis; acoustic neuroma - Very rare to cause recurrent episodes • Ear disease: cholesteatoma, otitis media
A Practical Guide to Dizziness and Disequilibrium April 5, 2019
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PERIPHERAL: OTOLOGIC SYMPTOMS • Hearing Loss - Actual hearing loss = can’t detect sound Not: being overwhelmed by sound, trouble understanding, not sure - Unilateral Bilateral symptoms are rarely from peripheral conditions - Fluctuations Unilateral, recurrent, actual hearing loss: Meniere’s disease - Associated with the dizzy attacks Occur in similar time-frame vs longstanding
A Practical Guide to Dizziness and Disequilibrium April 5, 2019
PERIPHERAL: OTOLOGIC SYMPTOMS • Ear Pain - Not a feature of otologic related dizziness - Common in migraine (think TMJ or headache) - Ear pain with no other ear symptoms (e.g., hearing loss) is not an ear infection • Ear Drainage - Pus, purulence, visible: suggestive of infection/cholesteatoma - Feels like there’s water in there, my finger is moist: not suggestive of ear issue
A Practical Guide to Dizziness and Disequilibrium April 5, 2019
PERIPHERAL: OTOLOGIC SYMPTOMS • Tinnitus - Ear-related dizziness (i.e., Meniere’s disease) low humm, ocean, truck idling, wind, rushing, buzzing unilateral - Not ear-related dizziness high-pitched, ringing, insects, tone bilateral - Autophony Special case of tinnitus: internal body sounds
A Practical Guide to Dizziness and Disequilibrium April 5, 2019
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RECURRENT DIZZINESS: NON-OTOLOGIC • Neurological signs and symptoms - Parasthesia, weakness, visual scotomas/loss, headache - Multiple sclerosis, Parkinson’s, Alzheimer’s, etc. • Behavioral health conditions: active - Depression, anxiety, medication changes (psychiatric) • Medical conditions: active - Labile blood pressure, thyroid issues, cancer, chemotherapy, autoimmune disease, neuropathy, arrythmia • Physical conditions - Head trauma, knee/hip replacement, frailty
A Practical Guide to Dizziness and Disequilibrium April 5, 2019
CHRONIC DIZZINESS
CHRONIC DIZZINESS
The patient is experiencing • Persistent dizziness or imbalance dizziness or imbalance which is always present to • Nature: what is it like? some extent for 3+ • Duration: how long has it lasted? months. • Triggers: when does it occur? Distinguish from a single • Associated symptoms attack of dizziness with prolonged course or • Associated conditions recovery.
A Practical Guide to Dizziness and Disequilibrium April 5, 2019
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CHRONIC DIZZINESS: PERIPHERAL • Vertigo (peripheral) - Impossible to have persistent vertigo for months - Get a better history and sense of the patient’s perception • Imbalance - The main chronic vestibular disorder is imbalance • Other sensations of motion (not peripheral) - Swaying, rocking, “on a boat” • Gait Disorder (not peripheral)
A Practical Guide to Dizziness and Disequilibrium April 5, 2019
CHRONIC DIZZINESS: PERIPHERAL • Imbalance - Weak or absent peripheral vestibular function - Oscillopsia: bilateral hypofunction - Trouble in the dark, uneven ground, soft ground, inclines - Wide-based gait, reduced speed, unable to recover • Not peripheral - Ataxia, shuffling, foot drop Oscillopsia
A Practical Guide to Dizziness and Disequilibrium April 5, 2019
CHRONIC DIZZINESS: NON-OTOLOGIC
• Motion sensitivity (common with hx/o migraine) - Cars, boats, rides • Visual sensitivity (visual vertigo) - Grocery store aisles, tunnels, video games, news ticker, scrolling on phone, patterns, 3D movies, crowds, malls • Rocking, swaying, on-a-boat - Mal de Debarquement: worse if still, better if moving - 3PD: better if still, worse with moving, or upright
A Practical Guide to Dizziness and Disequilibrium April 5, 2019
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CHRONIC DIZZINESS: NON-OTOLOGIC • Faint Sensation / Lightheaded - Standing in one place - Changing posture: lying to sitting to standing • Head Fullness / Pressure - Allergy, headache condition, muscle tension, stress • Just Not Right - Elderly, post-trauma, anxiety, vision-related
A Practical Guide to Dizziness and Disequilibrium April 5, 2019
SUMMARY • Acute, recurrent or chronic dizziness • Acute: HINTS • Recurrent - BPPV or Meniere’s if peripheral - Look for associated signs and symptoms • Chronic - Imbalance is most common peripheral - Assess nature of the sensation
A Practical Guide to Dizziness and Disequilibrium April 5, 2019
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