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Head Spinning?? Evaluation of Dizziness

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Head Spinning?? Evaluation of Dizziness Head Spinning?? Evaluation of Dizziness 1 Kirsten Bonnin, M.M.S., PA-C ASAPA Fall Conference October 5, 2019 Learning Objectives 2 Describe the pathophysiology of vertigo Discuss the etiologies of vertigo Compare and contrast peripheral and central vertigo Discuss the diagnostic studies used in the evaluation of vertigo Discuss clinical presentation and management of various causes of vertigo Presenting Problem 3 . Dizziness . Imbalance . Whirling . Unsteadiness . Twisting . Wooziness . Turning . Floating . Rotating . Lightheadedness . Tilting . Disorientation . Moving . Nearly blacked out . Rocking . Presyncope . Disequilibrium Vertigo 4 • Vertigo is a symptom • Defined as a sensation of motion, when there is no motion or exaggerated sense of movement May be associated with nystagmus and postural instability Differential Diagnosis for Vertigo 5 o Anxiety disorder o Ménière disease o Arrhythmia o Motion sickness/disembarkment o Benign paroxysmal positional vertigo syndrome (BPPV) o Multiple sclerosis o Cardiogenic (heart failure, tamponade, o Neurocardiogenic (neurally mediated aortic stenosis) syncope, postural tachycardia o Cerebellar degeneration, hemorrhage, syndrome) or tumor o Orthostatic hypotension o Cerebrovascular ischemia or stroke o Ototoxicity (medication) o Dehydration o Perilymphatic fistula o Eustachian tube dysfunction/middle o Parkinson disease ear effusion o Peripheral neuropathy o Hypoglycemia o Syphilis o Herpes zoster oticus o Vestibular migraine o Labyrinthine concussion o Vestibular neuritis o Medication-induced Etiologies of Vertigo 6 40% Peripheral vestibular dysfunction 10% Central brainstem vestibular dysfunction 15% Psychiatric disorder 25% Other (presyncope, disequilibrium) 10% Uncertain UpToDate Peripheral vs. Central causes 7 Peripheral causes Central causes Implies vestibular (otologic) dysfunction Implies central (brainstem) dysfunction Vestibular system: Central vestibular dysfunction: Vestibular apparatus in the Vestibular nuclei (superior, inner ear inferior, lateral, medial) Vestibular nerve Synapse with numerous Nucleus within medulla pathways (cerebellar, oculomotor, Connections to/from vestibular posterior column, proprioceptive, portions of cerebellum vestibulospinal) Pathophysiology of Vertigo 8 Illusion of motion (most commonly spinning) Asymmetry of the vestibular system Visual-vestibular conflict https://en.wikipedia.org/wiki/Semicircular_canals Clinical presentation: Peripheral vs. Central 9 Peripheral Central o Usually sudden, acute onset; o May be gradual and progressive may be severe o Rare to have associated ear o Associated ear symptoms symptoms Hearing loss, tinnitus o Nystagmus can occur in any o Nystagmus can be horizontal direction; can be dissociated in and/or torsional (rotary) the two eyes (often vertical, nonfatigable) o Neurologic symptoms are absent o Neurologic symptoms are present Diplopia, ataxia, dysarthria Clarify what the patient means by “dizziness” 10 Vertigo: sensation of abnormal movement; often spinning +/- sense of tumbling, falling forward/backward Disequilibrium: sense of imbalance (i.e. losing balance without sensation of movement); +/- gait difficulty Usually multifactorial . Explore contributing factors (e.g. visual acuity changes, peripheral neuropathy, degenerative joint disease) Lightheadedness: vague and nonspecific dizziness May be associated with psychiatric disorders (e.g. anxiety, depression, stress reaction); hyperventilation Presyncope: feeling of impending faint or LOC (no true syncope) Generally associated with cardiac etiology Evaluating the “Dizzy” Patient: Symptoms 11 o Hearing o Reduced acuity, hyperacusis, fluctuation, distortion, tinnitus o Gait/balance o Imbalance, falls, ataxia, retropulsion o Autonomic symptoms o Nausea, vomiting, diarrhea, diaphoresis, palpitations, presyncope/syncope o General symptoms o Headache, neck pain/stiffness, hydration status o Neurologic symptoms o Focal weakness/numbness/tingling, visual field reduction, mental status changes, photo/phonophobia, visual aura Cleveland Clinic Additional Pertinent History 12 o Past medical history . Head trauma, diabetes, hypertension, migraines, recent URI or illness . Psychiatric hx: anxiety, depression, or panic disorder . Medications, OTC o Social history . Occupational exposures . Alcohol use . Substance use . Stressors Drugs Associated with Vertigo 13 • Aspirin • Phosphodiesterase • Amiodarone inhibitors • Aminoglycosides • Sildenafil (Viagra) • ⍺-/β-blockers • Psychotropic agents Antipsychotics • Cocaine Antidepressants • Diuretics (e.g. furosemide) Anxiolytics • Ethanol Anticonvulsants Mood stabilizers • Insulin excess • Quinine • Muscle relaxants • Urologic medications • Nitrates Evaluating the “Dizzy” Patient: Signs 14 o Nystagmus: spontaneous, gaze-evoked, post-head-shake, positioning (Dix-Hallpike test) o Auditory: Weber and Rinne tests o Vestibular: Romberg, head-thrust test o Gait: base, stability, ataxia, arm-swing o Cervical spine: ROM (flexion/extension, rotation, lateral bend), tenderness/pain, spasm, weakness Cleveland Clinic Diagnostic Studies 15 o Dix-Hallpike maneuver . Most helpful for BPPV o Electronystagmography (ENG) or videonystagmography (VNG) . Assessment of vestibular function/ocular motility • Record eye movements in response to visual, positional or rotational stimuli o Caloric testing . Vestibular paresis • Impaired or absent thermally induced fast nystagmus indicates pathology in the labyrinth on the irrigated side o Audiometry . Sensorineural vs. conductive hearing loss o Imaging studies: MRI 16 http://www.newhealthadvisor.com/images/1HT04788/dix-hallpike.jpeg Caloric Testing 17 Used to test the vestibulo-ocular reflex http://www.aopo.org/wp-content/uploads/2014/12/BrainDeath-3.png Cold Caloric Testing: Normal Opposite 19 Warm o Mnemonic: 'COWS' can be used to Same remember the normal response Direction of the fast beating nystagmus response o Cold water: eyes deviate ipsilateral and nystagmus beats away to the Opposite side o Warm water: eyes deviate contralateral and nystagmus beats toward the Same side Benign Paroxysmal Positional Vertigo (BPPV) 20 o Most common cause of vertigo o Associated with otoconia in the semicircular canals o Transient (<1 minute) episodes of vertigo o Associated with changes in head position o No associated changes in hearing o Physical exam: normal Dix-Hallpike test can reproduce vertigo & nystagmus; symptoms fatigue with repetition BPPV: Management 21 o Patient education/reassurance . Condition is fatigable & self-limited o Particle repositioning maneuvers o Vestibular rehabilitation . Occupational therapy/positional exercises o Anti-vertigo meds +/- effective Vestibular Neuritis 22 o Aka vestibular neuronitis, acute peripheral vestibulopathy o Vestibular neuritis swelling of branch of vestibulocochlear nerve affecting balance o Labyrinthitis (neurolabyrinthitis) involves both branches affecting balance & hearing Vestibular Neuritis: Clinical Presentation 23 o Single attack of severe vertigo, associated with a viral URI . Nausea, vomiting, and gait instability o No associated tinnitus or hearing loss (pure) . If hearing loss present, called labyrinthitis o May see nystagmus o Positive head thrust test o No CNS deficits o Caloric testing will show vestibular paresis o Self-limited course . Symptomatic treatment (bed rest, vestibular suppressants, anti- emetics prn, prednisone taper over 10 days) Ménière Disease: Clinical Presentation 24 Triad: Episodic Vertigo Tinnitus Fluctuating hearing loss o Attacks come on suddenly . Last 20 minutes to 24 hours o Associated aural fullness, nausea & vomiting o Progressive hearing loss progresses; eventually irreversible o Lose low tones first, then high tones; speech discrimination is preserved until late o Attacks of vertigo stop when deafness is complete o Clinical diagnosis o Audiogram: sensorineural hearing loss Ménière Disease: Management 25 o Acute attack . Bed rest . Symptomatic care: Anti-emetics Vestibular suppressants o Prophylactic management . Low salt diets (1.5 gm/day) . Limit caffeine, nicotine, alcohol, MSG . Diuretics (e.g., HCTZ) Vestibular Suppressants* 26 o Anticholingerics * . Scopolamine (Trans-Derm Scop) o Antihistamines * . Meclizine (Bonine), dimenhydrinate (Dramamine) o Phenothiazines . Prochlorperazine (Compro), promethazine (Phenergan) o Benzodiazepines . Diazepam (Valium), lorazepam (Ativan), alprazolam (Xanax) * First line medications Ménière Disease: Refractory Management 27 o 90% of patients respond to medical therapy, but if refractory… o Surgical management: . Intratympanic corticosteroid injections . Endolymphatic sac decompression . Vestibular ablation o Transtympanic gentamicin o Vestibular nerve section o Surgical labyrinthectomy Circulation-related Causes of Vertigo 28 o Reduced cerebral perfusion . Low CO states: Heart failure Cardiac tamponade Aortic stenosis Arrhythmia Cleveland Clinic Subclavian Steal Syndrome 29 o Stenosis of subclavian artery near origin o See flow reversal in ipsilateral vertebral artery causing decreased cerebral perfusion o May see diplopia, vertigo, dysarthria, ataxia, syncope o Look for symptoms with arm exertion . Lightheadedness, syncope Lawrence, PF (2000). Essentials Of General Surgery, 5th Ed. o Look for difference in pulses in the upper extremities Circulation-related Causes of Vertigo 30 o Neurocardiogenic . Orthostatic hypotension . Postural tachycardia syndrome . Neurally mediated syncope Cleveland Clinic Orthostatic (Postural) Hypotension 31 Causes:
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