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  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 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 (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  , 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, , 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/, 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. o Imaging studies: MRI 16

http://www.newhealthadvisor.com/images/1HT04788/dix-hallpike.jpeg Caloric Testing

17

 Used to test the vestibulo-ocular reflex

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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:  Autonomic and peripheral neuropathies  Diabetic polyneuropathy  Parkinson Disease  Volume depletion  Aging/debilitation  Medications (e.g. anti-hypertensives, tricyclic antidepressants)

 Sxs can be immediate (common) or delayed  Delayed: a few moments to several min after standing is more worrisome  Malnutrition, anemia, blood loss, and adrenal insufficiency all worsen orthostatic hypotension Orthostatic Hypotension: Management 32 oAvoid volume depletion oMedication adjustment oBehavior modification . Slow changes in position . Dorsiflexion of the feet or handgrip exercises prior to standing . Jobst stockings Presyncope/Syncope Prodrome 33 o Uneasiness or apprehension o Lightheadedness Consistent o Facial pallor with vasovagal o Diaphoresis syncope o Nausea o Visual blurring o Chest pain or SOB o HA or focal neurologic symptoms Perilymphatic Fistula 34

 Abnormal connection between the perilymph and the middle ear  Canal through which inner ear fluid may leak into middle ear (via round or oval window)  Causes:  Barotrauma: trauma, airplane descent, scuba diving, weight lifting, vigorous coughing  Erosion  Congenital  Hearing loss, tinnitus, +/- vertigo  May confirm presence with fistula test with pneumatic otoscopy  Abnormal to see eye movements with changes in pressure; may see nystagmus  Management: bedrest, hydration, symptomatic, surgery Labyrinthine Concussion

35 Following head trauma

Vertigo  Nausea, vomiting, imbalance Hemotympanum Sensorineural hearing loss

Symptoms are maximal at onset and improve over days to months Semicircular Canal Dehiscence Syndrome

36 o Thin/absent bone overlying superior aspect of superior semicircular canal bone, pressure transmitted to inner ear o Vertigo provoked by coughing, sneezing, Valsalva . Tullio phenomenon: loud sound induces vertigo o CT of temporal bone o Surgical repair Vestibular Migraine

37 o Current or past history of migraine o Vestibular symptoms last minutes to hours . Vertigo +/- headache . Phonophobia, tinnitus, aural fullness, subjective hearing impairment o Clinical diagnosis o Treatments for migraine and/or vertigo . Avoid triggers . Acute attacks: vestibular suppressants . Prophylactic: B-blockers, TCAs, topiramate Brainstem/Cerebellar Ischemia

38 Continuous vertigo/dizziness

Normal head impulse test (head thrust) on both sides Direction-changing nystagmus Skew deviation Red Flags in Vertigo 39

. Neurologic deficit . Ipsilateral hearing loss . Gait abnormality . Direction changing nystagmus

5MinuteConsult Symptoms that help distinguish between common causes of Vertigo 40

Aural fullness: acoustic neuroma, Ménière disease Ear/mastoid pain: acoustic neuroma, acute middle ear disease (AOM, herpes zoster oticus) Facial weakness: acoustic neuroma, herpes zoster oticus Focal neurologic findings: cerebellar tumor, CVD, MS Headache: acoustic neuroma, migraine Hearing loss: Ménière disease, acoustic neuroma, otosclerosis, labyrinthitis, herpes zoster oticus, transient ischemic attack (TIA), , perilymphatic fistula Imbalance: acute vestibular neuritis (moderate), cerebellar tumor (severe) Phonophobia/photophobia: migraine Rash: herpes zoster oticus Tinnitus: acute labyrinthitis, acoustic neuroma, Ménière disease

5MinuteConsult Provoking factors that help distinguish different causes of Vertigo 41 Changes in head position: acute labyrinthitis, BPPV, cerebellar tumor, MS, perilymphatic fistula Spontaneous episodes/no clear provoking factors: vestibular neuritis, TIA/CVA, Ménière disease, migraine, MS Recent URI: vestibular neuritis Stress: psychogenic causes, migraine Immunosuppression: herpes zoster oticus Changes in ear pressure, trauma, loud noises: perilymphatic fistula

5MinuteConsult Summary: Vertigo & Auditory Symptoms

42

Duration of Typical Auditory Symptoms Auditory Symptoms Vertiginous Episodes Present Absent Seconds Perilymphatic fistula Positioning vertigo (cupulolithiasis), vertebrobasilar insufficiency, migraine- associated vertigo Hours Endolymphatic hydrops Migraine-associated (Ménière syndrome, vertigo syphilis) Days Labyrinthitis, labyrinthine Vestibular neuronitis, concussion, autoimmune migraine-associated inner ear disease vertigo Months Acoustic neuroma, Multiple sclerosis, ototoxicity cerebellar degeneration

Current Medical Diagnosis & Treatment 2018, Table 8-3 43

https://5minuteconsult-com.mwu.idm.oclc.org/data/GbosContainer/33/clin_algo_dizziness_print.jpeg 44

https://5minuteconsult-com.mwu.idm.oclc.org/data/GbosContainer/33/clin_algo_syncope_print.jpeg References 45 . Papadakis, MA, McPhee SJ, Rabow, MW (2018). Current Medical Diagnosis & Treatment, 57th Ed., McGraw-Hill Education. . 5MinuteConsult . UpToDate . Lawrence, PF (2013). Essentials of General Surgery, 5th Ed., Lippincott, Williams & Wilkens: Philadelphia. . Bader R, Sartini S (2016) Risk Stratification of Syncope in the Emergency Department, Clinical Decision Rules or Clinical Judgment?. Emergency Med 6:313. doi:10.4172/2165-7548.1000313 . Dizziness. Cleveland Clinic Center for Continuing Education.http://www.clevelandclinicmeded.com/medicalpubs/disease management/neurology/dizziness/. Accessed October 2, 2019. . Approach to the Patient with Dizziness. UpToDate. https://www- uptodate-com.mwu.idm.oclc.org/contents/approach-to-the-patient-with- dizziness?search=dizziness&source=search_result&selectedTitle=1~150 &usage_type=default&display_rank=1. Accessed October 2, 2019.