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
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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), cholesteatoma, 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.