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Nbenign Paroxysmal Positional Vertigo (BPPV) -- Bed Spins Bed Spins Ear Ear SStrtructucturesures of im importportanceance OtoloOtologigic Dizzinc Dizzinesesss (Dizz(Dizzineinessss ffroromm Ear)Ear) TimTimotothyhy C.C. HHaiain,n, MDMD NorthwesternNorthwestern U Unniivversersiittyy,, ChiChicagocago tt--haihainn@[email protected] TThehe earear i iss an inertialan inertial navnaviiggatatiionon VestibulVestibular Refar Refllexesexes devdeviicece nn SemSemiicicircurcullarar CanCanalalss nnVOR:VOR: VestiVestibbuullo-o- are are rate sensensors.sors. ocuocullar reflar reflexex nn OtolOtoliiths (uths (utritriclclee anandd nnVSR:VSR: VestiVestibbuullospinospinaall saccusacculle)e) are lliinnearear reflreflexex accelacceleromerometerseters nn BiBillateralateral sysymmmmetryetry mmeaneanss reduredunndandantt desidesigngn.. PPositionalositional Vertig Vertigoo OtolOtologogiicc (Ear(Ear)) DiDizzinesszziness TThehe mmostost commcommonon sysyndromendrome nn BPBPPPVV (b(benignenign paro paroxyxyssmmalal nn popossititionionalal ververtitigogo)) ----aboabouutt BeBeninigngn PParoxaroxyysmsmalal 5500%% oof otologtologicic,of 20%, 20% alalll Otologic Dizziness nn MeMeniere’niere’ss didisseaseasee ----aboaboutut Fistula SCD 2200%% Bilateral Other PPoositiositionalnal VertVertigigoo nn VesVestitibubulalarr neuneuritiritiss and relarelatetedd concondidititiononss (15(15%)%) Neuritis BPPV (BP(BPPPV)V) ----bed spbed spininss nn BiBilalateteralral vesvestitibubulalarr loslosss nn Menieres OrthostatiOrthostaticc hyhypotenpotensisionon (di(dizzyzzy uupripright)ght) (ab(abouout 1%)t 1%) nn nn SCD SCD and FisFistulatula (r(rare buare butt CenCentraltral posiposititiononalal nnyystagmstagmuuss (di(dizzyzzy eveveryerywhere)where) wwoorth knorth knowwinging)) nnLow Low CSFCSF pressu pressure syre synndromdromee (di(dizzyzzy uupripright)ght) 1 BeniBeniggnn PParoxyaroxysmalsmal PPositionalositional PPositionalositional Vertig Vertigoo VertigVertigoo (BP(BPPPV)V) DiDixx--HalHalllpikpikee ManeuvManeuverer 61 Y/O man slipped on wet floor. LOC for 20 minutes. In ER, unable to sit up because of dizziness Hallpike Maneuver: Positive BeniBeniggnn PParoxyaroxysmalsmal PPositionalositional BPPV Mechanism: Utricular debris migrates to VertigVertigoo (BP(BPPPV)V) posterior canal nn 2020%% ofof alalll vevertigrtigoo nn BrieBrieff anandd stronstrongg nn PrProvovookeked bd byy chchanangege ofof heheadad ppoositsitioionn nn DefDefininititivivelyely didiagagnonosedsed byby HHalallpiklpikee tetestst BPBPPPVV trtreateatmmentent UniUnillatateraerall VestibulVestibularar nn MeMedidicatcatioionn (e.g(e.g.. anantitivevert)rt) –– nnVestiVestibbuulalar Neuritr Neuritis/is/LLababyyrinrintthitihitiss(com(commmoon)n) mmininoror benefbenefitit nnMeMeniniere’s diere’s diseasesease (un(unuusuasual,l, 1/21/2000000 ––MayMay avavoioidd vvomomiitintingg bbyy pretreatipretreatinngg pprevarevalelennce)ce) nn nn ExExcelcellelentnt resprespononse tse to PTo PT AAcocoustusticic NeuromNeuromaa (very(very rare)rare) nn SurgeSurgeryry ––cancanalal plugpluggginingg ifif nnVestiVestibbuulalar pr paroxaroxyysmsmiaia(no(not sure ht howow reharehabb ffaiailsls (nee(needd mmoorere cocommmmonon)) reharehabb afafteterr plugplug).). RaRarelyrely ddonone.e. 2 Vestibular Spontaneous Nystagmus VestibulVestibular Neurar Neuriitis:tis: CaseCase seen with video Frenzel Goggles 56 y/o woman began to become dizzy after lunch. Dizziness increased over hours, and consisted of a spinning “merri-go-round” sensation, combined with unsteadiness. Vomiting ensued 2 hours later, and she was brought by family members to the ER. Vestibular Spontaneous Nystagmus recorded on ENG AAsideside :: howhow to eto examixaminene forfor S SNN (Electronystagmography) nnFFrenrenzelzel GGoggloggleses (b(best)est) nnOphthalOphthalmmoscopeoscope (good ––bbuutt bbackwards)ackwards) nnGGazeaze--evevoked noked nyystagmstagmuuss (pretty(pretty good)good) nnSheet Sheet of whiof white paper (nte (neat)eat) VestibulVestibular Neurar Neuriitistis ----rxrx Meniere’s DiMeniere’s Diseasseasee nn DisDisturbturbanceance ofof un unknowknownn causcausee (V(Viraliral ?? Vas Vascular)cular) nn invinvolvolvinging vesvestitibubulalarr nernerveve PrProospsperer MeMennieierere oror gangangglilionon –– FFlluuctuctuatinatingg hearihearinngg nn DisDisabiliabilityty typtypicicalallyly lalasststs 2 wweekeekss.. –– EpiEpisodisodic Vertic Vertigogo nn SteroidsSteroids if ddxxfirsfirstt 2 days2 days –– FFlluuctuctuatinatingg (roari(roarinng)g) TTiinnnniittuuss nn SySymmpptomtomataticic Rx –– AAuuralral FFuulllnlnessess (m(mecleclizizine,ine, phphenergenerganan,, benbenzodizodiazeazepinpine)e) nnAAbbououtt 11/20/200000 ppeoeopplele inin ppopuopulalatitionon nn ReRehabhab if sstitillll ssymymptoptommataticic nn afteafterr 2 m2 mononthsths.. ChChronronicic cocondndititioionn ––lalasts lifsts lifetetimeime nn ThesThesee patipatientsents can sstitillll get BPBPPPVV !! 3 EtiolEtiologogyy of Mof Meniere’s (Dogeniere’s (Dogmma)a) Meniere’s diMeniere’s diseassease –e – sysymmptomsptoms nn DilaDilatitionon and episepisodicodic ruruppture ofture of i innnner eaer earr mmemembrbranesanes (En(Endolymdolymphphataticic HyHydropdropss)) nnPrProoggressivressive he hearinearingg lolossss ----somsometetimimeses gogo nn AsAs endolym endolymphph vo volumlumee and ppresresssuurere increasincreaseses,, the dedeafaf utricular/utricular/ssaccaccuulalarr and ReReisisssnerner’’ss m memembrbranesanes ruruptupture,re, relereleasasinging popotatassssiumium--rrichich endolymendolymphph i intonto t thehe perperililymymphph nnEpisodEpisodicic v vertiertiggoo ––ooutut ooff cocommmmissiissioonn fforor causcausinging cochcochlelear/ar/vvesestitibubulalarr pparalaralysysisis sevseveraleral dadayyss nnAAtataxixiaa ––ggraduradualallyly inincreases ovcreases overer yyearsears nnVisuaVisuall sensensitsitivivityityàà ViVisualsual SSensitivensitiviittyy iis comms commonon OtolOtoliithicthic CriCrisesses of TTumumarkarkiinn nn SenSensorysory iinntegratitegratioonn nnDrDropop atattatackckss didisordersorder ––uupweipweightght nnGGoo ffromrom uupprigrightht toto vviisisionon,, downdownweiweightght onon f flolooror inin ffractiractionon eveveryerythithinngg elelsese ofof secoseconndd nn GGroceryrocery store, nnNo No LLOCOC OmOmnniimmax,ax, TTarget, etcarget, etc nnVerVeryy ddananggerouerouss nn TTyypipicalcal of diof disorderssorders nn wiwith ith inntermtermiittettenntt DestrucDestructitivvee vvestiestibbuullarar probprobllememss treattreatmmenentt is bestbest TTreareatmentstments of Mof Menieresenieres AAcoustcoustiicc NeuromNeuromaa nn MeMedidicalcal mmananagagememenentt –– ––UUsusualalllyy iinneffectieffectivvee nn BaBadd reh rehab canab canddididatatee wwhihilele ffluluctctuuatinatingg nn SurgeSurgeryry –– Low Low dose gengentamtamiicicinn treatmtreatmenentt workworks ns niicelcelyy ––HiHighgh dose gendose gentamtamiicincin treatmtreatmenentt (ov(overkierkillll)) nn ReRehhab useab useffulul ppoostst dedestrucstructitivvee treattreatmmenentt Hain TC, Ostrowski T. Unsteady Influence. Menieres disease. Advances for directors in rehabilitation October 2007, 51-51 4 AAcoustcoustiicc NeuromNeuromaa TTreareatmenttment of Aof Acoustcoustiicc NeuromNeuromaa nn CauCausese of uof unnililateralateral nnWWatatchchffulul wwaiaititingng (ab(abouout 2t 255%)%) vvestiestibbuullarar llossoss nnOpOperatierativeve rem remoovavall (ab(abououtt 5500%)%) ––lolosinsingg nn Rare Rare caucausese of grogrounundd uunniillateralateral llossoss nn nn GGeneneraleralllyy alalso deaf onso on GGamammmaa KKniniffee (ab(aboouut 2t 25%)5%) ––ggaiaininingng ononee sisidede grogrounund bd becaecauseuse efefffectectiiveve anandd nnoonininvnvasiasivvee nn SlSlowlowlyy progressiprogressivvee –– nnGGooood rd rehehab canab canddididatatee lliittlttlee or nor noo vvertiertigogo VVesestibutibularlar PParoaroxxyysmiasmia (A(AKAKA ClCliininicalcal DiDiagagnosisnosis of Mof MVCVC micrmicroovvasascucularlar cocompmpresressionsion)) nnQuiQuickck spin spinss nn IIrrrrititatatioion ofn of vevestistibulabularr nenerverve nnMaMayy hhavavee nnyystastaggmusmus oonn hhyypperveerventntilationilation nn QuicQuickk spspinins,s, titiltlts,s, ddipsips nnReRespspoonsense t too anantiticoconvnvuulsantlsant nn MoMotitioonn sensensitsitivivityity nnNo No reharehabb pot potenentitialal nn MaMayy ffololloloww 88thth nnerveerve surgsurgeryery,, GGamammmaa knknififee treattreatmmenent,t, acoacoustusticic neneuuromromaa nn WWastastebaskeebasket syt synndrodromeme inin somsomee casecasess ?? BiBillatateraerall VestibulVestibularar LLossoss SSYMPYMPTTOMSOMS OFOF BILBILAATTERALERAL VEVESSTTIBULIBULARAR LLOSOSSS A stewardess developed a toe-nail infection. She ll OSCIOSCILLOPSILLOPSIAA underwent course of gentamicin and vancomycin. 12 days after starting therapy she developed imbalance. 21 days after starting, she was “staggering like a drunk person”. Meclizine was prescribed. Gentamicin was stopped on day 29. One year later, the patient had persistent imbalance, visual symptoms, and had not returned to work. Hearing is normal. She unsuccessfully sued her doctor for malpractice. 5 SSYMPYMPTTOMSOMS OFOF BILBILAATTERALERAL BiBillatateraerall VestibulVestibularar LLossoss VEVESSTTIBULIBULARAR LLOSOSSS Causes:Causes: nnOtotoxiOtotoxicicityty !! ll AATATAXIAXIA nn Congenital BiBillateralateral formformss of Solvent 2% uunniillateralateral didisorderssorders (e.g. 5% Unknown bbiillateralateral vvestiestibb nneueurirititis)s) 26% nn ConCongengeniitaltal (e.g. Gentamicin MonMondidinnii mmalalformformatiatioonn)) V Neuritis 58% 9% nniididiopathiopathicc N=43, NMH 1990-1998 DyDynaminamicc IllIllegegiiblblee ‘‘E’E’ tetestst DIADIAGNGNOSOSIISS ISIS
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