How to work up a dizzy patient

1. How to work up a dizzy patient Betty S. Tsai, MD Assistant Professor, Otology/Neurotology Department of Otorhinolaryngology October 24, 2013

2. Disclosures • I have no financial or commercial interests to disclose.

3. Objectives • Perform the initial workup of a dizzy patient including appropriate history and physical examination • List the various neurologic, otologic, general medical, and psychiatric causes of dizziness • Describe the appropriate testing options based on differential diagnoses • Utilize various management options including pharmacological, vestibular rehabilitation, and particle repositioning procedures.

4. Dizziness • Accounts for about 5% of primary care visits, 3% of emergency department visits • Prevalence increases with age • 1.8% in young adults • >30% among elderly

5. Maintaining balance

6. “I’m dizzy” differential diagnosis • Infection/Inflammation • Vestibular neuritis • Acute otitis media • Chronic otitis media • Labyrinthitis • Late-stage syphilis • Trauma • BPPV • Perilymphatic Fistula • Post-traumatic endolymphatichydrops • Congenital/hereditary abnormality of the inner ear • Tumors of brain/CPA • Acoustic neuroma • Cerebellar lesions • Iatrogenic • New medications • Change in the dosage of a medication • Ear Surgery • Ototoxicity • Degenerative problems • Age-related dizziness • Cerebellar atrophy • Metabolic or hormonal • Hypoglycemia • Hypothyroidism • Diabetes • Migraine-related vertigo • Immune system disease • Autoimmune inner ear disease • Multiple sclerosis • Heart and vascular disease • Arryhthmias • Cerebellar infarction (stroke) • Transient ischemic attacks (TIA) • Vertebrobasilar ischemia (VBI) • Postural hypotension • Psychophysiologic dizziness • Hyperventilation • Panic disorder or anxiety attacks • Motion sickness • Mal de Debarquement • Idiopathic disorders • Meniere’s disease

7. Classification of Dizziness • Drachman and Hart (1972) – 4 categories • In primary care - • Vertigo (38%) – false sense of motion, possibly spinning • otolaryngologic • Dysequilibrium (10%) - off-balance or wobbly • orthopedic, neurologic, or sensory • Presyncope (10%) - feeling of losing consciousness or blacking out • cardiac or vasomotor • Atypical dizziness (17%) • Psychiatric • Includes lightheadedness (10%) – vague symptoms, possibly feeling disconnected with the environment • About 25% cannot be classified as there are multiple causes vs. neurologic

9. Dizziness • Nonspecific term that describes a sensation of altered orientation in space • INSERT TABLE 2.2

10. History taking • Describe the dizziness without using the word “dizzy” • Spinning • Blurry vision or eyes jumping • Tendency to fall • Lightheadedness • Blacking out • Eyes jumping • Off-balance • Swimming sensation • Loss of consciousness • Headache/pressure • Nausea

11. Questions to ask • How long does it last? • How frequent? • Provoking/Aggravating factors? • Associated symptoms? • Otologic vs. non otologic

12. “How long does it last?” • Seconds to Minutes • BPPV, migraines, cervical vertigo, orthostatic hypotension, panic disorder, perilymphatic fistula • Minutes to Hours • Meniere’s disease, migraines, TIA, panic disorder • Hours to Days • Labyrinthitis, migraines, medication effect, multiple sclerosis, age-related dizziness, acoustic neuroma, stroke, vestibular neuronitis • Weeks • psychogenic • Constant • Intermittent • Triggers • Positional • Bright lights • Associated symptoms • Hearing loss • Tinnitus

13. Provoking factors?

14. Associated symptoms • Otologic • Tinnitus • Hearing loss • Aural fullness • Otalgia • Otorrhea • Hyperacusis • Diplacusis • Dysacusis • Psychiatric • Anxiety • Pallor, sweating, diarrhea • Depression • Restlessness, agitation • “Spacey”, “foggy” sensation • Irritability • Neurologic • Headaches • Weakness, paralysis, numbness, hemiparesis • Visual disturbances, photophobia, diplopia • Tremors • Epilepsy symptoms (taste/smell/visual distortions, hallucinations) • Dysphagia, dysphonia, dysarthria • Memory/concentration issues • Ataxia • Loss of consciousness • Cranial nerve palsies • Neck stiffness • Other • Chest pain • Palpitations • Shortness of breath • Temperature intolerance • Fevers, chills • Nausea, vomiting • Sinus congestion, rhinorrhea

15. Risk factors • Cardiovascular • Leads to CNS hypoperfusion (lightheadedness, giddiness, and syncope) • Structural heart disease vs. arryhthmias • Peripheral vascular disease • Vasomotor tone abnormalities • Diffuse atherosclerotic disease • Diabetes vs. stroke vs. tobacco use • Autoimmune disease • Aging • Ear Disease • Head trauma • Medications • Neurologic • Cerebellar injury (ataxia, imbalance) • TIA • Wallenberg syndrome (lateral medullary syndrome) • Cerebellar infarction • Vertebrobasilar insufficiency/ ischemia • Multiple sclerosis • Seizure disorder • Arnold-Chiari malformation • Tumors • Migraines (15% of adult population) • Psychogenic

16. Medication effects • Be sure to include detailed medication history. • Ask about alcohol, nicotine, and caffeine intake

17. Medications commonly associated with dizziness from orthostatic hypotension

18. Physical Exam • Goal to reproduce patient’s dizziness in the office • Orthostatic hypotension • Measurement of blood pressure while supine and one minute after patient stands • Systolic decrease >20mmHg • Diastolic decrease >10mmHg • Pulse increase >30 bpm

19. Physical Exam • Cranial nerves, visual fields, nystagmus • Tuning fork exam • Cerebellar function (Finger-to-nose, heel-to-shin) • Romberg • Gait • Head shake (Doll’s head phenomenon) – tests vestibulocular reflex • Fukuda • Dix-Hallpike

20. Nystagmus • What is it? • Involuntary rapid eye movement resulting from vestibular, optokinetic or pursuit system dysfunction • Spontaneous or evoked • Description • Direction (determined by fast component) • Plane (horizontal, rotary, or vertical) • Intensity (primary, secondary, or tertiary)

21. Nystagmus • Unilateral peripheral vestibular lesion • Eyes to drift toward side of lesion (SLOW phase), with subsequent FAST, corrective phase directed contralaterally • Direction of nystagmus is in direction of *FAST* gaze • Lesion is opposite direction of fast gaze • Vertical nystagmus – NEVER normal • Downbeat – craniocervical junction abnormalities • Upbeat – lesions in medulla or cerebellum • Rotary (torsional) nystagmus – lesions in superior and posterior SCC on same size or lesions in lateral medulla Look for GAZE SUPPRESSION

22. Tuning Forks • Weber Test • the signal localizes to the better hearing ear or the ear with the greatest conductive deficit. • Lateralization to the poorer-hearing ear indicates an element of conductive impairment in that ear. • Lateralization to the better-hearing ear suggests that the problem in the opposite ear is sensorineural. Photos courtesy of audiologyonline.com

23. Tuning Forks • Rinne Test • comparison of bone conduction vs air conduction (20-30 db “reverses” the responses) • Air conduction > bone conduction as it is a more efficient means of sound transmission. (positive Rinne) • Bone conduction > air conduction when there is a deficit in the conduction mechanism (negative Rinne)

24. Dix-Hallpike maneuver

25. Central vs. Peripheral Vertigo

27. Audiologic testing

28. Hearing Test • Pure Tone Audiometry

29. Electronystagmography (ENG) • What is it? • Battery of tests based on the vestibulo-ocular reflex (compensatory eye movements elicited by motion or labyrinthine stimulation) • How is it done? • Labyrinth is stimulated and nystagmus is recorded

30. Electronystagmography • Traditional ENG: electrodes record differences in electrical charge between the cornea and retina • Videonystagmography (VNG): video cameras directly record eye movement

31. Electronystagmography • Measures • Nystagmus • Positional testing (eg. Dix-Hallpike) • Bithermal caloric testing • Fistula test • Saccadic and pursuit systems • Optokinetic system

32. Rotational (rotary) chair • Objective • Test integrated function of both ears • How it’s done • Chair oscillated from side to side, infrared camera monitors eye movement • Measures • Phase, gain, symmetry • Uses • Monitor changes in function over time, identify residual function in patients who had no caloric testing responses • Can distinguish between peripheral versus central causes when used in conjunction with an ENG

33. Computerized Dynamic Posturography (CDP) • used to objectively quantify and differentiate among possible sensory, motor, and central adaptive impairments to balance • Used in conjunctionwith physical therapy • Can be used to diagnose malingering or conversion disorder

34. CDP

35. Some common dizzy diagnoses • BPPV • Meniere’s disease • Vestibular migraines

36. Benign paroxysmal positional vertigo • Most common cause of vertigo • Presents with sudden, brief sensation of spinning with specific head movements • Related to a fluid disturbance within the semicircular canals of the inner ear either from cupulolithiasis or canalithiasis • Most common – posterior canal

37. Benign paroxysmal positional vertigo • Diagnosis with Dix-Hallpike maneuver • Latency of onset, usually 5-20 seconds • Short duration, typically < 30 second • Reversibility • Fatigability • Direction

39. Treatment of BPPV • Other maneuvers • Semont • Brandt-Daroff

40. Other resources for BPPV • Clinical guidelines (http://www.entnet.org/practice/upload/bppv-guideline-final-journal.pdf)

41. Meniere’s Disease • Characterized by • Fluctuating hearing loss • Tinnitus • Aural fullness • Vertigo • Typical episode from 30 minutes to 2 hours • Vertigo will typically resolve but may leave a dysequilibrium for several days

42. Meniere’s Disease • Thought to be due to endolymphatichydrops • Progressive dilation results in intralabyrinthine membrane rupture leading to vertiginous spells and hearing loss • Burns out with time

43. Diagnosis of Meniere’s Disease • Typically a normal exam except when patient is having attack • Horizontal-rotary beating nystagmus with fast phase toward unaffected ear • Usually low-frequency SNHL • Fluctuating progressive hearing loss

44. Diagnosis of Meniere’s Disease • Must also workup to exclude other causes as differential diagnosis is large • Trauma: acoustic trauma, temporal bone fracture, surgical trauma to the inner ear • Autoimmune: AIED, Cogan’s disease, lupus • Infectious: chronic OM, syphilis, labyrinthitis • Metabolic: otosclerosis, Paget’s disease, hyperlipidemia • Neoplastic: acoustic neuroma, leukemia • Congenital: Mondini’s, large vestibular aqueduct, jugular bulb diverticulum, SSCD • Endocrine: thyroid disease, diabetes • Idiopathic: PLF, Meniere’s

45. Treatment of Meniere’s Disease • Diet changes • Low sodium • Eliminate caffeine • Medical therapy • Diuretic therapy • PRN use of vestibular suppressant • Conservative surgical therapy • Endolymphatic sac decompression • Intratympanic steroids • Ablative surgical therapy • Intratympanic aminoglycosides • Labyrinthectomy • Vestibular nerve section

46. Vestibular migraines • Vertigo occurs in about 25% of migraine patients • Can occur as an aura preceding the headache or in place of the headache • “BPPV” type symptoms in children are migraines • Atypical Meniere’s is likely migraine (81% of pts) • Due to vasospasm of the labyrinthine artery or its branches and can potentially lead to hearing loss as well • Diagnosis of exclusion and by detailed history

47. Treatment of migraines • Vestibular suppressants for acute symptoms • Dietary modifications (avoidance of red wine, cheese, MSG, etc) • Stress management • Preventative medication • Beta-blocking agents • Calcium channel blockers • Tricyclic antidepressants • Serotonergic agents (SSRIs) • Gabapentin or Neurontin • Clonazepam or Klonapin • Acetazolamide or Diamox • Sodium valproate or Depakote • Topiramate or Topamax • Oxycarbazapine or Trileptal

48. Treatment options for dysequilibrium, vertigo and other symptoms • Treat the underlying disorder • Vestibular suppressants • Avoid in dysequilibrium of aging • Can interfere with compensation • Steroids • Antiemetics • Vestibular rehabilitation

49. Vestibular suppressants • A drug that lessens the symptoms of vertigo and nausea once they have occurred • They do NOT prevent vertigo attacks • Chronic use can interfere with compensation and some may create dependence • Diminishes the excitability of neurons in the vestibular nucleus

50. Vestibular rehabilitation • Treats dysequilibrium, lightheadedness, blurred vision with movement, postural instability, gait disturbances, and loss of balance • Based on adaptation of the vestibular system • Vestibular adaptation • Progressive exercises designed to increase gain of vestibular system by inducing retinal slip • Substitution • Exercises that enhance the substitution of other strategies to replace the lost function (use of somatosensory or visual cues) • Habituation • Exercises that reduce movement of position-induced symptoms • Must systematically provoke the symptom