A LOGICAL APPROACH TO THE DIZZY PATIENT

1. A LOGICAL APPROACH TO THE DIZZY PATIENT Dizziness and balance disorders center www.susqneuro.com

2. Conditions • Vertigo • BPPV • Labyrinthitis • Other Conditions: MS, migraine, Meniere’s etc • Non-Vertigo • Gait Dysfunction (countless neurological oto, ortho conditions • Elderly: • PD, frontal lobe disease, neuropathy, multi-deficit, stroke • Post-Injury • Psych

3. A philosopher in the vestibule • We move • An unmoving earth is our base of operation • If our base moves we have no hope of orientation: hopelessly lost. • Discomfort comes from shift in orientation. • Need an absolute set of coordinates. • Problem of shifting base. • Developed from lateral line system in fish • Which way is down??

5. Oscillopsia • Bilateral vestibular dysfunction • Shows function of vestibular system • When the world moves with your head it drives you crazy • We need a solid base of operations • Result: “Visual Dependence” • Foam Pad Romberg positive.

6. VESTIBULO-OCULAR REFLEX (VOR) KEEP YOUR EYES ON THE PRIZE Our world seems not to move though We Do

8. Dizziness- Logical Approach -strategy for lecture • Go into some basic principles • applications and testing • get into a few prominent diagnoses

9. DIZZINESS • EIGHT MILLION PHYSICIAN VISITS/YR • AVERAGE: 5 VISITS WITHOUT RESOLUTION OF PROBLEM • Dizziness affects 10% of adults over 40 • LOSS OF LIVLIHOOD, FALLS INJURIES • SYSTEMATIC APPROACH

10. DIZZINESS • VERTIGO • LIGHT-HEADEDNESS • DYSEQUALIBRIUM • GAIT DYSFUNCTION • NEAR SYNCOPE • ANXIETY

11. Dizziness: Pointed questions • Vertigo or Not? • Standing or Seated? • Isolated or ass’d with Other symptoms? • Constant or paroxysmal? • Caused by positional change?

12. DIZZINESS: • A MULTIDIMENSIONAL APPROACH • AREAS OF EXPERTISE • NEUROLOGIST • OTOLOGIST • REHAB SPECIALIST

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14. COWS: Fast Phase of Nystagmus • Cold – Opposite • Warm – Same • Each vestibule tonically pushes eyes to opposite side • Cold inhibits, warm stimulates and ear • Fast phase of nystagmus: cortical correction

15. Nystagmus

17. Pitch, Roll, Yaw

18. MODULAR VIEW OF VESTIBULAR SYSTEM

19. Vertigo or not? =Nystagmus or no nystagmus

20. Inner ear teleology • Utricle and Saccule – Gravity receptors • Which way is down?? • Semicircular Canals - Planar angular accelerometers • What’s moving what is still?? • Which Way is down??

21. Why Vertigo?? conditions • Converting accelerometer (semi-circular canals) into gravitometers – BPPV • Stimulating accelerometer: Meniere’s, labyrinthitis • “central” mechanism: hallucination in CNS – much less potent • Something stimulates accelerometer (SCC)

23. Vertigo DDx BPPV Meniere’s Vestibular neuritis Bilateral vestibular Loss Post-traumatic vertigo (labyrinthine concussion) Perilymph fistula Migraine and epilepsy Cerebro-vascular Disease

24. Dizziness Battery Orthostatics and both arms Hallpike Fukada Head Thrust Head Shake Romberg (conventional, tandem, foam pad) Fistula test

25. Benign Paroxysmal Positional Vertigo Recurrent One ear down position Positive Hallpike Transitory positional vertigo “Vertigo induced by postional change” Unique

26. BPPV History • Variable history: Many patients complain of waxing and waning dizziness, not always vertiginous and aren’t aware of episodic nature • Classic: In bed when turn, looking up, or down • Tie shoelace or put clothes on line • Remits and exacerbates

27. BPPV predispositions • Age • Post vestibular neuritis • Post trauma • Ear infections

28. BPPV • Canalithiasis: By far majority. Set up eddy currents in fluid filled canal • Cupulolithiasis: otoliths adherent to walls

29. Posterior nystagmus are delayed by approximately 15 seconds (latency), peak in 20-30 seconds, and then decay, with complete resolution of symptoms. • Symptoms and reversed nystagmus may recur when the patient is brought to a sitting position.Nystagmus fatigues on repeated trials. Peripheral nystagmus is latent, paroxysmal, geotropic, reversible, and fatigable. • Horizontal canal BPPV nystagmus is purely horizontal and asymmetric, with its stronger component beating toward the diseased canal. • Anterior canal nystagmus is rotary, with its vertical component beating downward. The vertical component of benign paroxysmal positioning nystagmus (BPPN) is best observed by asking the patient to move the eyes away from the down-most (tested) ear.

30. BPPV Variants – Eye Movements • Posterior SCC: Canalith or cupulo • Torsional to side down and upbeat • Horizontal SCC: Canalith • Horizontal geotropic • Horizontal SCC: Cupulolithiasis • Horizontal ageotropic • Anterior SCC: Canalith or Cupulo: • Downbeat and torsional to side down

31. BPPV

32. Logroll maneuver for horiz canal

33. CANALITH REPOSITIONING (EPLEY)

35. Semont Maneuver

36. Brandt Daroff

37. Paroxysmal psychological Vertigo Form of Panic Attack Sensory overload “Supermarket Syndrome” Complication of untreated BPPV + Anxiety Computation of position and movement Worst in Aisles and small spaces: comparator of near and distant movement: Car +claustophobia?? Your life depends on it: Therefore intense fear “Phobic positional vertigo”

38. Vestibular Neuritis • Sudden Vertigo and vomiting • Emergency room • Extreme motion sensitivity: Pts lay like a rock. • Kinetophobia • Viral or ischemic • Herpes simplex and other viruses. Bell’s palsy of the vestib n. • Rarely recurs • Look for other signs that may relate to VB system or posterior fossa.

39. Vestibular neuritis, neuronitis or labyrinthitis • No loss of hearing indicates inflammation of vestibular nerve or scarpa’s ganglion (neuronitis) • Inferior vestib nerve goes to posterior canal • Superior nerve goes to utricle, sup, lat canal • Herpes virus? • Hearing loss: may be labyrinthitis • Any pain or inflammation: ? Bacterial or other treatable infection • Can’t distinguish 100% from brainstem stroke

40. Vestibular Neuritis: Findings • Spontaneous horizontal or horizonto-rotatory nystagmus • You may have to block fixation to see it. • Fast phase away from the offending ear • Veer to slow phase • ENG suppressed on offending side • 5% or so cases may be recurrent • BPPV is frequent sequel

41. Meniere’s Severe vertigo and vomiting Fluctuating Hearing Loss Fullness unilateral Tinnitus Endolymphatic Hydrops

42. Meniere’s • Vertigo + Vomiting last hours • Few disorders are paroxysmal in just this way • Patients need not have entire tetrad • Most common: Severe vertigo, vomiting and tinnitus • A number of “Meniere-like” syndromes • Previous insults to inner ear

43. Meniere’s treatment • Avoid Salt and Caffeine • Diuretic • Surgeries • Gentamycin injection • Vestibular nerve section • Hearing sparing operations

44. Perilymph fistula • Dizziness with change in pressure • Nose-blowing dizziness • Sound sensitivity “Tullio Phenomenon” • Dizziness with exertion • Sensori-neural loss on audiogram

45. Perilymph Fistula • Breach of Round window • Superior canal dehiscence • Cholesteatoma • Trauma • Post-surgical esp fenestration for otosclerosis • Scuba diving

46. Perilymph Fistula: breach of round window. From Tim Hain

47. Fistula • Strain against closed glottis • Upbeat nystagmus CW for right ear CCW for left ear • Pull in thru closed nostrils • Downbeat nystagmus CW for left ear, CCW for right ear • OR do fistula test with bulb • OR Test for Tullio phenonenon

48. Cholesteatoma

49. cholesteatoma • Hearing loss and loss of balance or vertigo • Chronic infection or congenital • Basically tumor in middle ear and petrous bone