As the World Turns: Vertigo in the Emergency Department

1. As the World Turns: Vertigo in the Emergency Department

2. Andrew K. Chang, MD, FACEP Department of Emergency Medicine Albert Einstein College of Medicine Montefiore Medical Center

3. Teaching points to be addressed • What differentiates peripheral from central vertigo? • What differentiates benign paroxysmal positional vertigo (BPPV) from other causes of peripheral vertigo, such as labyrinthitis and vestibular neuritis? • What is the treatment of choice for BPPV?

4. Case Presentation • 67 year-old man • Rolled over in bed • After a few seconds delay, he developed nausea and felt as if the room was spinning • Symptoms resolved within 30 seconds • Room spun in the opposite direction when he rolled back to his original position

5. Past Medical History & Social History • Hypertension, on atenolol • No surgeries • Nonsmoker, occasional alcohol

6. Physical Exam • VS: 37.2, 145/85, 90, 18, sat 98% • Alert, anxious • Head, eyes, ears, neck exam: normal • Cardiac exam: normal • Rest of exam: normal • Neurologic exam (detailed): normal

7. Your Differential Diagnosis?

8. Differential Diagnosis • Peripheral Vertigo • Benign paroxysmal positional vertigo (BPPV) • Vestibular neuritis • Labyrinthitis • Meniere’s disease • Central Vertigo • Stroke/Vertebrobasilar insufficiency

9. ED Course • A diagnostic Hallpike test was performed • Torsional nystagmus and reproduction of symptoms in the right head-hanging position • Asymptomatic in the left head-hanging position

10. Hallpike Test

11. Hallpike Video Clip

12. Nystagmus video clip

13. ED course • The Epley maneuver was performed at the patient’s bedside with complete resolution of symptoms • No imaging or lab tests done • No intravenous line placed • Length of stay 20 minutes • Patient very grateful

14. BPPV • Benign Paroxysmal Positional Vertigo • Age • Head trauma

15. Characteristic story • Turn head • After a few seconds delay, vertigo occurs • Resolves within 1 minute if you don’t move • If you turn your head back, vertigo recurs in the opposite direction

16. Dissecting the acronym “BPPV” • “B” = Benign • Not a brain tumor • Can be severe and disabling

17. Dissecting the acronym “BPPV” • “P” = Paroxysmal • Episodic, not persistent • Helpful feature in the differential diagnosis

18. Dissecting the acronym “BPPV” • “P” = Positional • Occurs with position of head • Turning over in bed • Looking up • Bending over

19. Dissecting the acronym “BPPV” • “V” = Vertigo • An illusion of motion • “The room is spinning” • Other descriptions • Rocking • Tilting • Somersaulting • Descending in an elevator

20. Peripheral CN VIII Vestibular apparatus Central Brain stem Vestibular nuclei in medulla and pons Cerebellum Vertigo

21. Vertigo PERIPHERAL CENTRAL

22. Anatomy: Membranous labyrinth • Semicircular canals • Utricle • Endolymph

23. Anatomy: Semicircular canals • Semicircular Canals (SCC) • Horizontal • Anterior • Posterior • Cupula • End organ receptors • Endolymph

24. Anatomy: Utricle • Utricle • Connected to SCC • Contains endolymph • Otoliths (otoconia) • Calcium carbonate • Attached to hair cells • Macule (end organ)

25. Vestibular system • Tells brain which way the head moves without looking • SCC: angular acceleration • Utricle: linear acceleration

26. Pathophysiology of BPPV • Otoliths become detached from hair cells in utricle • Inappropriately enter the posterior semicircular canal1 1. Parnes LS, McClure JA. Laryngoscope 1992;102:988-92.

27. Physiology • Normal situation • As one turns head to the right • Endolymph moves SCC receptors fire  “head turning right” • Stop turning head endolymph stops moving  SCC receptors stop firing  “head has stopped moving”

28. Pathophysiology of BPPV • BPPV • Stop turning head  otoliths keep moving  drag endolymph  receptors continue to fire inappropriately  “head is still moving” • Eyes  “head is NOT moving” • Brain  room must be spinning in the opposite direction

29. The Epley Maneuver • First described in 19922 • Bedside • > 80% cure rate 2,3 • Immediate relief • Epley J. Otolaryngol Head Neck Surg 1992;107:399-404 • Lynn S, et al. Otolaryngol Head Neck Surg 1995;113:712-20.

30. Epley maneuver • Canalith repositioning maneuver • 5 step head hanging maneuver • Moves otoliths out of the posterior semicircular canal and back into utricle where they belong

31. Epley maneuver • 1. Repeat Hallpike • Previously performed diagnostic Hallpike test tells you the starting position (right or left)

32. Epley maneuver • Turn head 90 degrees in the other direction

33. Epley maneuver • 3. Patient rolls onto shoulder, rotates head and looks down towards floor

34. Epley maneuver • 4. Patient sits back up • 5. Head forward

35. Epley maneuver

36. Epley maneuver (video clip)

37. Epley maneuver • Repeating the Epley maneuver • Post procedure • Remain upright for 8-24 hours

38. The Epley Maneuver • Contraindications4 • Unstable heart disease • High grade carotid stenosis • Severe neck disease • Ongoing CNS disease (TIA/stroke) • Pregnancy beyond 24th week gestation (relative) 4. Furman JM, Cass SP. N Engl J Med 1999;341:1590-96

39. Complications • Vomiting • IV promethazine • Converting to horizontal canal BPPV • Bar-b-que maneuver

40. Lab studies • In a straightforward case, no lab studies are needed! • Hemoglobin • Fingerstick glucose • Electrolytes if prolonged vomiting

41. Medications • Sensory Conflict Theory • Class A: benzodiazepines • Prevents process of vestibular rehabilitation • Class B: anticholinergic • Scopolamine: takes 4-6 hrs; not effective in ED • Class C: antihistaminic • IV promethazine (Phenergan) • PO meclizine (Antivert)

42. Consultations • Will depend upon institution (neurology vs. otolaryngology) • If not better with Epley maneuver • If focal neurologic exam

43. Summary • BPPV may be a severe and incapacitating disease • Diagnosis via history, nonfocal neurological exam, and a positive Hallpike test • Treatment is with the Epley maneuver • IV promethazine (Phenergan) is probably the best ED medication if one is needed

44. Teaching points • What differentiates peripheral from central vertigo? • What differentiates benign paroxysmal position vertigo (BPPV) from other cause of peripheral vertigo, such as labyrinthitis and vestibular neuritis? • What is the treatment of choice for BPPV?

45. Teaching points • What differentiates peripheral from central vertigo? • Peripheral vertigo is more intense, has a sudden onset, is paroxysmal, has fatigable and rotatory nystagmus, and has a nonfocal neurological examination

46. Teaching points • What differentiates peripheral from central vertigo? • What differentiates benign paroxysmal position vertigo (BPPV) from other cause of peripheral vertigo, such as labyrinthitis and vestibular neuritis? • What is the treatment of choice for BPPV?

47. BPPV Requires head movement Duration of seconds Usually in elderly No relation to viral syndrome Responds to Epley maneuver Labyrinthitis/VN No head movement needed Duration of hours/days Any age Viral syndrome usually precedes Epley maneuver is ineffective What differentiates BPPVfrom labyrinthitis and vestibular neuritis (VN)?

48. Teaching points • What differentiates peripheral from central vertigo? • What differentiates benign paroxysmal position vertigo (BPPV) from other cause of peripheral vertigo, such as labyrinthitis and vestibular neuritis? • What is the treatment of choice for BPPV?

49. Teaching points • What is the treatment of choice for BPPV? • The Epley maneuver (canalith repositioning maneuver)

50. Questions??? FERNE www.ferne.org andrewkennethchang@hotmail.com