“A Moving Experience”

1. “A Moving Experience” John McDermott

2. PC • 59 Year old male • Collapsed in the street

3. HPC • On his usual walk to work the patient had suddenly collapsed and had been brought into A&E. With regards to the incident itself, what questions do we want to ask?

4. Collapse History taking... • Did the patient loose consciousness? • If so, for how long? • Was the recovery immediate, fast, delayed? • Were there environmental precipitants? • Were there any warning signs? • Aura or pre-syncope? • Is there a witness description? • Were there neurological disturbances? • Vertigo, ataxia, parkinsonism, visual impairment?

5. Collapse History taking... • Did the patient loose consciousness? • If so, for how long? • Was the recovery immediate, fast, delayed? • Were there environmental precipitants? • Were there any warning signs? • Aura or pre-syncope? • Is there a witness description? • Were there neurological disturbances? • Vertigo, ataxia, parkinsonism, visual impairment?

6. HPC • On his usual walk to work the patient had suddenly collapsed and had been brought into A&E. • He described a sudden onset of “dizziness” and nausea before he fell. He does however deny vomiting. • He denies loosing consciousness but says it took him a few minuets for the “dizziness” to go away. • When asked, he described that everything around him looked like it was moving in strange directions.

7. Dizziness or Vertigo? Vertigo: A sensation of dizziness or abnormal motion of one self and/or the environment, especially rotation or oscillation, resulting from a disorder of the sense of balance.

8. Dx? Vertigo: A sensation of dizziness or abnormal motion of one self and/or the environment, especially rotation or oscillation, resulting from a disorder of the sense of balance. • Vertebrobasilar insufficiency • Benign positional vertigo • Ménière’s disease • Middle ear disease • Wernicke’s encephalopathy • Ototoxic drugs – Aminoglycosides Vancomycin, Cisplatin, Furosemide • Posterior fossa tumour • Multiple Sclerosis • Migraine • Temporal lobe epilepsy • Hyperventilation – Anxiety, Panic attacks • Postural Hypotension • Anaemia • Epilepsy • Hypoxia • Side effect of a drug

9. PMH • On questioning he admitted that he had felt a little “unsteady” over the past year or so but nothing this bad. • These events would come on quite quickly, he’d feel a little sick, the room would spin but he’d sit down and it would go away. He put it down to his late nights running the pub. • High BP: 2 years • High Cholesterol: 4 years • Knee Replacement at 31 years

10. PMH • During the consultation it was noticed that his hearing in his right ear was very poor. • This had not been formally assessed but he said it’s been getting worse over the past 3 years. • He also said over the past year he’d been getting “ringing” in his ears which would come and go.

11. DH • Simvastatin • Ramipril • Bendrofluazide • Occasionally takes ibuporfen tablets for his knee although this is rare • No herbal or other over the counter remedies.

12. SH • Lives with wife who works as a teaching asssistant. • Has 3 children, all of whom have families in the area. • Smoking history of 10 pack years, stopped 12 years ago. • Drinks rarely. <5 units a week. • Not much exercise. Walks to and from work every day. • No recent history of foreign travel.

13. Differential?

14. Investigations A&E • Set of Observations/ECG: Normal. • CT scan: Normal. ENT • MRI: Ruled out Vestibular Schwanoma • Dix-Hallpike Manouver • Months of other investigations Intermittent Vertigo + Progressive/Intermittent hearing loss + Absence of any other diagnosis Meniere's Disease

15. Investigations for Meniere’s • Detailed History: Many other diseases may cause the same symptoms, in Meniere's however, the symptoms are intermittent not persistent. • Need to rule out any other causes of the patients presenting symptoms, by definition Meniere's is an idiopathic disease. • Investigations to rule out other potential causes: • Otolaryngological examination • FBC (anaemia?) • CT/MRI (Tumour, MS) • Electroencephalography (EEG) (epilepsy?) • Detailed drug history

16. What we can rule out- • From the normal CT and MRI: • Vestibular schwanoma • Posterior fossa tumour • Multiple Sclerosis • From the history: • Hyperventilation • Epilepsy • Any drug involvement • From other investigations (FBC, Examinations etc.): • Anaemia • Hypoxia • Middle ear disease

17. Anatomy of the inner ear Blocked drainage leads to swelling Bony Labyrinth Membranous Labyrinth Endolymphatic Sac Semicircular Canals Fibrosis or Narrowing Cranial Nerve VIII Overproduction (stria vascularis) Cochlea

18. What’s causing the symptoms? K+ K+ K+ K+ K+ K+ Stria vascularis (Source of Endolymph)

19. Symptoms • Aural Fullness – Ear pressure, Clogging Sensation • Drop Attacks Hearing Loss Méniére’s Disease Tinnitus Vertigo

20. Management 1st Line therapy to decrease endolymphatic pressure – • Low salt diet <1500mg/day • Diuretics - Triamterene / hydrochlorothiazide Symptomatic treatments Vertigo – Vestibular suppressants, anti-emetics, antihistamines, benzodiazepine Tinnitus – Tinnitus maskers, counselling, antidepressants Hearing loss – Corticosteroids, amplification hearing aids

21. Management Intratympanic therapy • Gentamicin • Corticosteroid (Dexamethasone, Methylprednisolone) Surgery • Endolymphatic sac decompression • Labyrinthectomy • Vestibular Neurectomy

22. Prognosis • No cure • Severity of the disease has great variation • Some may stop having attacks all together 5-10years after their first presentation • Permanent hearing loss or tinnitus (In one or both ears may be affected)

23. The End... ...Questions?