Dizziness and Ver,go. Inverness CPD August 31, 2018 Dr Blair Williams MD FRCSC Otolaryngology head & neck surgery

Transcription

1 Dizziness and Ver,go Inverness CPD August 31, 2018 Dr Blair Williams MD FRCSC Otolaryngology head & neck surgery

2 Disclosure Slide This speaker has been asked to disclose to the audience any involvement with industry or other organiza,ons that may poten,ally influence the presenta,on of any educa,onal material. Receiving evalua,ons is cri,cal to the accredita,on process. ARer the program, please provide feedback at hsps://surveys.dal.ca/opinio/s?s=44738

3 A bit about me From Barney s River Sta,on, NS Medical/surgical training at Dalhousie University Started prac,ce in Sydney in July 2017 I have an interest and a fellowship in Head and Neck Oncology Skin cancer, thyroid, paro,d, throat, oral Also offer Botox (medical and cosme,c)

4 Objec,ves Dizziness and Ver,go To differen,ate ver,go from other types of dizziness To determine whether ver,go is of central or peripheral origin To describe the presenta,on and treatment of peripheral ves,bular condi,ons

5 Dizziness This is a non-specific term, oren used by pa,ents that could mean any number of symptoms Light headedness Presyncope Ver,go Ataxia Unsteadiness Dysequilibrium A more specific term/descrip,on will help guide treatment, inves,ga,on, and appropriate referrals

6 Dizziness True Spinning To and fro rocking Lightheadedness Ataxia Ves$bular e$ology

7 Balance Visual Sensory Input Propriocept Soma,c sensa,on Sensory Integra$on Brainstem Cerebellum Cortex Output Muscle tone Balance Ves,bular

8 Dizziness Ves,bular or not? Vesitbular Ver,go Episodic Vomi,ng Otologic Symptoms Worse with head movement Other Lightheadedness Chronic disequilibrium Cardiac symptoms Neurologic symptoms Loss of Consciousness

9 Ver,go The sensa,on of movement in the absence of movement Most commonly spinning Typically ves,bular in origin inner ear, CN VIII, brainstem nuclei

10 Semicircular Canal Physiology

11 Push/Pull System

12 Push/Pull System Right HC Firing Rate Differen,al is Driving VOR LeR HC 0

13 Ver,go The sensa,on of movement in the absence of movement Most commonly spinning Typically ves,bular in origin inner ear, CN VIII, brainstem nuclei History is the key to diagnosis Features of the sensa,on Timing of the episodes Associated symptoms Triggers

14 Ver,go Differen,al Timing Hearing Preserved Hearing Loss Seconds - Minutes BPPV Minutes - Hours Ves,bular Migraine Meniere s Disease Days Ves,bular Neuri,s Labyrinthi,s

15 Features Sugges,ng Central Ver,go Five D s Dysarthria Dysphagia Dysmetria Diplopia Downbea,ng or Direc,on changing nystagmus Hemifacial or hemibody sensory or motor deficit Drop asacks, visual loss, confusion Unlikely peripheral with these features!

16 Acute Ver,go Central vs Peripheral

17 HINTS Study KaSah et al, Stroke. Acute Ver,go Presenta,on N=101, 25 ves,bular and 76 central Bedside exam and imaging for everyone A normal HINTS test correctly ruled out stroke at 96%, superior to MRI with DWI (12% false nega,ve)

18 HINTS Exam Absence of ALL of these features (IN-FA- RCT) essen,ally rules out a central e,ology

19 PERIPHERAL VESTIBULAR CONDITIONS

20 SECONDS TO MINUTES - BPPV

21 Benign Paroxysmal Posi,onal Ver,go Most common cause of ver,go (90%) Also the best: oren can be cured in the office! No meds, no scans Brief, intense episodes Rolling over,,tling head back, etc

22 BPPV Loose otoconia in semicircular canals Con,nued s,mula,on arer head movement stops Diagnosed by moving the otoconia Treated by guiding the otoconia to the utricle

23 ! Dix Hallpike (Diagnosis) BPPV Posterior Canal

24 ! Epley (Reposi,oning) BPPV Posterior Canal

25 BPPV Lateral Canal! Roll Test (Diagnos,c)! Barbecue Roll (Reposi,oning)

26 BPPV Home Exercises! Brandt-Daroff Thought to work through habitua,on rather than reposi,oning hsps:// Repeat 10-20x per session Brandt_Daroff_maneuver.jpg Up to 3x per day Minimal evidence to support High rate of spontaneous resolu,on in BPPV Stop when symptoms resolve Does not prevent recurrence hsps://

27 BPPV Summary Free par,cles in the semicircular canals Diagnosis and treatment at bedside No need for imaging No need for meds Low threshold to try the maneuvers Physiotherapists trained in ves,bular rehab are really good at this!

28 MINUTES TO HOURS: MENIERE S & MIGRAINE

29 Meniere s Disease Episodic ver,go (20 minutes to hours) Transient hearing loss,,nnitus, aural fullness with the ver,go Typically unilateral Thought to arise from endolympha,c hydrops S,ll poorly understood despite being described >150 years ago Treatment aims to prevent distension of the endolympha,c sac

30 Hearing loss fluctuates with episodes BUT there tends to be some baseline loss over,me Meniere s Disease

31 Meniere s Disease Betahis,ne (betahis,ne) is typically first line: Inner ear vasodila,on which helps prevent/relieve the hydrops Not given rou,nely for anything but Meniere s Works best as a preven,ve medica,on, not PRN Start as low as 8 mg TID, safe in higher doses if incomplete symptoms control Thiazide diure,cs, low sodium diet, avoid triggers Procedural treatments, if failure of medical management

32 Meniere s Disease Summary Episodic ver,go las,ng hours Prominent, transient unilateral aural symptoms Hearing loss,,nnitus, fullness Audiogram helpful in diagnosis Treatments address endolympha,c hydrops Regular betahis,ne dosing first line but limited evidence for any treatment

33 Ves,bular Migraine Rela,vely new diagnosis (~20 years) True ver,go, typically las,ng hours Imbalance, mo,on intol, boat-like rocking Visual triggers moving scenes, traffic, etc Similar triggers to other migraine Sleep depriva,on, stress, hormonal changes Can occur several,mes per year or as frequently as daily

34 Ves,bular Migraine Typical migraine headache Does not have to occur with ver,go episodes Can precede ver,go by years 1+ non-headache symptom Photophobia, phonophobia, aura Aural symptoms uncommon More common than Meniere s Some overlap exists Can be difficult to differen,ate

35 Ves,bular Migraine ICHD-3 Criteria for Ves$bular Migraine A. At least five episodes fulfilling criteria C and D B. A current or past history of migraine without aura or migraine with aura C. Ves,bular symptoms of moderate or severe intensity, las,ng between 5 minutes and 72 hours D. At least 50 percent of episodes are associated with at least one of the following three migrainous features: 1. Headache with at least two of the following four characteris,cs: a) Unilateral loca,on b) Pulsa,ng quality c) Moderate or severe intensity d) Aggrava,on by rou,ne physical ac,vity 2. Photophobia and phonophobia 3. Visual aura E. Not beser accounted for by another ICHD-3 diagnosis or by another ves,bular disorder Good for research, cumbersome for clinical use!

36 Ves,bular Migraine Treatment LiSle available data (case series and retrospec,ve studies) Current approach based on other migraine variants Lifestyle Adequate rest, exercise, diet Avoid known triggers Triptans as an abor,ve therapy Preven,on Consider frequency, dura,on, severity of asacks Venlafaxine 37.5 mg daily TCAs, CCBs (flunarizine)

37 Ves,bular Migraine Summary Suspect if no associated aural symptoms History of migraine common Prominent visual symptoms ORen exhibits aura, photo/phonophobia Typical migraine triggers avoidance! Treat as migraine triptans if infrequent, prophylacitc meds if frequent and severe

38 LASTING DAYS VESTIBULAR NEURITIS

39 Ves,bular Neuri,s Acute onset of severe, unrelen,ng ver,go Nystagmus, ataxia, nausea/vomi,ng, intolerance of head movement Unclear e,ology Neurotrophic virus Inflammatory, microcirculatory +/- hearing loss (termed labyrinthi,s if unilateral SNHL)

40 Ves,bular Neuri,s Self limi,ng Rule out ischemic event Variable recovery in ves,bular func,on Suppor,ve measures for first few days Steroids, an,-eme,cs, benzos Avoid long-term bedrest and suppressants Delays adapta,on to new level of ves,bular input

41 Acute Treatment of Ves,bular Neuri,s Short term use only 3-5 days Prolonged use will delay compensa,on No established role for betahis,ne hsps://

42 Ves,bular Neuri,s Right HC Firing Rate LeR HC (affected ear) 0

43 Dizziness Summary Ver,go versus other cause If ver,go, central vs peripheral (inner ear) If peripheral, limited number of causes Timing is key Associated symptoms help Tailor treatment to the most likely cause If ineffec,ve, reassess diagnosis and try something else

44 Reality Check Its nice to have labels but So oren pa,ent don t fit nicely into one of these categories Symptoms are vague or there are elements of mul,ple condi,ons Video nystagmography (VNG) can help Peripheral vs central e,ology Available through NS Hearing and Speech Ves,bular rehabilita,on can help most people regardless of e,ology Vision stability, posture training, strengthening

45 Key Messages Rule out central cause BPPV is most common no need for Rx or scan Betahis,ne should be reserved as first line med for suspected Meniere s Disease Ves,bular migraine is more common than Meniere s so suspec,ng this and trea,ng as migraine can do a lot of good! Compensa,on is key in Ves,bular neuri,s, so limit suppressive medica,on to several days dura,on

46 Thank you Thank you for your asen,on and your referrals I welcome your feedback Many images are copyrighted and cannot be posted I can send by if you want the full presenta,on bw@dal.ca

47 Sources Cummings Otolaryngology Head & Neck Surgery 6 th Edi,on UpToDate.com Dizziness-and-balance.com Evalua,on and Treatment of Dizzy Pa,ent - Halifax Otolaryngology Review Course