8/22/2011. Because Dizziness is an imprecise term, a major role of the clinician is to sort patients

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1 Approach to The Dizzy Patiet Timothy C. Hai, MD Cliical Professor Otolarygology, Physical Therapy Northwester Uiversity Dizziess is a imprecise term Vertigo (sesatio of motio) Lightheaded Ataxia Cofusio Because Dizziess is a imprecise term, a major role of the cliicia is to sort patiets Dizziess is VERY Commo Dizziess is the chief complait i 2.5% of all primary care visits. 30% lifetime prevalece of dizziess requirig medical attetio Older people have more dizzy problems Dizziess Age (years) 85+ Estimated percetage of ambulatory care patiets i whom dizziess was a primary complait (Sloae, et. al., 1989). Category Otological Neurological Medical Psychological Udiagosed Diagostic Categories Example Meiere s disease Migraie Low BP Axiety Post-traumatic traumatic vertigo Questio 1 Which category is associated with the most dizziess? 1. Ier ear disorders 2. CNS problems (e.g. Stroke) 3. Blood pressure 4. Psychological problems 5. Udiagosed Aswer 1 It depeds o your specialty 1. Ier ear disorders (about 50% of ENT, 30% i geeral) 2. CNS (about 25% of eurology, 5% everyoe else) 3. Blood pressure (30% of family practice, 5% everyoe else) 4. Psychological problems (15% to 50%) 5. Udiagosed (up to 50%) 1

2 Heuristics: multiple causes of dizziess, overlappig sigs/symptoms History Examiatio (otological, eurological, some medical, some psychiatry) Pick off easy oes BPPV, Vestibular Neuritis, Orthostatic hp, Migraie, bilateral loss. Admit the dagerous oes (focal euro) Refer the rest to outpatiet cliic Otologic (Ear) Dizziess BPPV (beig paroxysmal positioal vertigo) -- about 50% of otologic, 20% all Meiere s disease -- about 20% Vestibular euritis ad related coditios (15%) Bilateral vestibular loss (about 1%) The ear is a iertial avigatio device Semicircular Caals are rate sesors. Otoliths (utricle ad saccule) are liear accelerometers Bilateral symmetry meas redudat desig. Vestibular Reflexes VOR: Vestibulo- ocular reflex VSR: Vestibulospial reflex Positioal Vertigo The most commo sydrome Beig Paroxysmal Positioal Vertigo (BPPV) Beig Paroxysmal Positioal Vertigo (BPPV) 61 Y/O ma slipped o wet floor. LOC for 20 miutes. I ER, uable to sit up because of dizziess Hallpike Maeuver: Positive 2

3 Positioal Vertigo Dix-Hallpike Maeuver Beig Paroxysmal Positioal Vertigo (BPPV) 20% of all vertigo Brief ad strog Provoked by chage of head positio Defiitively diagosed by Hallpike test BPPV Mechaism: Utricular debris migrates to posterior caal Epley Maeuver for BPPV Move debris out of posterior caal by gravity Each positio for 30 secods. Three repetitios 75-90% cure rate Epley Epley Maeuver Maeuver: Demostratio Method Results of Epley Maeuver Most authors report 75% cure from a sigle treatmet, ad >95% from repeated treatmets (or Home Epley). The Epley maeuver is the treatmet of choice for classic BPPV. Epley JM. The caalith repositioig procedure: For treatmet of beig paroxysmal positioal vertigo. Otolarygol Head Neck Surg 1992 Sep;107(3):

4 Uilateral Vestibular Loss Vestibular Neuritis: Case 56 y/o woma bega to become dizzy after luch. Dizziess icreased over hours, ad cosisted of a spiig merri-go-roud sesatio, combied with usteadiess. Vestibular Neuritis/Labyrithitis Meiere s disease (uusual, 1/2000 prevalece) Acoustic Neuroma (very rare) Vomitig esued 2 hours later, ad she was brought by family members to the ER. Vestibular Spotaeous Nystagmus see with video Frezel Goggles Aside for how to examie for SN Should directio ad amout. Frezel Goggles (best) Ophthalmoscope (good but backwards) Gaze--evoked ystagmus Gaze (pretty good) Vestibular Neuritis Viral ifectio of vestibular erve or gaglio (HSV(HSV-1). Disability typically lasts 2 weeks. Course of steroids if acute Symptomatic Rx (meclizie, meclizie, pheerga, pheerga, bezodiazepie) These patiets ca still get BPPV! Physical Therapy For Uilateral Vestibular Loss Balace exercises Gaze stabilizatio 4

5 Bilateral Vestibular Loss A stewardess developed a toe-ail ifectio. She uderwet course of getamici ad vacomyci. 12 days after startig therapy she developed imbalace. 21 days after startig, she was staggerig like a druk perso. Meclizie was prescribed. Getamici was stopped o day 29. Oe year later, the patiet had persistet imbalace, visual symptoms, ad had ot retured to work. Hearig is ormal. She usuccessfully sued her doctor for malpractice. SYMPTOMS OF BILATERAL VESTIBULAR LOSS OSCILLOPSIA ATAXIA Bilateral Vestibular Loss Causes: DIAGNOSIS IS EASY Ototoxicity! Bilateral forms of uilateral disorders (e.g. bilateral vestib euritis) Cogeital (e.g. Modii malformatio) idiopathic Solvet 5% Ukow 26% V Neuritis 9% Cogeital 2% Getamici 58% History of recet IV atibiotic medicatio Eyes closed tadem Romberg is positive Dyamic illegible E test (DIE) failed ----> Dyamic Illegible E test (DIE test) Distace visio with head still Distace visio with head movig Normal: 0-2 lies chage. Abormal: 4-7 lies chage DIAGNOSIS Cotiued Ophthalmoscope test is failed too 5

6 Physical Therapy For Uilateral Vestibular Loss DIAGNOSIS Cotiued l ENG ad Rotatory chair to cofirm diagosis (you will eed this whe you give your depositio). Treatmet of Bilateral Loss Avoidace of ototoxis ototoxis/vest. /vest. suppressats Physical Therapy Balace exercises Gaze stabilizatio Diagostic Categories Otological (Vertigo or ataxia) Neurological Causes of Neurological Dizziess % subspecialty, 5% ER 15 Case HA 35% Stroke ad TIA 16% Migraie Ataxias (very commo) Head Trauma (commo) Seizures (extremely rare) Multiple Sclerosis (extremely rare) Tumors (extremely rare) eurological Medical (i.e. low blood pressure) Psychological (axiety) Udiagosed 50 year old surgeo developed vertigo ad usteadiess Cotiued to operate for a week before seekig medical attetio but wife would t let him drive. PICA stroke see o MRI 6

7 Commo Strokes with Dizziess Ataxias caused by everythig PICA (lateral medulla ad iferior cerebellum) hoarse/ptosis AICA (pos ad cerebellum) -- deaf SCA (cerebellar cerebellar) Cerebellar Basal Gaglia Hydrocephalus Sesory loss (B12) Bilateral vestibular loss Perivetricular WM lesios Drugs (e.g. aticovulsats) Degeeratios eurological eurological Brai Tumors Causig Dizziess We worry a lot about these rare disorders Acoustic Neuroma (0.1% populatio, 2.5% uilat hearig loss) Meigioma CP agle Cerebellar astrocytoma Cerebellar hemagioblastoma Seizures causig Dizziess Quick spis (1-2 secods) Also caused by vestibular erve irritatio/surgery (Moo ad Hai, 2005) Cofusio ad dizziess May be triggered by flashig lights Head ijury is commo Oxcarbamazie may stop them eurological Migraie & Vertigo: Prevalece Migraie: 10% of U.S. populatio has Migraie 20-30% of wome childbearig age Vertigo: 35% of migraie populatio.* Migraie + vertigo (MAV): ~ 3.5% of U.S. pop. ~ 10% of wome of childbearig age Lipto ad Stewart 1993; Stewart et al, 1994 *Kaya/Hood, 1984; Selby/Lace, 1960; Kuritzky, et al, 1981 Diagosis of MAV Cliical judgmet Headaches ad dizziess Lack of alterative explaatio (ormal otological exam, eurological exam, CT) High idex of suspicio i wome of childbearig age. Perimestrual patter. Family history i 50% Respose to prophylactic medicatio or a tripta 7

8 Treatmet of MAV Diet (avoid migraie triggers) Prophylactic medicatios work well Diagostic Categories Velafaxie (Effexor Effexor)) XL Topiramate 50 to 100 mg daily Verapamil 120 mg SR Propraolol ad other beta beta--blockers Amitriptylie ad other tricyclics Otological (Vertigo or ataxia) Neurological (i.e. posterior fossa) Medical Psychological (axiety, maligerig) Udiagosed Medical Dizziess 30% of ER cases Cardiovascular (23 (23--43%) Physical Therapy For Orthostatic Hypotesio Orthostatic Traiig Orthostatic hypotesio Arrhythmia Ifectio (4(4-40%) (7-12%) Medicatio (7(4-5%) Hypoglycemia (4 Source: Madlo Kay (85), Herr et al (89) Psychogeic Vertigo Axiety Log Log--duratio dizziess Situatioal Respods to bezodiazepies Some have vestibular disorders too Axiety, hypervetilatio, paic, Agoraphobia Somatizatio Maligerig 8

9 Somatizatio Chroic dizziess Numerous bodily ailmets Oe goes away to be replaced by aother We do t have a treatmet for SD. Do ot tell these people there is othig wrog. Rather, try to miimize the health- care cost. A good test for balace maligerig Movig Platform Posturography There is a formal algorithm for detectig icosistecy (Cevette score) Formulatig your impressio Otologic (30-50%) BPPV, Meieres, VN. CNS (5-30%) CVA, Migraie Medical (5%-30%) Orthostatic, drug Psychiatric (15-50%) 50%) Udiagosed (15%) Udiagosed Dizziess About 15% of all dizzy patiets Our tests are ot 100% sesitive We are ot perfect either Follow patiets over time it gets easier after a year goes by Refer to oes colleagues maybe someoe else will figure it out. Summary There are a immese umber of dizzy patiets May of them have ier ear disorders or migraie, but the differetial icludes medical coditios as well as psychiatric problems A flexible heuristic approach is eeded to sort them out. Not everyoe ca be diagosed Not every disorder has a treatmet More readig Hai, T.C. Approach to the patiet with Dizziess ad Vertigo. Practical Neurology (Ed. Biller), 2008, Lippicott-Rave ad-balace.com 9