Workshop: The Assessment of Patients with Dizziness and Vertigo

Transcription

1 Workshop: The Assessment of Patients with Dizziness and Vertigo Tamara Mijovic MD CM FRCSC Clinical Assistant Professor Department of Otolaryngology Head and Neck Surgery Otology, Neurotology & Skull Base Surgery McGill University Nov 28 th 2017

2 Disclosure No conflicts of interest

3 Objectives 1. Develop a systematic approach to the clinical assessment of patients with dizziness and vertigo. 2. Demonstrate the proper techniques for the physical examination of the vestibular system. 3. Discuss the features and treatments of the most common vestibular pathologies.

4 Functional anatomy of spatial orientation and balance SENSORS Vision Central nervous system Vestibular system (inner ear) 5 Organs per side Proprioception Joints Muscles

5 DDx: dizziness Central nervous system Lightheaded: Blood pressure and flow to the brain (Hypotension, arrhythmias, carotid stenosis) Vertigo: central Stroke (Vertebro-basilar) Vertebro-basilar insufficiency Multiple sclerosis Tumors of posterior fossa Migraines Psychogenic: Anxiety, Panic attacks Periods of high stress Vision and Ocular Motor function Diplopia Trauma, diabetes, neuropathies, cataracts Vestibular system (inner ear) Vertigo peripheral BPPV Ménière s disease Vestibular neuronitis Labyrinthitis Superior canal dehiscence Vestibular Proprioception schwannoma Cervical arthritis Cervical disk disease Diabetic neuropathy Aging!

6 DDx à treatments Central nervous system Polypharmacy: R/A meds R/O Postural hypotension Compression stockings MRI head Doppler of the carotids and vertebral Migraine prophylaxis Neurology Psychogenic: Support, psychotherapy, meds Vision and Ocular Motor function Optometrist Ophtho Well lit environment Vestibular system (inner ear) Vertigo peripheral Vestibular physio Otolaryngologist Proprioception Physio for mobilization exercises Occupational therapy fall prevention Exercise routine Proper footwear

7 Clinical Assessment HISTORY THIS IS KEY MOST OF THE DIAGNOSIS COMES FROM HISTORY

8 History Seconds Minutes Hours Days Always there AM/PM Vision Social history: what is going on in their life now?

9 Physical Examination The Basic assessment in Primary Setting General: Vitals and blood pressure: R/O Orthostatic hypotension Ears: Otoscopy and Tuning Fork (512 Hz) Eyes: Spontaneous nystagmus Ocular motor assessment Neurologic CN Cerebellar (coordination, RAM, fine motor) Functional balance: Romberg and Gait Vestibular: Dix-Hallpike Manoeuver

10 How to: If present: Reassess meds Compression stockings Active lifestyle If persists: Neurology consultation (tilt table study) +/- fludrocortisone

11 How to: Examine the ears Wax removal

12 How to: Examine the ears Tuning fork assessment 512 Hz TF Subjectively compare both ears (ID if one ear is clearly better hearing) OTOLARYNGOLOGY CONSULT Weber (on the forehead or nasal bridge) Midline Lateralize» To the better hearing ear: SNHL in worse ear» To the worse hearing ear: CHL in the worse ear Rinne (Bone vs Air conduction) Determines the degree of CHL

13 Examine the eyes How to: Smooth pursuit Extraocular movement function Saccades

14 Neurology screening Cranial nerves II, III, IV, VI, VIII à tested elsewhere V, VII, IX, X, XI, XII: How I do it? Cerebellar coordination: finger to nose, heel to toe RAM Fine motor Functional balance Romberg, sharpened Romberg Gait Ataxia: cerebellar problems, NPH Shuffling gate: parkinson MRI Neurology Consultation

15 How to: How to do a Dix-Hallpike Manoeuver BPPV Instruct the patient Eyes open even if feels dizzy Turn head to the corner of the room and lie down as fast as you can

16 Clinical Scenario 1 50 yo F, healthy RC: Violent spinning when she turns in bed Lasts secs, but she feels terrible after Physical examination: Normal ears, nose, throat and cranial nerves

17 Diagnosis: Dix-Hallpike Manoeuver

18 Dx: Benign Paroxysmal Positional Vertigo Most common cause of vertigo Lifetime prevalence: 2.4% Clinical presentation Sudden attacks of vertigo, lasting seconds, provoked by characteristic head movements Bending forward, looking up, rolling over in bed No other otologic or neurologic symptoms

19 BPPV Otoconia that have fallen off the utricle into the posterior semi-circular canal

20 Trauma Otologic surgery Head Trauma Risk factors Mastoiditis/Labyrinthitis/Vestibular neuritis Advancing age Prolonged unusual head postures Bed rest, hairdresser, dentist chair, surgery MOST ARE IDIOPATHIC

21 Treatment Repositioning manoeuver: Epley is the most common Proper training important ENT Vestibular physiotherapist

22 Treatment Epley Manoeuver

23 Treatment For recurrent disease or in post-menopausal women: Vit D IU qweekly Calcium 500 mg po BID There are surgical options (Plugging of canal) Risky and rarely done

24 What if the story typical for BPPV but the Dix- Hallpike is negative?

25 Horizontal canal BPPV Supine Roll test Observe for nystagmus 1. Start supine 2. Roll right 3. Roll left Violent nystagmus usually BBQ manoeuver - OTL or physio

26 What if pt is VERY dizzy but NO nystagmus on Dix-Hallpike nor Supine Roll? IT IS NOT BPPV What could it be? à Cervical spine problems (Hx trauma, neck pains, osteoarthritis): Trial of massage therapy / physio à Vertebro-basilar circulation problem Doppler of posterior circulation, Neurology, CTA

27 35 yo F, healthy Clinical scenario 2 Reports attacks of vertigo lasting 1-2h Associated symptoms: pressure and tinnitus (ringing) in left ear, nausea, vomiting during attacks Normal examination Except tuning forks Audiogram (aka hearing test) Shows left hearing loss

28 1 st step: exclude an acoustic neuroma (benign tumour of the vestibular nerve) à MRI of the Internal auditory canal

29 Ménière s Disease Endolymphatic Hydrops Endolymph: K+ rich fluid of the inner ear Hydrops: Accumulation of liquid Idiopathic

30 Treatments Low salt diet Serc (beta-histine) à ONLY FOR MENIÈRES Diuretics (pee out Na and K) Steroid injections Destruction of the inner ear: Chemical Surgical

31 Ménière s Disease Prevalence: per 100,000 Age of onset: 20 to 60 yo (peak 30-40s) If you have an older patient 60s and 70s MUST THINK OF STROKE AND TIA

32 TIA and stroke TIA: transient or episodic symptoms >40% of AICA infarctions preceded by TIA presented as transient dizziness, HL, and/or tinnitus High index of suspicious: Short total illness duration (<3-6months) Few number of episodes (<5) Escalating pattern of frequency (crescendo TIA) Vascular risk factors

33 30 yo M Clinical Scenario 3 Woke up in the morning with the room spinning around him. Unable to get up without falling. Spinning lasted 36h Normal neurological examination (no stroke) No ear symptoms (hearing normal)

34 Vestibular neuronitis Viral inflammation of the vestibular nerve With acute loss of vestibular function on that side Asymmetry between left and right inner ear = vertigo in the acute setting Spinning stops after a day or 2, but full recovery is slow (several weeks) Patients can still feel off when they move their head quickly to that side They cannot keep their eyes focused

35 Vestibulocular Reflex (VOR) VOR = Keeping eyes on the target when head is moving Head impulse test = Moving the head and seeing if eyes stay focused

36 Head moves quickly to left = eyes go off target

37 Treatment of Vestibular Neuronitis Prednisone in first 72h (controversial) Supportive: WE ARE WAITING FOR FUNCTION TO RECOVER OR COMPENSATION TO HAPPEN Anti-emetics (Gravol) for 2-3 days. Avoid long term use because it limits compensation Mobilisation (moving head around to compensate/recalibrate) It takes 6 weeks to 3 months to fully recover If still feels off after 6 weeks: Vestibular physiotherapy can help develop alternative mechanisms to stabilize vision.

38 Acute setting! Vestibular Neuronitis vs Stroke HINTS test Head Impulse Nystagmus Test of Skew In Vestibular neuronitis: - Head impulse: catch up saccade when you move the head quickly to the involved side - Nystagmus: beats away from the involved side and gets faster when looking away from the involved side - Test of Skew: Cover-uncover test usually normal In Stroke: Head impulse test is normal Nystagmus: absent, vertical or not fitting with head impulse Test of Skew: there might be vertical skew deviation

39 Cover-Uncover test Skew Deviation

40 Labyrinthitis??? Very rare The whole inner ear is inflamed Vertigo AND Hearing loss

41 Clinical Scenario 4 52 yo F, Perimenopausal HPI: 1 y hx of frequently feeling like she is on a boat, nauseated, unsteady, lasts hours sometimes a few days Never had spinning! Disabled: Computer work bothers her a lot. Looking at the metro approaching makes her very nauseated. PE: Neurotologic examination is normal ROS: Migraines (but has not had them in years), motion sickness Light and sound bother her during the episodes, she also has a headache at the same time MRI: N

42 Vestibular Migraine 1. 5 episodes with vestibular symptoms lasting 5min - 72hrs 2. History of migraine 3. 1 migraine features with 50% of episodes: Characteristic headache photophobia and phonophobia visual aura 4. Exclude other diagnosis Journal of Vestibular Research 22 (2012)

43 Probable Vestibular Migraine 1. 5 episodes with vestibular symptoms 2. History of migraine or migraine features 3. Exclude other diagnosis Journal of Vestibular Research 22 (2012)

44 Vestibular Migraines A form of hypersensitivity Rx: Migraine triggers avoidance Migraine prophylaxis Consult Neurology

45 Vestibular Migraine Prophylaxis

46 Clinical scenario 5 21 yo M, healthy student, football player New onset of brief vertigo when his dog barks next to his left ear and when he makes a big effort Associated symptoms: He can hear strange things: blinking and eye movements his heart in his left ear (pulsatile tinnitus) his footsteps and intestinal sounds

47 CT scan Superior canal is dehiscent No bone over it

48 Superior semicircular canal dehiscence Disruption of the normal fluid mechanics of the inner ear

49 Treatment Observation Surgery

50 Conclusions Spatial orientation and balance are multisensory functions Pathologies of the inner ear and vestibular organs are associated with unique clinical pictures Timing Associated otologic symptoms Physical examination findings

51 Thank you Questions