Benign paroxysmal positional vertigo: clinical characteristics of dizzy patients referred to a Falls and Syncope Unit

Transcription

1 Q J Med 2005; 98: Advance Access publication 8 April 2005 doi: /qjmed/hci057 Benign paroxysmal positional vertigo: clinical characteristics of dizzy patients referred to a Falls and Syncope Unit J. LAWSON 1, I. JOHNSON 2, D.E. BAMIOU 3 and J.L. NEWTON 1 From the 1 Falls and Syncope Service, Care of the Elderly Offices, Royal Victoria Infirmary, Newcastle, 2 Regional ENT Service, Freeman Hospital, Newcastle, and 3 Department of Neuro otology, National Hospital for Neurology and Neurosurgery, London, UK Received 29 September 2004 and in revised form 21 January 2005 Summary Background: Dizziness is a common symptom in older people that affects quality of life and increases the risk of falls. Benign paroxysmal positional vertigo (BPPV) is a common cause of dizziness that increases in prevalence with age, and is potentially curable. Aim: To compare patients with BPPV referred initially to a Falls and Syncope Unit (FSS group) with those initially referred to a Regional ENT/ Balance Service (ENT group). Design: Retrospective case-note review. Methods: Medical notes, investigations and outcomes were reviewed for all patients. Results: Of 59 patients with BPPV confirmed by Dix-Hallpike test, 31 (53%) were initially referred to the FSS (2.6 patients per month, 71% females) and 28 (47%) were initially referred to ENT (4.7 patients per month, 86% females). Compared to those referred initially to ENT, FSS patients were significantly older (mean SD vs years, p ¼ ) and had dizzy symptoms for longer before diagnosis (median (range) 12 (4 120) vs. 6 (1 36) months, p ¼ ). FSS patients were more likely to have more than one type of dizziness (16% vs. 0%, p ¼ 0.001), more likely to have cerebrovascular or cardiovascular co-morbidity (13% vs. 4%, p ¼ ) and were taking significantly more medications (3.2 vs. 1.7; p ¼ ). Cure rates on intervention were similar (83% FSS, 86% ENT). Discussion: BPPV is a potentially curable cause for dizziness in older people. Older people are frequently referred directly to Falls units, who will be seeing increasing numbers of patients with dizziness. A high index of suspicion allows early identification and treatment of this condition. Introduction Dizziness is one of the commonest symptoms described by older people, 1 and is associated with balance disorders, functional decline and falls. 2 4 Determining the exact aetiology of dizziness in older people is frequently difficult because of comorbidity and age-related changes within the cardiovascular, neurological and vestibular systems. Furthermore, a consultation for dizziness in an older person can be frustrating for the clinician, because the description of dizziness may be non-specific and there may be a lack of specific physical findings. This frustration has been compounded by the misconception that dizziness in older people is untreatable and regarded as a part of normal ageing. At least 50% of all older people with dizziness complain of two different types of dizzy symptoms. 4 The most common is a gait disorder (a feeling of disequilibrium on walking), 5 but they may also have Address correspondence to Dr J.L. Newton, Falls and Syncope Service, Care of the Elderly Offices, Royal Victoria Infirmary, Newcastle NE1 4LP. julia.newton@nuth.northy.nhs.uk! The Author Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For Permissions, please journals.permissions@oupjournals.org

2 358 J. Lawson et al. symptoms arising from the cardiovascular and peripheral vestibular systems. Although some causes of dizziness represent a life-threatening condition, 6 most are benign and self-limiting. Positional vertigo (vertigo provoked by changes in head position) is one of the most common neurootological symptoms. Benign paroxysmal positional vertigo (BPPV) accounts for the great majority of cases caused by peripheral vestibular rather than central pathology. BPPV is thought to result from malfunction of the posterior semicircular canal, with the canal becoming sensitive to gravity or linear acceleration. This is thought to arise because of debris that becomes free-floating in the endolymph. As a result, head movement may cause loose particles to move within the posterior semicircular canal. 7,8 The diagnosis of posterior canal BPPV is made when typical signs (nystagmus) and symptoms (vertigo and nausea) are provoked by positional tests such as the Dix-Hallpike test. 7,8 With appropriate intervention (e.g. the Epley repositioning manoeuvre), 80 90% of patients with BPPV will be cured. 9 The prevalence of BPPV increases with age, 10 and in older people is associated with falls, reduced activities of daily living and depression. 11 As a result benign may be an inappropriate description in this context, as BPPV can be a severe and disabling condition. 7,8 One study has suggested a prevalence of unrecognized BPPV of 9% in older people attending a medical out-patient clinic for other reasons. 11 Older people complaining of dizziness may be referred to a variety of specialities. From our own experience there is a clear rise in referrals with dizziness alone to geriatricians, particularly to Falls and Syncope Units. Most previous studies of BPPV have come from a select group of patients that have been referred to an Otolaryngologist or ENT department after reporting dizziness. The aim of this study was to (a) identify the prevalence of BPPV in patients initially referred to a Falls and Syncope Unit (FSS), (b) identify the clinical characteristics and additional co-morbidity of these patients, and (c) compare and contrast the clinical characteristics and comorbidity of these patients to patients who were referred directly to the ENT service of the same area. Methods Subjects referred directly to the FSS The Falls and Syncope Service (FSS) based at the Royal Victoria Infirmary in Newcastle is the largest facility of its kind in Europe. Each year, 1500 new patients are seen in the unit, of whom 500 (33%) describe either dizziness alone, or dizziness in addition to falls and or syncope. We identified consecutive patients referred by General Practitioners to the FSS between December 2002 and December 2003, in whom a diagnosis of posterior canal BPPV was made. In all new patients attending our unit, consistency of historytaking is ensured by the use of a standardized proforma. In patients complaining of positional dizziness, performing diagnostic testing for BPPV is mandatory. When a diagnosis of BPPV was made in the FSS at the time of this study, all patients were then referred to the same ENT surgeon (IJ) at the Balance Centre located in the ENT department in the same city but on a different site, to confirm the diagnosis of BPPV. This group will be referred to as the FSS group. Patients referred directly to ENT Using the same diagnostic criteria, a series of consecutive patients with posterior canal BPPV, who had been referred by General Practitioners directly to the same ENT surgeon (IJ), who runs the Newcastle Balance Centre, were identified during the 6-month period between June 2003 and December Symptoms are reviewed in patients attending the Balance Centre in a similar structured way as in the FSS but examination and investigations are directed to vestibular disorders only. This group will be referred to as the ENT group. Diagnosis and management of BPPV A diagnosis of BPPV was made on the basis of typical signs (nystagmus) and symptoms (vertigo and nausea) provoked by the Dix-Hallpike test. 9 All patients had the typical nystagmus expected with posterior canal BPPV i.e torsional-vertical geotrophic nystagmus, with latency and typical duration. If patients were still symptomatic and continued to have typical symptoms on Hallpike testing at consultation with the ENT surgeon, the care pathway in our area at the time of this study was that they were referred for appropriate re-positioning manoeuvres performed by a suitably trained Audiology Physician. The Epley manoeuvre for treating right posterior canal BPPV is shown in Figure 1. Where the Epley was felt to be inappropriate, the use of other repositioning techniques such as Brandt Daroff exercises and the Semont manoeuvre was recorded. Cure was defined for the purposes of this study as asymptomatic at clinic review.

3 Benign paroxysmal positional vertigo 359 Figure 1. Epley repositioning manoeuvre. Treatment of right posterior canal BPPV. (a) The patient is sat on the table with the head turned by 45 to the affected side. (b) The patient is quickly brought down with the head turned by 45 to the affected side and extended over the edge of the table. The neck is well supported during this step. The examiner may sit while keeping the patient in this position, which should be until well after the nystagmus has subsided. (c) The head is then turned 90 to the opposite side. (d) This is followed by rotating head (or head and body) 90 facing downwards (135 from the supine position). (e) The patient is brought to the sitting position with the head turned forward 20.

4 360 J. Lawson et al. Figure 1. Continued.

5 Benign paroxysmal positional vertigo 361 Figure 1. Continued. Data collected and statistics General Practitioner (GP) referral letters and the subsequent findings at both the FSS and ENT clinic were reviewed retrospectively by one observer. Data collected included age, sex, types of dizziness, working diagnosis as described by GP and a detailed description of dizziness and comorbidity obtained in the FSS and ENT clinic (dizziness on head movement, postural change, turning in bed, duration of dizziness, number of falls in the last 12 months, past medical history, additional cerebrovascular and cardiovascular morbidity, medications taken by the patient, history of head trauma, inner ear disease, or migraine). Data are expressed as means SD (parametric) or medians (range) (non-parametric). Comparisons were drawn between groups by students t test (parametric) or Mann-Whitney test (nonparametric), as appropriate. Proportions were compared using 2 test and Fisher s test, as appropriate. A statistically significant result was taken as p Results Clinical characteristics of those with BPPV (Table 1) In total, 59 patients with a diagnosis of BPPV confirmed by Dix-Hallpike test were identified. Of these, 31 (53%) had been initially referred by their General Practitioner to the FSS during the 12-month period, equating to 2.6 patients per month. Of these 31, 22 were females (71%). In the same 12-month period, the unit saw approximately 500 patients referred by General Practitioners who complained of dizzy symptoms; the prevalence of BPPV in subjects referred to our Falls and Syncope Unit with dizzy symptoms was thus 6.2%. Twenty-eight patients with BPPV were initially referred to ENT (47%) during the 6-month study period; 24 (86%) were female and, as would be expected, the referral rates were higher to ENT (4.7 patients per month). Comparing the characteristics of groups referred initially by GPs to FSS (n ¼ 31) and ENT (n ¼ 28),

6 362 J. Lawson et al. Table 1 Characteristics of patients with benign paroxysmal positional vertigo referred to a Falls and Syncope Unit (FSS) and to ENT from GP referral letters Referred to FSS Referred to ENT p n F:M 22:9 24:4 Age (years) (range) 69 (31 89) 55.4 (31 80) Duration of dizzy symptoms (months) Falls 23% (7) 0% Vertigo 40% (12) 89% (25) Dizzy with postural change 40% (12) 14% (4) Dizzy with up and down head movement 27% (8) 50% (14) (NS) Dizzy with side to side head movement 33% (10) 39% (11) (NS) 41 type of dizziness 16% (5) 0% Cardiovascular and cerebrovascular comorbidity 32% (10) and 10% (3) 4% (1) and 0% Absolute numbers of patients are shown in parentheses. those referred initially to the FSS were older (mean SD age vs years; p ¼ ), and had dizzy symptoms for longer before diagnosis (median (range) 12 (4 120) vs. 6 (1 36) months; p ¼ ). Those referred to the FSS were more likely to have more than one type of dizziness from the GP referral letter (16% vs. 0%; p ¼ 0.001), more likely to have cerebrovascular or cardiovascular co-morbidity (13% vs. 4%; p ¼ ) and were taking significantly more medications (3.2 vs. 1.7; p ¼ ). Symptom description in those referred directly to FSS was less classical for a diagnosis of BPPV i.e. patients were significantly more likely to describe dizziness with postural change (40% vs. 14%; p ¼ 0.044) and less likely to describe vertigo (40% vs. 89%; p ¼ ). Those referred to FSS were significantly more likely to have also experienced falls (p ¼ ). Following assessment at the FSS, 45% had more than one type of dizziness and 26% had an additional cardiovascular type of dizziness. In the group referred direct to ENT, no additional types of dizziness were identified by the ENT department. In the group referred to ENT, the GP made a provisional diagnosis of BPPV in 25% and clearly described positional vertigo in a further 25% in the referral letter. No GP made a provisional diagnosis of BPPV or positional vertigo in the group referred to FSS. The effect of intervention upon outcome Reassuringly, 100% of the diagnoses of BPPV were confirmed either on history or in symptomatic patients, with repeat Hallpike, when the patient was seen in the ENT clinic. Whilst waiting for ENT review, three (10%) of the FSS patients recovered without intervention. Epley was possible in 22 of the 25 patients (88%) referred from the FSS who remained symptomatic and who had a positive Hallpike test. Eighty-three percent were cured by intervention if initially referred to FSS; this was not significantly different from the 86% cure rate if referred directly to ENT (Table 2). Discussion We have described the characteristics of patients presenting to a Falls unit with BPPV, a common and potentially curable cause of dizziness. Considering the number of older people found to have BPPV and referred by their General Practitioner to a Falls unit rather than directly to an ENT department, we would suggest our study highlights this as an important diagnosis for physicians to consider when seeing older people with dizziness. In our study, patients found to have BPPV and describing postural symptoms were more likely to be referred to a Falls clinic managed by geriatricians, while patients complaining of vertigo were referred to an ENT service. When presented with older patients with dizzy symptoms, maintaining a high index of suspicion is important, as making a diagnosis of BPPV in older people may be more difficult, particularly as this group frequently have more than one type of dizziness, may describe postural dizzy symptoms (raising the suspicion of orthostatic hypotension), and may have multiple co-morbidity and coexistent cardiovascular diagnoses. Although this is a relatively small series of patients, we have confirmed that a trained and motivated team of geriatricians working in a Falls

7 Benign paroxysmal positional vertigo 363 Table 2 Outcome of 59 patients with confirmed benign paroxysmal positional vertigo on attending ENT out-patient clinic for intervention FSS group ENT group Diagnosis confirmed by ENT department Hallpike s positive at ENT attendance Number considered for Epley repositioning manoeuvre Number better who had intervention 100% (31) 100% (28) 89% (25) 3 symptomatically better 3 Hallpike s negative 90% (22) 1 contra-indicated, 2 given Brandt Daroff exercises 100% (28) 83% (20) 86% (18 of 21) 3 not better 84% (21 of 25) 1 Semont manouevre 1 Brandt Daroff exercises 4 better while awaiting particle repositioning manoeuvre Absolute numbers of patients are shown in parentheses. No significant difference in successful outcome between those initially referred to the FSS and those referred to ENT. clinic can diagnose BPPV successfully in what might be considered to be a difficult group. We suggest that training geriatricians in repositioning manoeuvres could further improve management of these patients, and avoid delays before what is known to be an extremely effective intervention. In addition, we would suggest that ENT services may not be considering what may be a high prevalence of co-morbidity in older patients with BPPV. The presence of medical co-morbidity adversely affects overall improvement of dizzy symptoms in other vestibular conditions, 12 and identifying and managing other medical pathologies is an integral part of effective rehabilitation. With intervention, comparable numbers of those with BPPV were cured. Irrespective of the initial referral route, although referral to a Falls clinic (in our locality) probably delayed that intervention. Despite this, there are some potential benefits in initial referral to a Falls clinic, as this does allow a multidisciplinary comprehensive assessment, with identification and treatment of other causes of dizziness (most particularly cardiovascular diagnoses). It is important that evidence-based care pathways are established to ensure equity of access for all patients with BPPV to suitably trained experts, particularly for particle re-positioning manoeuvres, investigations such as audiograms, and vestibular rehabilitation exercises. 13 These facilities could be provided in a Falls clinic environment with close links to an ENT/Balance centre, where repeated physical manoeuvres (rather than single manoeuvres) and self-treatment programmes that have been shown to be superior might also be done. 14,15 We would suggest that services for dizzy patients should allow for efficient, seamless movement between Falls clinics run by geriatricians and a Balance/Vertigo service run by ENT or Audiological Physicians, and that joint working to optimize management in this difficult group may be the path to future progress. References 1. Sloane P, Blazer D, George LK. Dizziness in a community elderly population. J Am Geriatr Soc 1989; 37: Boult C, Murphy J, Sloane P, et al. The relation of dizziness to functional decline. J Am Geriatr Soc 1991; 39: Sloane PD, Baloh RW. Persistent dizziness in geriatric patients J Am Geriatr Soc 1989; 37: Baloh RW. Dizziness in older people. J Am Geriatr Soc 1992; 40: Tinetti ME, Williams CS, Gill TM. Dizziness among older adults: a possible geriatric syndrome. Ann Intern Med 2000; 132: Froehling D, Silverstein M, Mohr D, Beatty C. Does this dizzy patient have a serious form of vertigo? JAMA 1994; 271: Furman JM. Cass SP. Benign paroxysmal positional vertigo. N Engl J Med 1999; 341: Parnes LS, Agrawal SK. Atlas J. Diagnosis and management of benign paroxysmal positional vertigo (BPPV). CMAJ 2003; 169: Hilton M, Pinder D. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database Syst Rev 2004; (2):CD Katsarkas A, Kirkham TH. Paroxysmal positionsal vertigo a study of 255 cases. J Otolaryngol 1978; 7: Oghalai J, Manolidis S, Barth J, Stewart M, Jenkins H. Unrecognised benign paroxysmal positional vertigo in

8 364 J. Lawson et al. elderly patients. Otolaryngol Head Neck Surg 2000; 122: Gillespie MB, Minor LB. Prognosis in bilateral vestibular hypofunction. Laryngoscope 1999; 109: Angeli SI. Hawley R. Gomez O. Systematic approach to benign paroxysmal positional vertigo in the elderly. Otolaryngol Head Neck Surg 2003; 128: Radtke A, von Brevern M, Tiel-Wilck K, Mainz-Perchalla A, Neuhauser H, Lempert T. Self-treatment of benign paroxysmal positional vertigo: Semont maneuver vs Epley procedure. Neurology 2004; 63: Gordon CR, Gadoth N. Repeated vs single physical maneuver in benign paroxysmal positional vertigo. Acta Neurol Scand 2004; 110: