1. Dizziness Paul Chatrath Consultant ENT Surgeon Barking Havering & Redbridge Hospitals NHS Trust 21 st January 2009

2. Objectives Definitions Definitions Clinical history & examination Clinical history & examination Multiple factors Multiple factors Key conditions – BPPV, Meniere’s, labyrinthitis, non-vestibular Key conditions – BPPV, Meniere’s, labyrinthitis, non-vestibular

3. “Dizziness” Presyncopal faintness Presyncopal faintness Loss of balance/imbalance Loss of balance/imbalance Unsteadiness Unsteadiness Light-headedness Light-headedness Whooziness Whooziness Vertigo Vertigo Feeling of rotation or movement Feeling of rotation or movement

4. Balance Vestibular system Vestibular system Peripheral vestibular (labyrinth) Peripheral vestibular (labyrinth) Cerebellar Cerebellar Visual system - VOR Visual system - VOR Proprioceptive system - VSR Proprioceptive system - VSR

5. Vestibular Labyrinth 3 semicircular canals 3 semicircular canals rotational movement rotational movement cupula cupula 2 otolithic organs - utricle & saccule 2 otolithic organs - utricle & saccule linear acceleration linear acceleration macula macula

7. Clinical approach Vertigo vs dizziness Vertigo vs dizziness Vertigo – peripheral vestibular or cerebellar Vertigo – peripheral vestibular or cerebellar Dizziness – non vestibular Dizziness – non vestibular Questions to establish causes for each of these Questions to establish causes for each of these

8. Vertigo vs Dizziness Definition of vertigo: Definition of vertigo: Illusion of movement of oneself or the surroundings Illusion of movement of oneself or the surroundings Typically rotatory Typically rotatory Looking for vestibular causes Looking for vestibular causes If no rotatory component: If no rotatory component: Likely to be nonspecific dizziness Likely to be nonspecific dizziness Looking for non-vestibular causes Looking for non-vestibular causes

9. Vertigo vs Dizziness: Unclear? Vertigo: Vertigo: Rotatory Rotatory Worse on head movements Worse on head movements Nausea/vomiting on head movements Nausea/vomiting on head movements Vague descriptions: rarely true vertigo Vague descriptions: rarely true vertigo

10. Vertigo - causes Vestibular Viral labyrinthitis Viral labyrinthitis BPPV BPPV Meniere’s disease Meniere’s disease Acute Otitis Media Acute Otitis Media Trauma Trauma Cholesteatoma Cholesteatoma Drug induced Drug induced Postsurgical PostsurgicalCentral Migraine Migraine Vertebrobasilar ischaemia Vertebrobasilar ischaemia MS MS Tumours Tumours Cerebellopontine angle Acoustic neuroma Brainstem CVA CVAPsychogenic

11. History: Vertigo Vestibular Viral labyrinthitis Viral labyrinthitis BPPV BPPV Meniere’s disease Meniere’s disease Acute Otitis Media Acute Otitis Media Trauma Trauma Cholesteatoma Cholesteatoma Drug induced Drug induced Postsurgical Postsurgical Central Migraine Migraine Vertebrobasilar ischaemia Vertebrobasilar ischaemia MS MS Tumours Tumours Cerebellopontine angle Acoustic neuroma Brainstem CVA CVAPsychogenic Onset After URTI or ear infection Duration >24hrs: Viral labyrinthitis Several hours: Meniere’s, migraine <1min: BPPV, Psychogenic Associated ear features Tinnitus Hearing loss Headache Discharge

12. History: Vertigo Vestibular Viral labyrinthitis Viral labyrinthitis BPPV BPPV Meniere’s disease Meniere’s disease Acute Otitis Media Acute Otitis Media Trauma Trauma Cholesteatoma Cholesteatoma Drug induced Drug induced Postsurgical Postsurgical Central Migraine Migraine Vertebrobasilar ischaemia Vertebrobasilar ischaemia MS MS Tumours Tumours Cerebellopontine angle Acoustic neuroma Brainstem CVA CVAPsychogenic Associated central features Face or arm weakness/numbness Frequency Single: labyrinthitis, MS Constant: decompensation neurological psychogenic Trauma Drug history Aminoglycosides Diuretics Aspirin Chemotherapy Surgery

13. Non-specific dizziness: Causes Cardiovascular Cardiovascular Arrhythmias Reduced cardiac output Carotid artery stenosis Arteriosclerosis Hypotension (postural) Proprioception Proprioception Arthritis Metabolic Metabolic DM Hypothyroidism Hypercholesterolaemia Anaemia Peripheral neuropathy Peripheral neuropathy DM Renal or hepatic failure Alcohol Vasculitis Infections Leprosy, TB, syphilis Vitamin deficiencies B1, B6, B12 Genetic - Refsum’s disease Toxins Lead, metronizadole Psychogenic Psychogenic

14. Examination Ears Ears TMs TMs Cranial nerves Cranial nerves All are useful! All are useful! General examination General examination Nystagmus: ‘rhythmic oscillating involuntary movement of eyes’ Nystagmus: ‘rhythmic oscillating involuntary movement of eyes’ Cerebellar Cerebellar Posture Posture Romberg’s Unterberger’s Hallpike’s Hallpike’s

15. Nystagmus Movement of the eyes: Movement of the eyes: Rhythmic Rhythmic Oscillating Oscillating Synchronous Synchronous Involuntary Involuntary Two phases Two phases Slow phase (pathological) Fast phase (corrective) Direction described in terms of fast phase Direction described in terms of fast phase

16. X LNystagmus Eyes central Slow drift to right Rapid corrective flick to left = Left nystagmus L R Normal labyrinths Abnormal Right Labyrinth

17. Vertigo: Vestibular v Central VestibularCentral Type of dizzinessVertigoVertigo / Dizzy Effect of head movementWorseEquivocal Tinnitus/hearing lossMay be presentAbsent CompensationOccursDoes not occur NystagmusHorizontalHorizontal or vertical + unilateral+ bilateral + away from affected ear

18. Vertigo: Compensation Vestibular phenomenon Vestibular phenomenon Steady accommodation to the effects of vertigo Steady accommodation to the effects of vertigo Gradual resolution of symptoms over time Gradual resolution of symptoms over time Typically occurs 6-12 weeks after acute insult Typically occurs 6-12 weeks after acute insult Mechanisms Mechanisms Habituation Reduced output good side Increased output affected side Sensory substitution Increased reliance on eyes and musculoskeletal system

19. Vertigo: Compensation Impaired compensation due to: Impaired compensation due to: Poor visual acuity Poor visual acuity Musculoskeletal problems Musculoskeletal problems Reduced peripheral sensory input Reduced peripheral sensory input Ongoing vestibular pathology Ongoing vestibular pathology Medication (prolonged stemetil) Medication (prolonged stemetil) Rehabilitation: Rehabilitation: General fitness Vision, walking stick Physical programs Cawthorne-Cooksey Psychological support Specific exercises Eg. Brandt-Daroff exercises for BPPV

20. Cawthorne - Cooksey Developed in 1940s Developed in 1940s Head movements Head movements Balance tasks Balance tasks Coordination of eyes with head Coordination of eyes with head Total body movements Total body movements Eyes open & closed Eyes open & closed Noisy environments Noisy environments Early exacerbation of vertigo Early exacerbation of vertigo

21. Investigations Radiology (anatomical imaging) Radiology (anatomical imaging) MRI – good for IAM’s MRI – good for IAM’s CT – good for vestibular anatomy CT – good for vestibular anatomy Audiogram Audiogram Asymmetry needs further imaging Asymmetry needs further imaging Tests of vestibular function Tests of vestibular function ENGs (electronystagmography) Caloric tests Rotation tests

22. Symptomatic Tx Acute phase Phenothiazines Phenothiazines Prochlorperazine Prochlorperazine(Stemetil) Antihistamines Antihistamines Cinnarizine (Stugeron) Cinnarizine (Stugeron) Cyclizine (Valoid) Cyclizine (Valoid) Promethazine (Avomine) Promethazine (Avomine) Histamine analogues Histamine analogues Betahistine (Serc) Betahistine (Serc) Longer term: Depends on specific condition Depends on specific condition

23. Caution: Prochlorperazine Powerful vestibular sedative Powerful vestibular sedative Suppresses acute vertiginous symptoms Suppresses acute vertiginous symptomsBUT Also suppresses natural compensatory response Also suppresses natural compensatory response LT use: ‘non-specific dizziness’ persists LT use: ‘non-specific dizziness’ persists

24. Psychogenic Type of dizziness: any (nonspecific or vertigo) Type of dizziness: any (nonspecific or vertigo) Frequency: constant Frequency: constant Duration: Typically brief <1min Duration: Typically brief <1min Trigger: Stress, anxiety, crowds Trigger: Stress, anxiety, crowds Associated features: palpitations, sweating, tremor Associated features: palpitations, sweating, tremor Examination: Normal Examination: Normal

25. Labyrinthitis Otitic Otitic Infective Infective Viral (serous) Viral (serous) CMV, influenza, adenovirus CMV, influenza, adenovirus Bacterial (suppurative) Bacterial (suppurative) Strep pneumoniae Strep pneumoniae Haemophilus Haemophilus Moraxella Moraxella Other causes Other causes cholesteatoma cholesteatoma Other source Other source Meningeal TB Syphilis Neoplasia Haematogenic

26. Labyrinthitis History History Vertigo Vertigo >24hrs >24hrs Vomiting Vomiting Constitutional symptoms Constitutional symptoms Examination Examination Nystagmus Nystagmus Fast phase away from affected ear Fast phase away from affected ear Pyrexia Pyrexia Treatment Treatment Bed rest Vestibular sedatives Fluids Cawthorne-Cooksey vestibular rehabilitation exercises

27. Meniere’s Disease Key features: Key features: Vertigo Vertigo Hours not minutes or days Hours not minutes or days Associated tinnitus and hearing loss Associated tinnitus and hearing loss Before, during or after vertigo Before, during or after vertigo Other symptoms Other symptoms Pressure feeling Pressure feeling Nausea Nausea Aetiology Aetiology Vascular ‘Hydrops’ Natural history Natural history One episode Episodic Increasing frequency

28. Meniere’s Disease: Medical therapy Salt restriction Salt restriction Diuretics Diuretics Thiazides - Na absorption in distal tubule Thiazides - Na absorption in distal tubule Side effects - hypokalemia, hypotension, hyperuricemia, hyperlipoproteinemia Side effects - hypokalemia, hypotension, hyperuricemia, hyperlipoproteinemia Vasodilators Vasodilators Betahistine, cinnarizine Evidence – no RCTs Evidence – no RCTs Cinnarizine > placebo Diuretics = placebo Serc of marginal benefit Salt restriction of marginal benefit

29. Meniere’s Disease: Surgical therapy Hearing preservation Vestibular preservation Vestibular preservation Endolymphatic sac drainage Endolymphatic sac drainage Intratympanic injection of steroid Intratympanic injection of steroid Vestibular destruction Vestibular destruction VIII nerve section VIII nerve section Hearing destruction Intratympanic injection gentamicin Intratympanic injection gentamicin Labyrinthectomy Labyrinthectomy

30. ITAG

31. BPPV: Benign Paroxysmal Position Vertigo Calcific debris in semicircular canals Calcific debris in semicircular canals Cupulolithiasis Cupulolithiasis Canalolithiasis Canalolithiasis Vertigo Vertigo Brief (<1min) Brief (<1min) On head turn in a particular direction On head turn in a particular direction Typically self-limiting Typically self-limiting Primary Primary Secondary Secondary Trauma (HI) Trauma (HI) Prolonged bed rest Prolonged bed rest Otological condition (up to 70%) Otological condition (up to 70%) Labyrinthitis Labyrinthitis Central Central

32. BPPV: Benign Paroxysmal Position Vertigo Posterior SCC Posterior SCC In plane on lying in bed In plane on lying in bed Hallpike’s test Hallpike’s test Nystagmus on lying back to one side Nystagmus on lying back to one side Problem: how to distinguish BPPV from central causes Problem: how to distinguish BPPV from central causes

33. BPPV: Hallpike’s test – Character of Nystagmus BPPVCentral Latency5-10sNone AdaptationGone in 50sPersists FatiguableYesNo VertigoAlwaysAbsent DirectionRotatory (geotropic)Variable IncidenceCommonRare

34. BPPV - Epley Epley, 1992

35. BPPV - Brandt & Daroff Brandt & Daroff, 1980

36. Migraine Clinical features Clinical features family history family history motion intolerance motion intolerance Vertigo occurs with classical headache Vertigo occurs with classical headache ENT/vestibular examination usually NAD ENT/vestibular examination usually NAD Lifestyle change Lifestyle change exercise, diet, avoidance of stimulants exercise, diet, avoidance of stimulants Medication: Medication: Abortive therapy eg. Sumatriptan Abortive therapy eg. Sumatriptan Prophylactic therapy eg. B blockers Prophylactic therapy eg. B blockers

37. Vertebrobasilar Insufficiency Vertigo, diplopia, dysarthria, ataxia, sensory and motor disturbance Vertigo, diplopia, dysarthria, ataxia, sensory and motor disturbance NOT synonymous with cervicogenic vertigo NOT synonymous with cervicogenic vertigo 30% of TIA’s 30% of TIA’s Aspirin Aspirin

38. Dizziness Paul Chatrath Consultant ENT Surgeon Queen’s/King George’s Hospitals Any Questions? Email:paul.chatrath@bhrhospitals.nhs.ukpaul@chatrath.com

39. A Final Thought...... QIn a patient with vertigo, if you had only one question to ask him/her, what would it be? AHow long does the vertigo last for? - BPPVSeconds - Meniere’sHours - LabyrinthitisDay