1. Clinical diagnosis and treatment of vertigo Ta-Wei Yeh M.D. Hsin-Chu Branch of NTU hospital

2. 2 BPPV Vestibular nerve and labyrinthine Disorders: Vestibular neuritis Meniere’ s Dx Perilymph fistulas Peripheral vestibular paroxysmia Bilateral vestibulopathy Infectious vertigo Autoimmune inner ear disorders Tumors Central vestibular disorders Central positional vertigo Vascular vertigo Traumatic vertigo Hereditary vestibular disorders Drugs and vertigo Visual vertigo Somatosensory vertigo Psychogenic vertigo Physiological vertigo

3. Periphery vertigo (refers to the disorders that involve disturbances in the inner ear) Central vertigo (refers to the dizziness or vertigo that result from problem in the brain)

4. Correct diagnosis Targeted history taking: most important Clinical office (bedside) examinations Functional testing of the vestibular system imaging

5. History! History! History!

7. “SO STONED” S What are the Symptons O How Often do the symptons occur S Since when did it start T Trigger of symptons O Otological additional symptons N Neurological additional symtons E Evoluation of symptons D Duration of symptons Wutys et al Barany Seoul 2016

8. S: Symptons “What is the main problem?” ． Vertigo illusion of self-motion or surroundings ． Presyncope /Near fainting /Lightheadedness Seeing black, hypotension ． Disequilibrium/ Falling Sensation A sense of imbalance and when walking, or especially without a visual clue ． Non-specific With tension headache, numbness

9. S: Symptons “Is it a true vertigo? Yes” ． Spinnning/ Linear sensation/ Tilting √ BPPV, VN, MD, bil vestibulopathy (VP) √ Vestibular migraine (VM) √ Vestibular Basilar Insufficiency (VBI)MD

10. S: Symptons “Is it a true vertigo? No” ． Presyncope/ Near fainting/ Lightheadedness √ Cardiac irregularities, Orthostatic hypotension √ Epilepsy √ Hypoglycemia

11. S: Symptons “Is it a true vertigo? No” ． Disequilibrium/ Falling sensation √ Multiple sensory deficits, peripheral neuropathy, cervical spondylosis, musculoskeletal, vestibular, cerebellar Dz √ CVA, TIA (VBI) √ Chronic subjective dizziness (CSD) or persistent postural perceptual dizziness (PPPD) √ Visual impairment PPPD

12. S: Symptons “Is it a true vertigo? Well, I’m not sure…” ． Non-spefic √ Patient has difficulty describing symptons, & NOT related to positional changes √ Anxiety, Depression, Agoraphobia, Panic √ Hypoglycemic episodes √ Multiple sensory deficits in the elderly, CVA √ Medications: antidepressant, anticholinergics

13. O: How Often ． A single attack of acute vertigo is a hallmark of √ VN, labyrinthitis, Stroke ． Episodic that occurs almost daily √ BPPV, perilymphatic fistulas, SSCD, VM ． Attacks more than once, symptom-free wk/mon √ MD, sometimes VM ． More like a continuous character √ Stroke, bil VP, poor compensated uni VP, PPPD

14. S: Since Head trauma occuriring some wks/ days √ BPPV, SSCD, PFSSCD, PF Viral illness √ VN, delayed BPPV, PPPD Medication, autoimmune Dz √ bil VP, drugs adverse effect (aminoglycoside, loop diuretics, vancomycin, antineoplastics, quinine, NSAIDS, antihypertensive, hypnotics, levodopa, bestibular suppressants…)

15. Drugs with peripheral vestibular effects (Ototoxic) Aminoglycoside, Loop diuretics Vancomycin, Erythromycin Antineoplastics, Quinine, NSAIDs Drugs with central vestibular or central nervous effects Quinolone, Tetracycline Antihypertensive (  -adrenergic blocker,  -blocker, Diuretic, CCB) Mood-altering/ Hypnotics (BZD, TCA, SSRI, SNRI, MAOI……) Levodopa, Vestibular suppressants

16. T: Trigger A specific act/situation that probokes or aggravates the symptons. ． Bending over, lying down, rolling over in bed and looking up √ typical of BPPV ． Sitting up, stnding up √ cardiac problem, orthostatic hypotension, TIA ． Spontaneously √ Stroke, MD, VM ． Rapid head move √ uni/bil VP, VM, PPPD

17. T: Trigger ． Dark √ bil VP, poor compensated uni VP ． Valsalva maneuver, couging or loud sounds √ PFs, SSCD ． Prolonged sleep disturbances, acute periods of stress √ MD, VM, uni/bil VP, aggravate PPPD ． Open squares, shopping malls and crowded spaces √ VM, panic attacks, typical for PPPD

18. O: Otology ． Sudden HL √ labyrinthitis ． Tinnitus, HL, pressure in the ears √ MD, VM ． Other types of HL √ third mobile window lesions, IAC/CP angle tumors, VMthird mobile window lesions ． Hyperacusis, autophonia √ VM, MD, SSCD

19. N: Neurology ． Central lesion (TIA, stroke, tumor) √ ABCD2 (?) √ NE: sensation/strength change ． Vestibular migraine √ headaches, current or past migraine, photophobia, scotoma, phonophobia, paresthesia, diplopia

20. ABCD2 ≥ 4 was sensitive (86.7%) to TIA but not specific (35.4%) for recurrent stroke within 7 days

21. E: Evolution ． Very disturbing int the early stage, gradual improvement over days √ VN ． Sudden attacks, with periods of little~no vertigo in between √ MD ． Fluctuating severity √ all other forms of vertigo ． May worsen over time √ PPPD, stroke, central lesion

22. D: Duration ． Secs √ VN ． Secs~mins √ BPPV, cardiac, panic ． Hours √ MD, VM, panic, TIA ． 5 mins~72 hrs √ VM ． Days~wks √ labyrinthitis, VN, stroke, drugs ． Variable √ bil VP/ poorly compensated uni VP, VM, PPPD, psychiatric

23. Take home messages ． It takes TIME… (notoriously unreliable, frustrated) ． Ask specific questions ． Might be more than one cause! ． Be aware of CVA risk factors always!

24. Correct diagnosis Targeted history taking: most important Clinical office (bedside) examinations Functional testing of the vestibular system imaging

25. Office physical examination ． EOM, Nystagmus spontaneous Gaze, positional DixHallpike, head roll test ． Head impulse test ． Weber/Rinne test ． Check BP,PR ． NE ． Romberg, Fukuda test ． HINTS

26. DixHallpike test for PC-BPPV 26

28. Head roll test for HC-BPPV

29. Geotropic Ny. vs. ApoGeotropic Ny. (Canalithiasis vs. Cupulolithiasis) canal side of cupulolithiasis utricle side of cupulolithiasis 水平半規管良性陣發性位置性眩暈的分類與其治療原則 中耳醫誌第 39 卷第 6 號 2004 邱文耀 蔡世哲 于篤學 李信賢 ．

30. 30

31. FPP ( Forced Prolonged Position)

32. Quiz: lesion side?

33. -> Cupulolithiasis of HC-BPPV,Lt ？？ <= 33

34. A single therapy for all subtypes of horizontal canal positional vertigo. Laryngoscope. 2005 Aug;115(8):1432-5 Cup-U HC-BPPV: HC-Cup :cupulolithiasis of HC-BPPV Cup-U: utricle side of cupulolithiasis Cup-C: canal side of cupulolithiasis

35. A single therapy for all subtypes of horizontal canal positional vertigo. Laryngoscope. 2005 Aug;115(8):1432-5 Cup-C HC-BPPV: HC-Cup :cupulolithiasis of HC-BPPV Cup-U: utricle side of cupulolithiasis Cup-C: canal side of cupulolithiasis

36. -> Cupulolithiasis of HC-BPPV,Lt （✘） <= 36

37. -> Cupulolithiasis of HC-BPPV （✔） <= 37

38. A single therapy for all subtypes of horizontal canal positional vertigo. Laryngoscope. 2005 Aug;115(8):1432-5 Cup-U ○ Cup-U,Lt ○

39. A single therapy for all subtypes of horizontal canal positional vertigo. Laryngoscope. 2005 Aug;115(8):1432-5 Cup-C

40. Diretion of cupula deviation equals slow phase of nystagmus

41. always lying to the side of weaker nystagmus => FPP (Forced Prolonged Position) Geo.(Rt stronger) FPP to Lt cured …>Dx: HC-Can,Rt ApoGeo.(Rt stronger) FPP to Lt cured …>Dx: Cup-U,Rt FPP to Lt Geo.(Lt stronger) …>Dx: Cup-C,Lt FPP to Rt cured

42. Lt DH: Rt AC: ampullofugal (downward, counterclockwise ) or ampullopetal (upward, clockwise) Lt AC: ampullofugal ~> common crus ~> Lt Post. canal

44. Head thrust/impulse test

45. Check BP, HR Orthostatic hypotension Lying-Sitting-StandingFunctional testing of the vestibular system EKG, Hb, blood sugar

47. NE (cerebellum) Test of coordination √ finger-nose-finger (FNF) √ Rapid alternating movement (RAM)

48. NE (muscle power) ． Is patient’s unsteadiness due to weakness? √ stand on heels and toes √ deep knee bend ． checking for inconsistency √ if can’t do Romberg, but can do others

49. Romberg test ． Not testing VOR, Not VSR, Not peripheral vestibular dysfunction ． Very nonspecific, but a fair tool for general assessment of postural ocontrol ． Assess the dorsal column of the spinal cord √ dorsal column damage √ peripheral neuropathy √ cerebellar lesions

50. Fukuda stepping test ． assess VSR (vestibule-spinal reflex)

51. HINTS 3 step “H.I.N.T.S.” eye examination ． Head Impulse ． Nystagmus type ． Test of Skew Stroke findings “I.N.F.A.R.C.T” ． Impulse Normal ． Fast-phase Alternating ． Refixation on Cover Test

52. Take home messages ． Undiagnosed: about 15~30% of all patients ． PE are not 100% sensitive √ follow the patient √ consider consultation orother tests

53. Correct diagnosis Targeted history taking: most important Clinical office (bedside) examinations Functional testing of the vestibular system Imaging

54. ． Videonystagmography (VNG) ． video Head Impulse Testing (vHIT) ． Caloric test ． Vestibular Evoked Myogenic Potentials (VEMP)

56. Correct diagnosis Targeted history taking: most important Clinical office (bedside) examinations Functional testing of the vestibular system Imaging

57. √ acute sustained vertigo √ findings suggestive of a central cause of dizziness ． Rule out a vascular event in patients who have vascular risk factors ． S/S that is not completely typical of a peripheral vestibulopathy The procedures of choice: MRI and MRA