“as the world turns” saleh fares aal-ali frcp-r3

““As the world Turns”As the world Turns”

Saleh Fares Aal-AliSaleh Fares Aal-Ali

FRCP-R3FRCP-R3

Objective to be Objective to be addressed:addressed: Difference between dizziness and vertigo.Difference between dizziness and vertigo.

• Treatment Considerations.

• Characteristics of central vertigo.

• Characteristics of peripheral vertigo.

• Diagnostic approach to True vertigo.

Patients refer to Dizziness Patients refer to Dizziness as:as:

• “out-of-it”

• Imbalanced

• Giddy

• Faintness• Sense of strangeness

• Light headednessLight headedness

Most dizzy patients can be placed Most dizzy patients can be placed in to one of four categories:in to one of four categories:

1- True Vertigo (50%)

2-Pre-syncope:2-Pre-syncope:

Transient sensation that a faint in Transient sensation that a faint in about to occur.about to occur.

• Transient.

• May present as nausea ,weakness, SOB or change in vision.

3-Dysequilibrium:3-Dysequilibrium:

A sensation of imbalance when A sensation of imbalance when standing or walking.standing or walking.

• No sense of faintness.

• No illusion.

4-Vague 4-Vague lightheadedness:lightheadedness: Holds the reminder of symptoms Holds the reminder of symptoms

of dizziness (which can’t fit to of dizziness (which can’t fit to the other categories)the other categories)

1.Psychiatric disorders,

2.Hyperventilation syndrome

3.Encephalopathies

What is Vertigo?What is Vertigo?

True vertigo:True vertigo:

Defined as an “illusion” or Defined as an “illusion” or “hallucination” of movement.“hallucination” of movement.

• Both vertigo and dysequilibrium imply a loss of balance, but vertigo involves a sense of motion.

How do we maintain How do we maintain equilibrium?equilibrium?

Visual inputVisual input

Proprioceptiual

input

Vestibular input

labyrinths.

equilibrium

Anatomy: Semicircular Anatomy: Semicircular canalscanals

Semicircular Canals Semicircular Canals (SCC)(SCC) HorizontalHorizontal AnteriorAnterior PosteriorPosterior

CupulaCupula End organ receptorsEnd organ receptors

EndolymphEndolymph

Anatomy: UtricleAnatomy: Utricle

UtricleUtricle Connected to SCCConnected to SCC Contains Contains

endolymphendolymph Otoliths Otoliths

(otoconia)(otoconia) Calcium carbonateCalcium carbonate Attached to hair Attached to hair

cellscells Macule (end organ)Macule (end organ)

Vestibular systemVestibular system

Tells brain which way the head Tells brain which way the head moves without lookingmoves without looking SCC: angular accelerationSCC: angular acceleration Utricle: linear accelerationUtricle: linear acceleration

How can we clinically How can we clinically evaluate the patient with evaluate the patient with

vertigo?vertigo?

labyrinthCN VIII

(Vestibular portion)

Vestibular

nuclei

Brainstem

VertigoCerebellum

VertigoVertigo

Central peripheral

Key points in History:Key points in History:

•Is true vertigo present?

•Are there associated neurologic symptoms?

•What is the pattern of onset ?

•What is the duration of the symptoms?

•Have there been auditory symptoms?

•Are there other associated symptoms?

•What medications is the patient taking?

•What is the patient’s past medical history?

•Any recent or remote head or neck injury?

Key points in the physical Key points in the physical examination:examination:

•Vital signs

•Bruits

•Ear exam

•Eye exam

•Positional testing

•Neurological exam (including gait)

SPINNEDSPINNED

SSudden (Onset)udden (Onset) YesYes Slow, gradualSlow, gradualPPositionalositional YesYes NoNoIIntensityntensity SevereSevere Ill definedIll definedNNausea/ausea/DiaphoresisDiaphoresis

FrequentFrequent InfrequentInfrequent

NNystagmusystagmus Torsional/Torsional/horizontalhorizontal

VerticalVertical

EEar (hearing loss)ar (hearing loss) Can be presentCan be present AbsentAbsentDDurationuration ParoxysmalParoxysmal ConstantConstantCNS signsCNS signs AbsentAbsent Usually Usually

presentpresent

PERIPHERAL CENTRAL

Carvalho et al. CTU , Oct, 2004

Case 1Case 1

Peripheral vertigo:Peripheral vertigo:•Approximation 85% of ED patients with vertigo.

•Due to dysfunction of one of vestibular organs.

•Asymmetry of input

•Sensation of rotation

•Associated with nausea, pallor and diaphoresis.

Differential DiagnosisDifferential Diagnosis Benign paroxysmal positional Benign paroxysmal positional

vertigo (BPPV) (50%)vertigo (BPPV) (50%) Vestibular neuritisVestibular neuritis Labyrinthitis (suppurative, serous, Labyrinthitis (suppurative, serous,

toxic, chronic) toxic, chronic) Meniere’s diseaseMeniere’s disease FB in ear canalFB in ear canal A cute otitis mediaA cute otitis media Perilymphatic fistula.Perilymphatic fistula.

BPPVBPPV

Benign Paroxysmal Positional Benign Paroxysmal Positional VertigoVertigo

Age 60- 70 (F:M 2:1)Age 60- 70 (F:M 2:1) Head traumaHead trauma

Characteristic storyCharacteristic story

Turn headTurn head After a few seconds delay, vertigo After a few seconds delay, vertigo

occursoccurs Resolves within 1 minute if you don’t Resolves within 1 minute if you don’t

movemove If you turn your head back, vertigo If you turn your head back, vertigo

recurs in the opposite directionrecurs in the opposite direction

““BBPPV”PPV”

““B” = BenignB” = Benign Not a brain Not a brain

tumortumor Can be Can be

severe and severe and disablingdisabling

““BBPPPV”PV”

““P” = ParoxysmalP” = Paroxysmal Episodic, not persistentEpisodic, not persistent Helpful feature in the differential Helpful feature in the differential

diagnosis diagnosis

““BPBPPPV”V”

““P” = PositionalP” = Positional Occurs with position of headOccurs with position of head

Turning over in bedTurning over in bed Looking upLooking up Bending overBending over

““BPPBPPVV””

““V” = VertigoV” = Vertigo An illusion of motionAn illusion of motion ““The room is spinning”The room is spinning” Other descriptionsOther descriptions

RockingRocking TiltingTilting SomersaultingSomersaulting Descending in an elevatorDescending in an elevator

Pathophysiology of BPPVPathophysiology of BPPV

Otoliths become Otoliths become detached from detached from hair cells in hair cells in utricleutricle

Inappropriately Inappropriately enter the enter the posterior posterior semicircular semicircular canalcanal

. Parnes LS, McClure JA. Laryngoscope 1992;102:988-92.

PhysiologyPhysiology

Normal situationNormal situation As one turns head to the rightAs one turns head to the right Endolymph moves Endolymph moves SCC receptors SCC receptors

fire fire “head turning right” “head turning right” Stop turning headStop turning head endolymph endolymph

stops moving stops moving SCC receptors stop SCC receptors stop firing firing “head has stopped moving” “head has stopped moving”

Pathophysiology of BPPVPathophysiology of BPPV BPPVBPPV

Stop turning head Stop turning head otoliths otoliths keep movingkeep moving drag endolymph drag endolymph receptors continue to fire receptors continue to fire inappropriately inappropriately “head is still “head is still moving”moving”

Eyes Eyes “head is NOT moving” “head is NOT moving”

Brain Brain room must be spinning room must be spinning in the opposite directionin the opposite direction

Dix-Hallpike ManeuverDix-Hallpike Maneuver

•The diagnosis of BPPV is generally from the

history.•Can confirm the diagnosis of BPPV

•First described by Dix and Hallpike in 1952.

•Also called the Nylen-BárányBárány, BárányBárány, Nylen, or Hallpike maneuver

Dix-Hallpike ManeuverDix-Hallpike ManeuverThey include:

1- Nystagmus

2- Provocative head position

3- Brief latency to symptoms after change in position

4- Short duration of attack

5- Fatigability of nystagmus on repeat testing

6-Reverse of nystagmus on returning to upright position.

Lab studiesLab studies

In a straightforward case, no In a straightforward case, no lab studies are needed! lab studies are needed!

HemoglobinHemoglobin Fingerstick glucose Fingerstick glucose Electrolytes if prolonged Electrolytes if prolonged

vomitingvomiting BHCG

1-The Epley Maneuver1-The Epley Maneuver

First described in 1992First described in 199222

BedsideBedside Immediate reliefImmediate relief

2. Epley J. Otolaryngol Head Neck Surg 1992;107:399-4043. Lynn S, et al. Otolaryngol Head Neck Surg 1995;113:712-20.

ED Therapy:

Epley reported an 80% success rate after a single time and 100% success rate after more than one session

30% recurrence rate over a

30-month period.

Epley Maneuver:Epley Maneuver:

Randomized controlled trials reported Randomized controlled trials reported success rates ranging fromsuccess rates ranging from

44% - 88%44% - 88%

•Froehling et al. Mayo clin proc Jul 2000

•Wolf et al. Clin otolaryngol feb 1999

•Asawarichianginda et al. ENT J Sep 2000

Epley maneuverEpley maneuver

Canalith repositioning maneuverCanalith repositioning maneuver 5 step head hanging maneuver5 step head hanging maneuver

Moves otoliths out of the Moves otoliths out of the posterior semicircular canal and posterior semicircular canal and back into utricle where they back into utricle where they belongbelong

Epley maneuverEpley maneuver

1. Repeat 1. Repeat Hallpike Hallpike Previously Previously

performed performed diagnostic diagnostic Hallpike test tells Hallpike test tells you the starting you the starting position (right or position (right or left)left)

Epley maneuverEpley maneuver

2. Turn head 90 2. Turn head 90 degrees in the degrees in the other directionother direction

Epley maneuverEpley maneuver

3. Patient rolls 3. Patient rolls onto shoulder, onto shoulder, rotates head and rotates head and looks down looks down towards floortowards floor

Epley maneuverEpley maneuver

Epley maneuverEpley maneuver

Repeating the Epley maneuverRepeating the Epley maneuver Post procedurePost procedure

Remain upright for 8-24 hoursRemain upright for 8-24 hours

The Epley ManeuverThe Epley Maneuver

ContraindicationsContraindications Unstable heart diseaseUnstable heart disease High grade carotid stenosisHigh grade carotid stenosis Severe neck diseaseSevere neck disease Ongoing CNS disease (TIA/stroke)Ongoing CNS disease (TIA/stroke) Pregnancy beyond 24Pregnancy beyond 24thth week week

gestation (relative)gestation (relative)

Furman JM, Cass SP. N Engl J Med 1999;341:1590-96

ComplicationsComplications

VomitingVomiting Converting to horizontal canal Converting to horizontal canal

BPPVBPPV

ED therapyED therapy

2- Vestibular Suppressants:

•Meclizine is the most commonly used (H1 – antagonist)

•Can significanthy reduce symptoms.

Cohen et at. Arch Nenrol. Aug 1972(RCT)

•Dimenhydrinate (Gravol) and diphenhydramine (Benedryl) have also been used.

•Their efficacy is likely mediated by their anticholinergic activity.

•They inhibit muscarinic acetylcholine receptors involved in feedback from the brainstem to the vestibular labyrinth.

•If N/V promethazine (phenergan) or prochlorperazine (stemetil)

(extrapyramidal effect)

BenzodiazepinesBenzodiazepines generalized inhibition of neural generalized inhibition of neural

activityactivityIn a review article:Authors did not encourage the use of vestibular suppressants:

• suppress the intensity of symptoms.

• but do not reduce the frequency of attacks.

Furman JM, Cass SP. N Engl J Med 1999;341:1590-96

The Vast majority of peripheral The Vast majority of peripheral vertigo can be managed vertigo can be managed conservatively.conservatively.

Surgery for intractable and Surgery for intractable and incapacitating symptoms.incapacitating symptoms.

Labyrinthitis and Vestibular Labyrinthitis and Vestibular neuronitisneuronitis

A cute unilateral loss of peripheral A cute unilateral loss of peripheral vestibular functionvestibular function

Associated with vertigo, N/V, and Associated with vertigo, N/V, and nystagmusnystagmus

Worsened by head movementWorsened by head movement Occurs in healthy young to middle-Occurs in healthy young to middle-

aged adultsaged adults Often after respiratory infections Often after respiratory infections self-limitingself-limiting

Perilymphatic fistula:Perilymphatic fistula:

Due to a traumatic “fistula” at the Due to a traumatic “fistula” at the round or oval window.round or oval window.

After forceful cough, sneeze, scuba After forceful cough, sneeze, scuba diving or direct blow to the ear.diving or direct blow to the ear.

Recurrence of vertigo with pneumo-Recurrence of vertigo with pneumo-otoscopy (Hennebert’s sign)otoscopy (Hennebert’s sign)

Self-limitingSelf-limiting

Meniere’s disease:Meniere’s disease:

Characterized by triad of:Characterized by triad of:• vertigovertigo• tinnitustinnitus• hearing loss (sensorineural)hearing loss (sensorineural)

Chronic relapsing illness (? familial)Chronic relapsing illness (? familial) Due to a build-up of endolymphatic Due to a build-up of endolymphatic

pressure in the labyrinth.pressure in the labyrinth. Treatment: vestibular suppressants.Treatment: vestibular suppressants.

Meniere’s diseaseMeniere’s disease

When to D/C?When to D/C?

1- Peripheral vertigo.1- Peripheral vertigo.2- Healthy

3- Help at home.

4- Symptoms controlled.

5- Able to ambulate.

F/U with PMD to arrange F/U with PMD to arrange further evaluation if patient further evaluation if patient does not improve. does not improve.

Case 2Case 2

Central vertigoCentral vertigo

May include disorders with May include disorders with significant potential significant potential morbidity.morbidity.

Warrants the initiation of Warrants the initiation of further work-up.further work-up.

SPINNEDSPINNED

SSudden (Onset)udden (Onset) YesYes Slow, gradualSlow, gradualPPositionalositional YesYes NoNoIIntensityntensity SevereSevere Ill definedIll definedNNausea/ausea/DiaphoresisDiaphoresis

FrequentFrequent InfrequentInfrequent

NNystagmusystagmus Torsional/Torsional/horizontalhorizontal

VerticalVertical

EEar (hearing loss)ar (hearing loss) Can be presentCan be present AbsentAbsentDDurationuration ParoxysmalParoxysmal ConstantConstantCNS signsCNS signs AbsentAbsent Usually Usually

presentpresent

PERIPHERAL CENTRAL

Carvalho et al. CTU , Oct, 2004

Differential DiagnosisDifferential Diagnosis::

Vertebral-basilar Vertebral-basilar circulation events:circulation events:1.1. Vestibular nuclei (TIA or Vestibular nuclei (TIA or

stroke)stroke)2.2. Cerebellar infarction or Cerebellar infarction or

hemorrhagehemorrhage3.3. Lateral medullary Lateral medullary

infarction (Wallenberg’s infarction (Wallenberg’s syndrome)syndrome)

4. Vertebral artery dissection4. Vertebral artery dissection MigraineMigraine Post concussive syndrome.Post concussive syndrome. Tumors (acoustic reuromas)Tumors (acoustic reuromas) Multiple sclerosisMultiple sclerosis Infection (encephalitis, Infection (encephalitis,

meningitis)meningitis)

Neuroimaging in vertigo:Neuroimaging in vertigo:

Headache(sudden onset or severe)Headache(sudden onset or severe) Hard neurological findingsHard neurological findings No imaging for patients with no No imaging for patients with no

risk factors and exam suggestive risk factors and exam suggestive of peripheral vertigo.of peripheral vertigo.

Twenty four patients with risk factors Twenty four patients with risk factors with stroke with history of vertigo with stroke with history of vertigo (>48 hrs) and normal neurologic (>48 hrs) and normal neurologic exam (except nystagemus) 25% exam (except nystagemus) 25% had inferior cerebellar infarction.had inferior cerebellar infarction.

Norrving et al. Norrving et al. Acta Neurol Scand.Acta Neurol Scand. Jan 1995 Jan 1995

CT CT vs vs MRI:MRI:

MRI/MRA for vertebrobasilar MRI/MRA for vertebrobasilar disease and cerebellar ischemia .disease and cerebellar ischemia .

CT is more sensitive for CT is more sensitive for hemorrhagehemorrhage

negative CT is not always negative CT is not always reassuring. reassuring.

Bad Excuses In Court:Bad Excuses In Court:

1. "I thought the medications 1. "I thought the medications would help…not cause her to fall would help…not cause her to fall and break her hip.“and break her hip.“

2. "I know it was vertical 2. "I know it was vertical nystagmus, but there were no nystagmus, but there were no other neurological findings so I other neurological findings so I assumed it was peripheral assumed it was peripheral vertigo." vertigo."

3. "I thought it was obvious that 3. "I thought it was obvious that the patient shouldn’t drive." the patient shouldn’t drive."

4. "The vertigo had subsided, so 4. "The vertigo had subsided, so I thought it was okay for him to I thought it was okay for him to walk to the bathroom.“walk to the bathroom.“

5. "The patient was too young to 5. "The patient was too young to worry about a stroke”.worry about a stroke”.

6. "I didn’t know that the patient 6. "I didn’t know that the patient had decreased hearing.“had decreased hearing.“

7. "The CT was normal, so I 7. "The CT was normal, so I thought it was safe to send the thought it was safe to send the patient home." patient home."

8. "The patient came from the 8. "The patient came from the psychiatric hospital, so I psychiatric hospital, so I assumed that he was crazyassumed that he was crazy." ."

The endThe end