13 eval of giddiness

13 eval of giddiness

1. Evaluation of giddiness 1

2. Introduction Classification of vertigo Evaluation Diagnosis Management Evaluation of giddiness 2

3. Introduction Dysequilibrium , unsteadiness, vertigo, and lightheadedness Vertigo is an illusory sense of motion Internal feeling Objects in the surroundings are moving or tilting Sense of motion Rotatory Linear Change in orientation relative to the vertical 3

4. Introduction 9 th Most common symptom Significant sorting problem Patients prefer a "symptom" oriented setting to a "cause" oriented setting Causes Otologic (40-50%) Neurologic (10-30%) General medical (10-30%) Psychiatric/undiagnosed (15-50%) 4

5. Classification 5

6. Classification Duration of involvement Central & peripheral Topographical classification Non vestibular causes 6

7. Duration of giddiness Short lived episodic rotatory vertigo (few sec) BPPV Labyrinthine fistula Caloric effect Alternobaric vertigo Post concussion syn Vertebrobasilar insufficiency Cervical vertigo 7

8. Duration of giddiness Few minutes to < 24 hrs Meniere’s disease Syphilitic labyrynthitis Delayed endolymphatic hydrops Foll middle ear surgery Decompensation of previous vestibular lesion 8

9. Duration of giddiness Prolonged rotatory vertigo Vestibular neuronitis Trauma Head injury Ear surgery Labyrinthectomy Vestibular neuronectomy Labyrinthitis Vascular lesions Mets at CP angle 9

10. Classification CENTRAL Cerebellopontine angle tumor Cerebrovascular disease Migraine Multiple sclerosis Cerebellar lesions Epilepsy Parkinsonism meningitis PERIPHERAL Acute labrynthitis Vestibular neuritis BPPV Cholesteatoma Meniere’s disease Ostosclerosis Perilymphatic fistula 10

11. Non vestibular System Disease Endocrine Hypoglycaemia , adrenal failure, pheochromocytoma CVS Vasovagal syncope, orthostatic hypotension, embolic disease, cardiac dysarythmias Haematological Hyperviscosity syn , anaemia Psychological Anxiety, phobias, panic attacks 11

12. Post head injury Post concussion BPPV Destructive labyrinth lesions Perilymph fistula Delayed endolymphatic hydrops Functional 12

13. Evaluation 13

14. Evaluation - history Define patient's dizziness - Vertigo, Impulsion, lightheaded, oscillopsia , ataxia, confusion. Timing (BPPV-seconds, TIA-minutes,  meniere’s -hours, Vestibular Neuronitis -Days,  ototoxicity -years) Associations head motion or change in head position, hearing disturbance, headache, cognitive symptoms, relation to stress. Review of systems especially vascular risk factors and ear surgery. Family History Similar disorder ? Migraine Medication History present and past exposures to ototoxins , antihypertensives . Previous studies 14

15. Topographical Symptom Site of lesion Tinnitus, hearing loss Peripheral (labyrinth / 8 th CN) Ear fullness, Tinnitus, hearing loss Labyrinthine 5 th ,6 th ,7 th CN CP angle EAC vesicles 7 th , 8 th neuritis Diplopia , 3 rd ,4 th ,6 th , facial numbness, difficulty swallowig , choking Brainstem Uni / bilateral numbness, weakness, ataxia, long tract, hemianopia Cerebral hemisphere 15

16. Symptom Diagnosis Aural fullness Acoustic neuroma ; Ménière's disease Ear or mastoid pain Acoustic neuroma ; acute middle ear disease (e.g., otitis media, herpes zoster oticus ) Facial weakness Acoustic neuroma ; herpes zoster oticus Focal neurologic Cerebellopontine angle tumor; cerebrovascular disease; multiple sclerosis Headache Acoustic neuroma ; migraine Associated symptoms & diagnosis 16

17. Symptom diagnosis Nystagmus Peripheral or central vertigo Photophobia Migraine Tinnitus Acute labyrinthitis ; acoustic neuroma ; Ménière's disease Imbalance Acute vestibular neuronitis cerebellopontine angle tumor Hearing loss Ménière's disease; perilymphatic fistula; acoustic neuroma ; cholesteatoma , otosclerosis ; TIA or stroke involving anterior inferior cerebellar artery,herpes zoster oticus Associated symptoms & diagnosis 17

18. Provoking Factors for Different Causes Provoking factor Suggested diagnosis Changes in head position Acute labyrinthitis ; benign positional paroxysmal vertigo; multiple sclerosis; perilymphatic fistula Spontaneous episodes Acute vestibular neuronitis; cerebrovascular disease (stroke or transient ischemic attack); (i.e., no consistent provoking factors) Ménière's disease; migraine; multiple sclerosis Recent upper respiratory viral illness Acute vestibular neuronitis 18

19. Provoking factor Suggested diagnosis Stress Psychiatric or psychological causes; migraine Immunosuppression (e.g., immunosuppressive medications, advanced age , stress) Herpes zoster oticus Changes in ear pressure, head trauma, excessive straining, loud noises Perilymphatic fistula 19 Provoking Factors for Different Causes

20. Historical algorithm 20

21. Examination 21

22. Examination General Medical Examination Personality Anaemia Blood pressure  Orthostatic changes in blood pressure or pulse, Hypertensive Cardiac Arrhythmia, murmur, bruit 22

23. Examination Otologic Examination Middle ear pathology Hearing Neurotological examination Cranial nerves Motor power and reflexes, pathological reflexes (e.g. Babinski ) Sensory ( proprioception ) Cerebellar signs 23

24. Examination Cerebellar Tests Ataxia, atonia , and asthenia Intention tremor (tremor that increases on activity) Dyssynergia ( incoordination ) Dysmetria (overshooting or undershooting) Dysrhythmia (inability to repeat a rhythmic tap) Dysdiadochokinesis (difficulty with rapid alternating movements) Dysarthria (staccato or scanning speech) 24

25. Examination Oculomotor examination Spontaneous nystagmus unilateral vestibular hypofunction + head is still, dampened by visual fixation increased or only becomes apparent when fixation is eliminated Slow phase Alexander’s law Grading nysagmus 25

26. Examination Vestibular examination Specific T Dix Hallpike T Fistula T Non Specific Test ENG Rotation T Otolith Function T Ocular counterrolling Parallel swing T Axis rotation T Whiplash T Passive neck torsion T Static Neck Torsion Vestibulospinal T Rhombergs T Untenberger T craniocorpography Posturography VEMP Others Caloric T Head shaking T Hyperventillation 26

27. Examination Dix hallpike T or Nylén-Bárány sign Procedure Head 45° turned Lowered & hyperextended -30 sec Rt Dix Hallpike Rt PSCC - Upbeat , Torsional , Lt SSCC - Downbeat Torsional Lat SCC – modified T Geotropic, Ageotropic 27

28. Examination Nystamus Latency 5-10 s Max 1 minute Severe vertigo Fatigues rapidly Fatiguability A positive dix-hallpike maneuver has a 50-80 percent sensitivity Contra indications carotid stenosis vertebrobasilar vascular disease cervical spine disease spinal injury cardiovascular disease or cardiac dysrhythmia 28

29. Examination Fistula T Procedure Politzer bag Siegle otoscope Digital pressure Impedance bridge Bony fistula in a Lat semicircular canal Vestibulofibrosis Hennebert's sign - + ve in > 25% of Ménière's patients Perilymph fistula of the oval or round window 29

30. Caloric T Robert Barany in 1906 Nobel prize 1914   Mechanism Barany Convective flow Coats and Smith direct effect of temperature on hair cells or vestibular-nerve afferents Scherer and Clarke thermal expansion of labyrinthine fluids will result in a maintained cupular displacement 30

31. Caloric T Tests Fitzgerald hallpike Alternate binaural, bithermal T Air Caloric T Kobrak’s T Dunda’s T Fitzgerald hallpike T Testing procedure Lat SCC closest to EAC oriented in the plane of the temperature gradient 31

32. Caloric T Head elevated – 30 degree Irrigation 250 ml, 60 cms high, over 60 sec right warm, left warm, right cold, left cold COWS – 2-3 mins 10 mins - between successive irrigations Results Jonkees , Maas & philipzoon Formula Canal paresis Directional preponderance Significant UW of greater than 20% DP of greater than 25% 32

33. Caloric T Air caloric T Kobrak’s T Dundas Grant cold air Caloric T Ethylene chloride sprayed Cloth wrapped Coiled copper tube Air blown through coil 33

34. Examination Untenberger’s T Stepping T, 1938 Blindfolded stretched arms Spot Stepping 90 steps in 1 min Inferance Displacement – 2 mts Angular deviation – 70- R, 50 – L Angular rotation – 85 – R, 60 – L Lateral sway – 15 cms 34

35. Examination Rhomberg’s T Sensory From cerebellar Sway > 10 cms Craniocorpography Crude Test Dark room Stepping T Rhomberg’s T 35

36. Examination Cervicogenic Vertigo Vascular theory Neurosensory theory Whiplash T Passive neck torsion T Head mobile Static Neck Torsion Body mobile 36

37. Lab tests Electronystagmography Defn Mechanism CRP Electrode placement 1 channel 2 channel 4 channel Criteria Eye movt to have a slow & fast phase Amplitude > 20 microvolts 37

38. ENG Saccade T Tracking T Optokinetic T Gaze T Positional T Caloric T 38

39. ENG Gaze T N – end point nystagmus > 40 degree Vertical N – CNS pathology Horizontal N B\L , equal – CNS B\L , unequal – CNS Unilateral - peripheral 39

40. VNG Method of oculography Frenzel glasses with VNG apparatus Video recording Torsional movt No artefacts as in ENG 40

41. ENG Vs VNG ENG 50 – 1000 Hz recordable Eyes closed / open Artefacts + Torsional Nyst - Calibration difficult Cheap VNG 60 Hz only Eyes open No Artefacts Torsional Nyst + Calibration easy Expensive 41

42. Rotatory Chair Principle Testing procedures Indications Bilateral canal paresis Inconclusive/equivocal ENG reults Testing of special populations (pediatric, handicapped) Evaluation of vestibular compensation Ototoxicity management 42

43. Posturography Nasher & Black Sensory organisation Motor coordination Procedure Sensory organisation chart Motor coordination T Sudden movement emg of gastrocnemius 43

44. VEMP Vestibulo-collic reflex Unilateral reflex Procedure 3 electrodes 95 -105 dB emg of SCM Uses Acoustic neuroma Vestibular neuritis Sup SCC dehiscence Tulio phenomenon 44

45. VEMP Pathology VEMP Response Meniere's disease Absent, reduced, enhanced Superior canal dehiscence syndrome Enhanced Neurolabyrinthitis Absent, reduced Vestibular neuritis Absent, reduced Migraine Absent, reduced, delayed Spinocerebellar degeneration Absent, delayed Multiple sclerosis Absent, delayed Brainstem stroke Absent, delayed 45

46. Diagnosis 46

47. BPPV Vertigo without auditory symptoms Severe vertigo < 1 min Triggerred by head movt Latent period after head movement Dix hallpike is confirmatory ENG 47

48. Vestibular neuronitis Vertigo without auditory symptoms Lasts for > 24 hrs h/o preceding URTI Unilateral Caloric T - Canal paresis 48

49. Meniere’s disease Episodic vertigo with fluctuant hearing loss Vertigo lasting upto 20 min Tinnitus with aural fullness Electrocochleography Glycerol dehydration T 49

50. Thank you 50