2. Vertigo Diagnosis Management_Short version.pptx

ENT management

1. Diagnosis and Management of Vertigo

2. Vertigo- Definition ‘The sensation of motion when no motion is occurring relative to earth’s gravity’ 1 A feeling of movement, a sensation as if the external world were revolving around the patient (objective vertigo) or as if he himself were revolving in space (subjective vertigo) 2 Sense of rotation Symptom expression of disorder of vestibular system Committee on Hearing and Equilibrium , Otolaryngol Head Neck Surg 1995;113:181–5. 2. International Classification of Disease [Online] Access at http://www.icd9data.com/2012/Volume1/780- 799/780-789/780/780.4.htm

3. Vertigo- Epidemiology The lifetime prevalence of vertigo in adults (18–79 years) is 7.4% The one-year prevalence is 4.9%, & the one year incidence is 1.4%. Female preponderance is observed among individuals with vertigo (one-year prevalence ratio for male to female 1:2.7) In patients >65 years prevalence rate is 8-9% 3 times more frequent in the elderly compared to the young Neuhauser HK, von Brevern M, Radtke A, et al. Neurology 2005;65:898–904.

4. Vertigo Impact Neuhauser HK, von Brevern M, Radtke A, et al. Neurology 2005;65:898–904.

5. Diagnosis Dizziness is a common presenting complaint Determination of accurate cause remains challenging Accurate diagnosis helps in appropriate intervention and resolution of symptoms In a study of 3400 patients over 70 years of age an accurate diagnosis was possible in more than 75% 1. Katsarkas A. Geriatrics 2008;63:18–20. 2. Moeller JJ, Kurniawan J, Gubitz GJ, et al. Can J Neurol Sci 2008;35:335–41.

6. Diagnosis Proper history and a good clinical examination can provide a diagnosis in the majority of the patients .(75% cases accurate diagnosis possible) Systematic approach to patients with vertigo 1)Presence of vertigo is established 2)Duration of vertiginous event and recurrence is determined 3)Type of nystagmus is observed 4)Additional co occuring symptoms Garg RK, Kothari S. Guidelines on Vertigo, Indian Academy of Neurology

7. Duration of vertiginous event and recurrence 1) BPPV: few seconds to <1 min [recurrent] 2) Menieres disease:20 min to 20 hr/few hr[recurrent] 3)Migraine associated vertigo: >few min to 60min [recurrent] 4)Acute long duration:vestibular neuritis,labyrinthitis,labyrinthine concussion/ischemia cerebellar infarct/ ischemia,brain stem infarct/ischemia

8. Nystagmus characteristics Peripheral: Horizontal/ tortional , fixed direction, suppressed by optical fixation, follows Alexanders and Ewalds law Central: Vertical horizontal tortional , not suppressed by optical fixation, d irection changing,

9. Additional symptoms that aid in making diagnosis A) Auditory symptoms:hearing loss,tinnitus,aural fullness B) Nausea: Seen in both peripheral > central C) Focal neurological signs: dysarthria , inco-ordinationo D) Imbalance Patients with central cause have prolonged time for symptoms to subside compared to relatively faster central compensation that is possible and typical of peripheral causes

10. Test during examination 1. Spontaneous nystagmus 2. Gaze nystagmus 3. Smooth pursuit 4. Saccades 5. Fixation suppression 6. Head thrust 7. Headshake 8. Dynamic visual acuity 9. Hallpike positioning 10. Static positional 11. Limb co-ordination 12. Romberg stance 13. Gait observation 14. Specialized tests Garg RK, Kothari S. Guidelines on Vertigo, Indian Academy of Neurology

11. The Head Thrust Test Edlow JA, Newman- Toker DE, Savitz SI. Diagnosis and initial management of cerebellar infarction. Lancet Neurol 2008;7:951–964.

12. Dix- Hallpike Positioning Test Parnes LS, Agrawal SK, Atlas J. Diagnosis and management of benign paroxysmal positional vertigo (BPPV). CMAJ. 2003:169:681-693

13. Supine Lateral head Turns Lee S-H, Kim JS. Benign Paroxysmal Positional Vertigo. Journal of Clinical Neurology (Seoul, Korea). 2010;6(2):51-63. doi:10.3988/jcn.2010.6.2.51.

14. Test of Skew Skew deviation is vertical ocular misalignment that results from a right-left imbalance of vestibular neural firing. Skew deviation is generally detected by alternate cover testing Skew deviation in acute vestibular syndrome was strongly linked to the presence of brainstem lesions. Garg RK, Kothari S. Guidelines on Vertigo, Indian Academy of Neurology

15. 3 dangerous, subtle occulomotor signs “INFARCT” IN - impulse normal FA - fast phase alternating RCT – re-fixation on cover test Garg RK, Kothari S. Guidelines on Vertigo, Indian Academy of Neurology

16. Horizontal Head-Impulse Test, Nystagmus and Test of Skew (HINTS) HINTS has recently been shown to detect brainstem and cerebellar stroke with greater sensitivity than neuro-imaging Garg RK, Kothari S. Guidelines on Vertigo, Indian Academy of Neurology

17. Algorithm For various tests Garg RK, Kothari S. Guidelines on Vertigo, Indian Academy of Neurology

18. Menière’s disease BPPV Vestibular paroxysmia Bilateral vestibulopathy Acute unilateral vestibulopathy The five most frequent peripheral vestibular disorders: acute unilateral and bilateral vestibulopathy, vestibular paroxysmia, BPPV, Menière’s disease

19. Vertigo Triggers Thomas S, Cherian A. Guidelines on Vertigo, Indian Academy of Neurology Triggers Suspected Diagnosis Change of head posture BPPV, vestibular migraine, central positional vertigo Menstruation, sleep deprivation Vestibular migraine Elevators, closed spaces Panic attacks Loud noise, Valsalva Fistula syndromes

20. Duration of events *Vertigo with early acute vestibular neuritis can last as briefly as 2 days or as long as 1 week or more. Duration Suspected Diagnosis A few seconds Peripheral cause: unilateral loss of vestibular function; late stages of acute vestibular neuronitis ; late stages of Ménière’s disease Several seconds to a few minutes Benign paroxysmal positional vertigo; perilymphatic fistula Several minutes to 1 hour Posterior transient ischemic attack; perilymphatic fistula Hours Ménière’s disease; perilymphatic fistula from trauma or surgery; migraine; acoustic neuroma Days Early acute vestibular Neuronitis*; stroke; migraine; multiple sclerosis Weeks Psychogenic (constant vertigo lasting weeks without improvement) Garg RK, Kothari S. Guidelines on Vertigo, Indian Academy of Neurology

21. Approach to a vertigo patient Cont … on next slide Patient presents with dizziness History of medication, caffeine, nicotine, and alcohol intake; history of head trauma or whiplash injury False sense of motion of spinning sensation Vertigo Headache and other symptoms s/o migraine Hearing loss Migraine Neurological deficit CNS causes Other causes: traumatic, cervicogenic Neuro -imaging Kanikanna MA, Kandadai RM, Jabeen SA, Guidelines on Vertigo, Indian Academy of Neurology

22. Approach to a vertigo patient (cont) Hearing loss Yes No No fever: Ménière’s Disease Fever: labyrinthitis Vestibular neuritis: viral infection BPPV Perform Dix- Hallpike Kanikanna MA, Kandadai RM, Jabeen SA, Guidelines on Vertigo, Indian Academy of Neurology

23. Investigations Test Evaluates Electronystagmography VOR + LSCC Videonystagmography VOR + LSCC + oculomotor system Craniocorpography VSR Video head impulse test VOR of 6 SCCs Subjective visual vertical Otolithic system Stabilometry VSR + stability Vestibular evoked myogenic potential Saccule + inferior vestibular nerve Pure tone audiometry Middle ear/cochlear/ retrocochlear function Brainstem evoked response audiometry Retrocochlear electrocochleography Cochlear function nerve conduction velocity; and somatosensory evoked potential Neural conduction in the peripheral nerves and in the ascending and descending columns Biswas A, Guidelines on Vertigo, Indian Academy of Neurology VOR: vestibulo -ocular reflex; LSCC: lateral semicircular canal; VSR: vestibulospinal reflex; SCCs: semicircular canals.

24. Distinguishing Features (1) Test Peripheral (labyrinth) Central (brainstem or cerebellum) Direction of associated nystagmus Unidirectional; fast phase opposite lesion Bidirectional or unidirectional Purely horizontal nystagmus without torsional component Uncommon Common Vertical or purely torsional nystagmus Never present May be present Visual fixation Inhibits nystagmus and vertigo No inhibition Severity of vertigo Marked Often mild Direction of spin Toward fast phase Variable Direction of fall Toward slow phase Variable Kothari S, Guidelines on Vertigo, Indian Academy of Neurology

25. Imaging studies in vertigo 1)Acute vertigo with neurological signs, central nystagmus,profound imbalance 2)Older patients with vascular risk factors even if other characters support a peripheral cause 3)Patients with auditory symptoms ,supporting peripheral cause imaging is less necessary.

26. Distinguishing Features (2) Test Peripheral (labyrinth) Central (brainstem or cerebellum) Duration of symptoms Finite (minutes, days, weeks) but recurrent May be chronic Tinnitus and/or deafness Often present Usually absent Associated CNS abnormalities None Extremely common (e.g., diplopia , hiccups, cranial neuropathies, dysarthria ) Common causes BPPV, infection ( labyrinthitis ), Ménière’s , neuronitis , ischemia, trauma, toxin Vascular, demyelinating, neoplasm Kothari S, Guidelines on Vertigo, Indian Academy of Neurology

27. Vertigo management

28. Empathy and Reassurance Most patients with acute vertigo are very anxious Alleviate their anxiety by explaining cause of vertigo and nature of the disorder Positive counseling Kirtane MV, Biswas A, Guidelines on Vertigo, Indian Academy of Neurology

29. Vestibular Rehabilitation (VR) Should be started from day 1 Defined as a form of physical therapy recommended for vertigo which uses specialized exercises to regain gaze and gait stabilization. Singly or in combination with pharmacological treatment has proved useful for managing vestibular or central balance dysfunction Panagariya A, Dubey P Guidelines on Vertigo, Indian Academy of Neurology

30. In BPPV Canal repositioning maneuver is the mainstay of management of BPPV, such as: Epley’s maneuver and the Semont’s maneuver The Brandt- Daroff ’s exercises Log-roll exercises Panagariya A, Dubey P Guidelines on Vertigo, Indian Academy of Neurology

31. Pharmacotherapy Anti-vertigo drugs, mainly to provide symptomatic relief and not for a curative treatment Vestibular Suppressants to be discontinued within 1 to 3 days 1 Suppressants current recommendation is < 24hrs 2 1. Lacour M., Restoration of vestibular function: basic aspects and practical advances for rehabilitation. Curr Med Res Opin 2006; 22:1651-59 2. Baloh RW, Kerber KA. Clinical Neurophysiology of the vestibular system. Fourth ed. New York: Oxford University Press, 2011.

32. Betahistine – Dose & Duration Personalized doses – vestibular compensation varies tremendously between patients as it is a function of neuroplastic adaptation Betahistine – Dose and Duration dependent efficacy ( Alcocer et al 2015) IAN recommends 48-72mg/day as a reasonable dose to treat sub acute vertigo Betahistine 48mg daily for 3-6 months is an effective and safe treatment for Ménière’s disease and different types of peripheral vertigo. ( Alcocer et al 2015) Use of “higher dose” (48mg TID) proven to be more effective in reducing vertigo attacks compared to “lower dose” (16mg or 24mg TID) (Strupp et al., 2008) 1. Kirtane MV, Biswas A, Guidelines on Vertigo, Indian Academy of Neurology 2. Lacour M. Curr Med Res Opin 2006; 22:1651-59 3. Strupp et al. Acta Oto-Laryngologica 2008; 1-5. 4. Alcocer et al. Acta Otolaryngol . 2015 Aug 6:1-7.

33. Commonly used medications Kirtane MV, Biswas A, Guidelines on Vertigo, Indian Academy of Neurology

34. Management of Acute Vertigo Providing symptomatic relief is important, to reduce anxiety and morbidity Anti-vertigo drugs are recommended for 1-3 days Detailed examination is required Antiemetic (Dimenhydrinate, Prochlorperazine etc) are prudent to use for 1-3 days Once acute symptoms subside, put the patient on a non-CNS depressant drug like Betahistine at a dose of 48–72 mg Put the patient on vestibular exercises right from the first or second day Kirtane MV, Biswas A, Guidelines on Vertigo, Indian Academy of Neurology

35. Concerns in Management Use of combinations of anti histamine with histamine analogues Usage of drugs in sub-therapeutic dosage Tapering off of anti vertigo drugs Long-term use of anti vertigo drugs without establishing a definitive diagnosis Kirtane MV, Biswas A, Guidelines on Vertigo, Indian Academy of Neurology

36. Case 1: A 41 year old male with recent vertigo 24 hours in duration and hearing loss in right ear following upper respiratory infection.

37. Case 2: A 35 year old female with 2 year history of monthly intense vertigo with duration of 2-3 hours.No auditory symptoms. But has lateralised moderate headache,as well as light and sound sensitivity.

38. Case 3: A 72 year old male with 2 month history of intense vertigo provoked with turning to his right side in bed.Duration is less than one minute but patient becomes nauseated.

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