Vertigo presentation: Presentation and management

Vertigo presentation: Presentation and management

1. Vertigo

2. How do we maintain equilibrium

3. Vestibular system

4. Definition Subjective sense of imbalance “Sensation as if the external world is revolving around the patient or as if he himself is revolving in a space”

5. Importance

6. Evaluation of patients Onset (acute/chronic) Frequency – how often Duration Associated auditory symptoms Aggravating and relieving factors Ear disease or ear surgery – tinnitus? Trauma Migraine Ototoxic drug intake – (chemotherapy, aminoglycosides, methotrexate) Family history Motion sickness

7. Differential Diagnosis:

8. Peripheral vs Central Vertigo

9. Nystagmus: Features of Peripheral

10. Features of Central Nystagmus -Prominent with and without fixation -Can be purely vertical (always central), horizontal, or torsional, of have some combination -The rule is if the nystagmus is vertical (upbeat or downbeat), it is central i.e. not coming from the inner ear -Cerebellar: spontaneous downbeat with vertical amplitude increasing with horizontal gaze deviation or brought out when placed in supine position

11. Bedside Tests of Horizontal VOR: Head Thrust Test Rapid, high-acceleration head thrust with patient fixating on examiner’s nose Corrective saccade (catch-up saccade) when head is rotated toward the affected vestibular periphery is positive Positive in vestibular neuritis+ May be normal to have slight VOR hypometria bilaterally in older patients

12. Bedside Vestibulospinal Examination

13. Peripheral Causes  Vestibular neuritis Benign paroxysmal positional vertigo ( BPPV) Meniere’s disease (Endolymphatic hydrops )

14. Vestibular Neuritis Viral infection of vestibular organ Affect all ages but rare in children – mostly adults Affected patient presents acutely with spontaneous nystagmus ,vertigo and nausea &vomiting stays for hours and sometimes days. Patient requires only symptomatic treatment It takes 3 weeks to recover from vestibular neuritis Diagnosis – no other tool other than history. Recent study studies show that giving steroids decreases the 3 week recovery period.

15. BPPV The most common cause of vertigo in patient > 40 years Calcium carbonate particles shear off and enter the canal leading to brief episodes of vertigo. Repeated attacks of vertigo usually of short duration less than a minute . Provoked by certain positions (rolling in beds, looking up ,and head rotations) Not associated with any hearing impairment

16. BPPV: Diagnosis HISTORY++ Posterior canal++ Dix- Hallplike : only standard clinical test of great clinical significance in posterior canal BPPV The pathognomonic sign of BPPV is the rotatory nystagmus with latency and short duration. Horizontal canal: Supine head roll test Superior canal: Extremely rare Dix- Hallplike

17. Dix- Hallplike : Assessment of Posterior canal

18. Supine Head Roll

19. Treatment Best treatment: Canal repositioning maneuvers Posterior canal BPPV: Epley++, Semont liberatory maneuver Lateral canal: BBQ maneuver Superior canal: Yacovino

20. Epley

21. Semont

22. BBQ Maneuver

23. Superior Canal: Challenging to diagnose Vertical downbeat nystagmus with torsional component toward the affected side on Dix No accepted specific maneuver for diagnosis Yacovino maneuver may be tried for treatment (independent of affected side)

24. Yacovino Maneuver

25. Meniere’s Disease: Clinical condition 2 ≤ Spontaneous vertigo episodes (20 mins- 12 hours) Documented SNHL (low/mid-frequencies) Fluctuating aural symptoms (tinnitus/ fullness) Etiology not clear. Endolymphatic hydrops?

26. Diagnosis Clinical diagnosis: disease typically presents with unilateral ear symptoms that can last for several decades MD attacks are typically random and episodic (approximately 6-11 per year), with periods of remission that may last months to years As such, the diagnosis of MD is typically not made at 1 point in time; rather, it may take months or even years to fully appreciate the clinical manifestations leading to definitive diagnosis

27. Treatment: The goals of MD treatment are to prevent or at least reduce the severity and frequency of vertigo attacks. In addition, treatment approaches aim to relieve or prevent hearing loss, tinnitus, and aural fullness and improve overall quality of life (QOL) Dietary restriction , Betahistine, Diuretics…

28. Central Causes CVA (Cerebro vascular accident)- most common Brain tumor ( acoustic neuroma ) Multiple sclerosis

29. CVA Elderly patient with chronic disease like (DM ,HTN) with sudden attack of vertigo Most commonly will also have: -Dysarthria -Ataxia -Facial numbness -Hemiparesis -Diplopia -Headache Tinnitus and hearing loss unlikely Vertical nystagmus is characteristic+ Requires emergent care and referral

30. Acoustic Neuroma: Benign tumor Arise from vestibular division of VIII Clinical presentation: Unilateral tinnitus Hearing loss Dizziness The only way to differentiate between Meniere's disease and the Acoustic tumor is by MRI.

31. Multiple Sclerosis Not as common as other causes Referral to neurology is warranted

32. Vestibular Rehabilitation

33. Thank You