Dizziness: More than BPPV or Meniere s. William J Garvis, MD Otology, Neurotology & Skull Base Surgery Ear, Nose & Throat SpecialtyCare of MN, PA
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1 Dizziness: More than BPPV or Meniere s William J Garvis, MD Otology, Neurotology & Skull Base Surgery Ear, Nose & Throat SpecialtyCare of MN, PA
2 American Family Physician Dizziness: A Diagnostic Approach Am Fam Physician Aug 15;82(4): Dizziness accounts for an estimated 5 percent of primary care clinic visits. The patient history can generally classify dizziness into one of four categories: vertigo, disequilibrium, presyncope, or lightheadedness. The main causes of vertigo are benign paroxysmal positional vertigo, Meniere disease, vestibular neuritis, and labyrinthitis.
3 Dizziness
4 Dizziness: It is not the final term Lightheadedness Woosiness Off balance Unsteadiness Weakness Vertiginous
5 What is Vertigo? Latin: verter--to turn It is a sensation of spinning, or whirling, either of the individual or of the environment It does NOT imply giddiness, lightheadedness, imbalance or presyncope
6
7
8 Epidemiology of Vertigo Neuhauser, H.K., Lempert, T. Vertigo: Epidemiologic aspects (2009) Seminars in Neurology, 29 (5), pp month incidence 1.4% 12 month prevalence 4.9% Lifetime prevalence 7.4%
9 Etiologies Otologic (50%) BPPV Vestibular neuritis/viral labyrinthitis Meniere s Disease SSCCD PLF Acoustic tumor PPPD Neurologic (30%) Vestibular Migraine VBI Cervical Vertigo Low CSF Pressure Others (20%) Hypoglycemia, BP, arrhythmia, medication, B12 deficiency, anxiety, psychiatric
10 What do we see in practice based upon frequency 1. BPPV 2. Vestibular migraine 3. Vestibular neuronitis/viral labyrinthitis 4. Meniere s disease 5. Retrocochlear tumors (i.e. acoustic neuromas) 6. Fistulae
11 BPPV Episodic vertigo Triggered by head movements with typically a few sec lag Vertigo/nystagmus last 30 sec-2 minutes Identified by Dix Hallpike test Most easily treated No evidence that medications help
12 BPPV
13 What do we see in practice based upon frequency 1. BPPV 2. Vestibular migraine 3. Vestibular neuronitis/viral labyrinthitis 4. Meniere s disease 5. Retrocochlear tumors (i.e. acoustic neuromas) 6. Fistulae
14 Vestibular Migraine
15 Vestibular Migraine 2nd most common cause of vertigo Most often missed as diagnosis--chameleon Vertigo, motion intolerance, diminished visual focus Photo- and phono-sensitivity, spatial disorientation Spontaneous vertigo with duration seconds to days, loss of balance, ataxia Notable food and environmental triggers Managed with pharmacotherapy, lifestyle modifications and vestibular therapy
16 Vestibular Migraine
17 What do we see in practice based upon frequency 1. BPPV 2. Vestibular migraine 3. Vestibular neuronitis/viral labyrinthitis 4. Meniere s disease 5. Retrocochlear tumors (i.e. acoustic neuromas) 6. Fistulae
18 Vestibular Neuritis/Neuronitis/Labyrinthitis Neuritis--inflammation of nerve Neuronitis--inflammation/damage to sensory neurons at vestibular (Scarpa s) ganglion Labyrinthitis--inflammation of labyrinth resulting in vertigo and hearing-related changes
19 Vestibular Neuritis/Neuronitis/Labyrinthitis 3rd most common cause of vertigo 7% of all cases of vertigo Sudden onset of severe, incapacitating vertigo, accompanied by unsteadiness, N/V Unilateral horizontal nystagmus Symptoms exacerbated with head movements Usually resolves in a few days to weeks Tx symptomatically
20 What do we see in practice based upon frequency 1. BPPV 2. Vestibular migraine 3. Vestibular neuronitis/viral labyrinthitis 4. Meniere s disease 5. Retrocochlear tumors (i.e. acoustic neuromas) 6. Fistulae
21 Meniere s Disease/Syndrome
22 Meniere s Disease/Syndrome
23 Meniere s Disease/Syndrome Episodic vertigo, aural fullness, tinnitus, hearing loss Spells last 20 min-hours (not shorter or longer than day) Audiologic findings of fluctuant low-mid freq SNHL Thought to be related to endolymphatic hydrops Diagnosis of exclusion Managed with low sodium diet, dietary changes, diuretics, Valium Steroids, gentamicin injections, ELS surgery, inner ear over pressurization
24 What do we see in practice based upon frequency 1. BPPV 2. Vestibular migraine 3. Vestibular neuronitis/viral labyrinthitis 4. Meniere s disease 5. Retrocochlear tumors (i.e. acoustic neuromas) 6. Fistulae
25 Retrocochlear tumors Hearing loss, hearing distortion Balance disorder, unsteadiness, vertigo Tinnitus Facial numbness Diagnosis with MRI Managed with observation, surgery and/or SRS
26 What do we see in practice based upon frequency 1. BPPV 2. Vestibular migraine 3. Vestibular neuronitis/viral labyrinthitis 4. Meniere s disease 5. Retrocochlear tumors (i.e. acoustic neuromas) 6. Fistulae
27 Superior Semicircular Canal Dehiscence Ear sensitive to sound and pressure Vertigo and oscillopsia Autophony, apparent CHL, hear eyeballs move Developmental and perhaps related to BMI Diagnosed with audiometry, VEMP testing and TB CT Managed with surgical repair
28 Superior Semicircular Canal Dehiscence
29 Perilymphatic Fistula Abnormal connection between inner ear perilymph and middle ear (often thru thin membranes which can rupture--rwm and OW/ stapes) Similar issues as with SSCCD More often seen with erosion of lateral SCC with cholesteatomas, but can be related to trauma or idiopathic Identified with fistula test
30 Perilymphatic Fistula
31 So Now What?
32 Questions 1. Is there true vertigo? 2. Is it a first-event or long-standing recurrent vertigo? 3. Is it spontaneous or positional? 4. What is the duration of each spell? 5. What are associated symptoms?
33 Examination
34 Exam Status Gait Romberg Tandem F-N-F Interpretation Alert and oriented? May lean toward side of lesion Primarily proprioceptive Sway correlates more with front foot Dysmetria--cerebellar dysfunction
35 Exam Sm Pursuit FL:Nystag FL:Post HS FL:HIT Interpretation Abnl indicates brain/cerebellar disease Observe for spontaneous or gaze-evoked nystagmus Nystagmus indicates vest. asymmetry Examines ipsilateral ear function
36 Dix-Hallpike Maneuver
37 Fistula Test
38 Pearls of Treatment R/O central causation--do a thorough neurologic exam Listen to the pt--they ll tell you nearly everything to reduce differential Inquire about provocative measures Be aware of vestibular migraine as a diagnosis Don t assume it s BPPV, vestibular neuritis or Meniere s
39 Pearls of Treatment Be comfortable asking for neurology or ENT/neurotology assistance Make sure pt is not at risk for falls or injury If you need to treat acute vertigo, use Valium, not Antivert Vestibular therapy is often an integral component to therapy
40 Dizziness: More than BPPV or Meniere s Thanks for your attention
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