Dizziness Revisited : An ENT Work-up for the PCP Carol A. Foster, M.D. Associate Professor Depts. Otolaryngology, Audiology & Rehabilitation Medicine Course Objectives At the conclusion of this talk, you should be able to: Recognize the major dizziness disorders Describe the tests used to diagnose these disorders Provide a basic treatment strategy 1
Key disorders to recognize BPPV Migraine associated dizziness Sleep apnea Multisensory imbalance Meniere disease Acute unilateral vestibular disorders BPPV 2
BPPV symptoms Brief spells brought on by position changes In bed: rolling over, arising, lying down When upright: tipping the head up, bending over In elderly, also causes imbalance Pattern of dizziness: Flurries lasting days to weeks; remissions lasting weeks to years Dix Hallpike Test Turn head 45 degrees toward you Recline the patient quickly Wait at least 15 sec for the response Nunez 2000 3
BPPV Diagnosis Abnormal Dix Hallpike: Nystagmus < 1 min or brief dizziness without nystagmus Pupil moves in an arc up and towards the floor Digitalrevolution Flikr 2011 Foster 4
Complications of Maneuvers Failure to clear the canal Particles form one or more chunks in the canal Need to repeat maneuver 2-5 times in a session Should repeat until free of symptoms on last maneuver Complications of Maneuvers Particles removed can enter other canals during maneuvers Causes nystagmus Reduce risk by waiting 15 minutes between repetitions Or simply treat by sitting the patient back upright 5
Complications of Maneuvers Patients can move particles back in overnight Have them sleep propped up on 2 pillows for 2 nights Avoid sleeping with the treated ear down for a week Permanently propping up in bed for frequent recurrences Avoid: BPPV Prevention Procedures involving vibration of the skull Bumping the head sharply Sleeping on a very thin/flat pillow Performing situps vigorously Performing inverted yoga positions Any position that places the head below horizontal for a long time 6
Migraine Associated Dizziness Most common cause of dizziness in youth Combines central and peripheral factors Headache Nausea Photo, phonophobia Aura Variable length of vertigo spells Quality of vertigo Internal spinning sensation Rocking sensation, boat-like Rarely, true spinning of surroundings 7
Migraine Diagnosis Exam and tests are usually normal History is critical Anxiety, depression common Fibromyalgia Strong family history often found Exacerbations due to triggers: Foods Weather Hormonal changes Migraine Treatment Trigger avoidance is important Medications for migraine pain are not helpful (triptans) Migraine prophylactic medications help: Tricyclics, venlafaxine Verapamil Topiramate Propranolol 8
Sleep apnea Newly recognized as a major cause of dizziness Flikr: Screamin' Cyn-Cyn and the Pons' Sleep apnea symptoms Three S s Snoring Sleepiness Significant other notes apneas Dizziness symptoms Momentary dizziness on and off throughout day Can have true vertigo spells Headaches: am or migraines 9
Sleep apnea exam Obesity in most Thick neck Heavy chest But not always Look inside the mouth Large tonsils Thick, low soft palate Large tongue Hypertension Diagnosis Polysomnography with CPAP titration: Gold standard Portable monitoring devices: have a role in major centers Overnight pulse oximetry : detects moderate to severe sleep apnea only 1 0
Treatment Weight loss, avoidance of sedatives CPAP Surgical procedures Uvulo-palato-pharyngoplasty (UPPP) and tonsillectomy Variety of other debulking procedures Outcomes Daily brief dizziness usually resolves completely on CPAP More serious dizziness disorders, including Meniere attacks, often resolve completely with CPAP 11
Multisensory Imbalance Related to aging Feel off balance while walking Not usually dizzy while seated Feel better using a grocery cart Most common cause of dizziness in the elderly MSI Diagnosis Impaired binocular vision Bifocal or progressive lenses Lasik Macular degeneration, glaucoma Impaired limb sensation, mobility Evidence of an inner ear problem Hearing loss BPPV Dizzy spells 1 2
MSI: Treatment Avoid bifocals or progressive lenses Don t use monovision Flikr:joneorange MSI: Treatment Provide a rolling walker Cane OK in early stages Encourage daily walking 1 3
Meniere s Disease Often called Endolymphatic Hydrops A type of attack rather than a true disease Due to many underlying causes, esp disorders affecting cerebral vasculature (migraine, autoimmune disorders, sleep apnea) Hydrops is present on autopsy Symptoms of Meniere Attacks Vertigo spells lasting hours, usually with vomiting Hearing loss in one ear during spells Tinnitus in one ear during spells Gradually worsening permanent hearing loss 1 4
Meniere workup Search for migraine, hypertension, sleep apnea, diabetes, stroke, MI, thrombosis Serum studies: Clotting: CBC, PT/PTT,fibrinogen, hexagonal phospholipid antibodies Inflammation: ESR, C reactive protein, ANA Infection: HIV, FTA Basic metabolic tests including magnesium MRI with contrast IAC s Treatment of Meniere s Reduce vascular risk factors Daily baby aspirin Provide migraine prophylactic meds if headache is present or strong family history of migraine Treat vascular disorders Refer to hematology, rheumatology, neurology if needed Treat hydrops Refer to ENT Diuretics and sodium restriction are the first line of treatment Surgery is often used 1 5
Meniere warnings Patients are at increased risk of stroke and heart attack Migraine with aura and sleep apnea have a similar increased risk Counsel re. the symptoms of these disorders Acute Unilateral Vestibulopathy The Suddenly Dead Ear Sudden, severe vertigo lasting days Visible nystagmus, usually horizontal Mild head tilt Staggering to one side Long lasting mild residual symptoms 1 6
Exam for sudden loss VOR Vestibulo-ocular reflexes Doll s eye test---head thrust Nystagmus: continuous horizontal Weber/Halmagyi et al 2008 Findings on head thrust Normal Absent Bronstein 2010 1 7
Acute Unilateral Diagnosis ENG/VNG shows loss of function in one ear Audiogram may show hearing loss in one ear Send all sudden hearing loss to ENT MRI should be obtained to rule out mass lesion Acute Unilateral Treatment Suppressants only for vomiting Usually not longer than 3 days after onset Get the patient up and moving Vestibular rehab for imbalance Watch for additional sudden vertigo indicating a progressive disorder 1 8
References Baloh RW, Halmagyi GM. Eds. Disorders of the Vestibular System.NY:Oxford University Press (1996) Bronstein AM, Lempert T, Seemungal BMA : Chronic dizziness: a practical approach. Pract Neurol (2010)p. 129-139 doi:10.1136/jnnp.2010.211607 Foster CA: Epley maneuver for BPPV. In: Goldman,L & Bennett, JC. Cecil s Textbook of Medicine 21 st ed. Saunders,1999, Ch. 24 p. 2027 Foster CA: Vestibular disorders. In: Jafek BW (ed). Otolaryngology Secrets, 3rd Ed. Philadelphia: Elsevier,Hanley and Belfus (2004) 79-84 Nunez RA. Cass SP. Furman JM. Short- and long-term outcomes of canalith repositioning for benign paroxysmal positional vertigo. Otolaryng-HN Surg (2000) p. 647-52 Viirre E. Purcell I. Baloh RW. The Dix-Hallpike test and the canalith repositioning maneuver. Laryngoscope (2005) p.184-7 Weber K P. Aw S T. Todd M J. McGarvie L A. Curthoys I S. Halmagyi G M. Head impulse test in unilateral vestibular loss: vestibulo-ocular reflex and catch-up saccades. Neurology(2008) p.454-63 www.flickr.com (graphics) 1 9