A LOGICAL APPROACH TO THE DIZZY PATIENT

Dizziness and balance disorders center

www.susqneuro.com

Conditions

Vertigo– BPPV– Labyrinthitis– Other Conditions: MS, migraine, Meniere’s etc

Non-Vertigo– Gait Dysfunction (countless neurological oto, ortho conditions

Elderly:– PD, frontal lobe disease, neuropathy, multi-deficit, stroke

Post-Injury Psych

A philosopher in the vestibule

We move An unmoving earth is our base of operation If our base moves we have no hope of orientation:

hopelessly lost. Discomfort comes from shift in orientation. Need an absolute set of coordinates. Problem of shifting base. Developed from lateral line system in fish Which way is down??

Oscillopsia

Bilateral vestibular dysfunction Shows function of vestibular system When the world moves with your head it drives

you crazy We need a solid base of operations Result: “Visual Dependence” Foam Pad Romberg positive.

VESTIBULO-OCULAR REFLEX (VOR)

KEEP YOUR EYES ON THE PRIZE

Our world seems not to move thoughWe Do

Dizziness- Logical Approach -strategy for lecture Go into some basic principles applications and testing get into a few prominent diagnoses

DIZZINESS EIGHT MILLION PHYSICIAN VISITS/YR AVERAGE: 5 VISITS WITHOUT

RESOLUTION OF PROBLEM Dizziness affects 10% of adults over 40 LOSS OF LIVLIHOOD, FALLS INJURIES SYSTEMATIC APPROACH

DIZZINESS VERTIGO LIGHT-HEADEDNESS DYSEQUALIBRIUM GAIT DYSFUNCTION NEAR SYNCOPE ANXIETY

Dizziness: Pointed questions

Vertigo or Not? Standing or Seated? Isolated or ass’d with Other symptoms? Constant or paroxysmal? Caused by positional change?

DIZZINESS: A MULTIDIMENSIONAL

APPROACH AREAS OF EXPERTISE

– NEUROLOGIST– OTOLOGIST– REHAB SPECIALIST

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COWS: Fast Phase of Nystagmus

Cold – Opposite Warm – Same Each vestibule tonically pushes eyes to opposite

side Cold inhibits, warm stimulates and ear Fast phase of nystagmus: cortical correction

Nystagmus

Pitch, Roll, Yaw

MODULAR VIEW OF VESTIBULAR SYSTEM

Vertigo or not?

=Nystagmus or no nystagmus

semicircularcanals

(movement)

utricle & saccule(gravity)

cochlea

(hearing)

Inner ear teleology

Utricle and Saccule – Gravity receptors– Which way is down??

Semicircular Canals - Planar angular accelerometers– What’s moving what is still??– Which Way is down??

Why Vertigo?? conditions

Converting accelerometer (semi-circular canals) into gravitometers – BPPV

Stimulating accelerometer: Meniere’s, labyrinthitis

“central” mechanism: hallucination in CNS – much less potent

Something stimulates accelerometer (SCC)

Vertigo DDx

BPPV Meniere’s Vestibular neuritis Bilateral vestibular Loss Post-traumatic vertigo (labyrinthine concussion) Perilymph fistula Migraine and epilepsy Cerebro-vascular Disease

Dizziness Battery

Orthostatics and both arms Hallpike Fukada Head Thrust Head Shake Romberg (conventional, tandem, foam pad) Fistula test

Benign Paroxysmal Positional Vertigo Recurrent One ear down position Positive Hallpike Transitory positional vertigo “Vertigo induced by postional change” Unique

BPPV History

Variable history: Many patients complain of waxing and waning dizziness, not always vertiginous and aren’t aware of episodic nature

Classic: In bed when turn, looking up, or down– Tie shoelace or put clothes on line

Remits and exacerbates

BPPV predispositions

Age Post vestibular neuritis Post trauma Ear infections

BPPV

Canalithiasis: By far majority. Set up eddy currents in fluid filled canal

Cupulolithiasis: otoliths adherent to walls

Posterior nystagmus are delayed by approximately 15 seconds (latency), peak in 20-30 seconds, and then decay, with complete resolution of symptoms.

Symptoms and reversed nystagmus may recur when the patient is brought to a sitting position.Nystagmus fatigues on repeated trials. Peripheral nystagmus is latent, paroxysmal, geotropic, reversible, and fatigable.

Horizontal canal BPPV nystagmus is purely horizontal and asymmetric, with its stronger component beating toward the diseased canal.

Anterior canal nystagmus is rotary, with its vertical component beating downward. The vertical component of benign paroxysmal positioning nystagmus (BPPN) is best observed by asking the patient to move the eyes away from the down-most (tested) ear.

BPPV Variants – Eye Movements

Posterior SCC: Canalith or cupulo – Torsional to side down and upbeat

Horizontal SCC: Canalith– Horizontal geotropic

Horizontal SCC: Cupulolithiasis– Horizontal ageotropic

Anterior SCC: Canalith or Cupulo:– Downbeat and torsional to side down

BPPV

Logroll maneuver for horiz canal

CANALITH REPOSITIONING (EPLEY)

Semont Maneuver

Brandt Daroff

Paroxysmal psychological Vertigo

Form of Panic Attack Sensory overload “Supermarket Syndrome” Complication of untreated BPPV + Anxiety Computation of position and movement Worst in Aisles and small spaces: comparator of near and

distant movement: Car +claustophobia?? Your life depends on it: Therefore intense fear “Phobic positional vertigo”

Vestibular Neuritis

Sudden Vertigo and vomiting Emergency room Extreme motion sensitivity: Pts lay like a rock. Kinetophobia Viral or ischemic

– Herpes simplex and other viruses. Bell’s palsy of the vestib n. Rarely recurs Look for other signs that may relate to VB system or

posterior fossa.

Vestibular neuritis, neuronitis or labyrinthitis No loss of hearing indicates inflammation of vestibular

nerve or scarpa’s ganglion (neuronitis)– Inferior vestib nerve goes to posterior canal– Superior nerve goes to utricle, sup, lat canal– Herpes virus?

Hearing loss: may be labyrinthitis Any pain or inflammation: ? Bacterial or other treatable

infection Can’t distinguish 100% from brainstem stroke

Vestibular Neuritis: Findings

Spontaneous horizontal or horizonto-rotatory nystagmus– You may have to block fixation to see it.

Fast phase away from the offending ear Veer to slow phase ENG suppressed on offending side 5% or so cases may be recurrent BPPV is frequent sequel

Meniere’s

Severe vertigo and vomiting Fluctuating Hearing Loss Fullness unilateral Tinnitus Endolymphatic Hydrops

Meniere’s

Vertigo + Vomiting last hours– Few disorders are paroxysmal in just this way

Patients need not have entire tetrad Most common: Severe vertigo, vomiting and

tinnitus A number of “Meniere-like” syndromes

– Previous insults to inner ear

Meniere’s treatment

Avoid Salt and Caffeine Diuretic Surgeries

– Gentamycin injection– Vestibular nerve section– Hearing sparing operations

Perilymph fistula

Dizziness with change in pressure Nose-blowing dizziness Sound sensitivity “Tullio Phenomenon” Dizziness with exertion Sensori-neural loss on audiogram

Perilymph Fistula

Breach of Round window Superior canal dehiscence Cholesteatoma Trauma Post-surgical esp fenestration for otosclerosis Scuba diving

Perilymph Fistula: breach of round window.

From Tim Hain

Fistula

Strain against closed glottis– Upbeat nystagmus CW for right ear CCW for left ear

Pull in thru closed nostrils– Downbeat nystagmus CW for left ear, CCW for right

ear OR do fistula test with bulb OR Test for Tullio phenonenon

Cholesteatoma

cholesteatoma

Hearing loss and loss of balance or vertigo Chronic infection or congenital Basically tumor in middle ear and petrous bone

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INPUTS TO BALANCE

Construct Program. Elements:

Clinicians to Evaluate– PM&R, Neurology

Diagnosis Therapeutic Recommendations

– Gait Analysis

Treatment– Vestibular (habituation, exercise, Canalith)– Gait and Balance– Devices trial and recommendation

Vestibular Rehabilitation

Compensations– Avoidance (BPPV)– Substitution (Bilateral Vestibular Loss)– Plasticity (Vestibular Neuritis)– Massed practice to retune CNS and compensate– “habitutation”– Repositioning– Gait retraining

Vestibular Rehab

Habituation Canalith repositioning Balance Retraining Exercises and retraining Conditioning Compensation Strategies

– As in visual dependence Assistive devices Bracing Muscle strengthening

Vestibular Rehabilitation

VOR Stimulation Exercises Oculomotor Exercises Balance Exercises Gait exercise Obstacle course

www.emedicine.com/ent/topic666.htm#target1

Cawthorne-Cooksey Exercises In bed or sitting

– Eye movements -- at first slow, then quick up and down from side to side focusing on finger moving from 3 feet to 1 foot away from face

– Head movements at first slow, then quick, later with eyes closed bending forward and backward turning from side to side

Sitting

– Eye movements and head movements as above – Shoulder shrugging and circling – Bending forward and picking up objects from the ground

Standing

– Eye, head and shoulder movements as before – Changing form sitting to standing position with eyes open and shut – Throwing a small ball from hand to hand (above eye level) – Throwing a ball from hand to hand under knee – Changing from sitting to standing and turning around in between

Moving about (in class)

– Circle around center person who will throw a large ball and to whom it will be returned – Walk across room with eyes open and then closed – Walk up and down slope with eyes open and then closed – Walk up and down steps with eyes open and then closed – Any game involving stooping and stretching and aiming such as bowling and basketball

VESTIBULAR REHABILITATION

HABITUATION ADAPTATION OF OTHER SENSORY

SYSTEMS

Neurologic Syndromes

MS PD NPH Stroke Aging Multi-sensory Deficit

Normal Gait

Sitting Balance Leans or slides in chairSteady, safe= 0= 12. Arises Unable without helpAble, uses arms to helpAble without using arms= 0= 1= 23. Attempts to arise Unable without helpAble, requires > 1 attemptAble to rise, 1 attempt= 0= 1= 2

Tinetti

Tinetti (2) 4. Immediate standing balance (first 5 seconds) Unsteady (swaggers, moves feet, trunk sway) Steady but uses walker or other support Steady without walker or other support0,1,2 5. Standing Balance Unsteady Steady but wide stance (medial heels > 4 inches apart) and uses cane or other support Narrow stance without support0,1,2 6. Nudged (subject at max position with feet as close together as possible, examiner pushes lightly on subject’s sternum with palm of hand 3 times. Begins to fall Staggers, grabs, catches self Steady0,1,2

Tinetti (3)

7. Eyes closed (at maximum position #6) Unsteady Steady0,1 8. Turning 360 degrees Discontinuous steps Continuous steps Unsteady (grabs, swaggers) Steady0,1,2 9. Sitting Down Unsafe (misjudged distance, falls into chair) Uses arms or not a smooth motion Safe, smooth motion0,1,2

Tinetti Gait

10. Initiation of gait (immediately after told to “go”) Any hesitancy or multiple attempts to start No hesitancy0,1 11. Step length and height a. Right swing foot does not pass left stance foot with step b. Right foot passes left stance foot0,1 c. Right foot does not clear floor completely with step0,1 d. Right foot completely clears floor0,1 e. Left swing foot does not pass right stance foot with step0,1 f. Left foot passes right stance foot0.1 g. Left foot does not clear floor completely with Step0.1 h. Left foot completely clears floor 0.1

Tinetti Gait 2

12. Step Symmetry Right and left step length not equal (estimate) Right and left step appear equal0,1 13. Step Continuity Stopping or discontinuity between steps Steps appear continuous0,1,2 14. Path (estimated in relation to floor tiles, 12-inch diameter; observe excursion of 1 foot over about 10 feet of the course). Marked deviation Mild/moderate deviation or uses walking aid Straight without walking aid0,1,2 15. Trunk Marked sway or uses walking aid No sway but flexion of knees or back, or spreads arms out while walking No sway, no flexion, no use of arms, and no use of walking aid0,1,2 16. Walking Stance Heels apart Heels almost touching while walking0,1

Multiple Sclerosis

May present as typical peripheral vestibulpathy ? lesion at root entry zone

Multi-sensory deficit

Aging Loss of neurons in CNS

– degenerative– vascular

Arthritis Peripheral nerve dysfunction Vestibular dysfunction

Multi-sensory deficit

Physical therapy– falls prevention– muscle strengthening– trying out assistive devices– minimizing deficits

Acoustic Neuroma

Acoustic Neuroma

Unilateral Hearing Loss VII and V Unsteadiness rarely paroxysmal vertigo

Vertebrobasilar Insufficiency

Vertigo Diplopia Dysarthria Dysphagia Ataxia Sensory or Motor Loss Drop attack Most feared misdiagnosis in older vertiginous patient

Post-Traumatic Vertigo

BPPV Meniere’s “Cervical” vertigo Perilymph fistula Factitious (psychological) vertigo

Migraine Associated Vertigo

Headache Bickerstaff Vertigo occurs as aura or part of HA syndrome

Autoimmune Inner Ear Disease (AIED) Hearing Loss Vertigo Bilateral “meniere’s”

AIED

Anti HSP-70 Anti Raji Cell Sed, ANA, RF, C1Q, FTA, Lyme, Thyroids

Bilateral Vestibular Loss

Oscillopsia Visual Dependence Aminoglycosides Advanced Age + Chronic ear disease

Bilateral vestibular dysfunction

Advanced age Unsureness on feet. Symptomatic only when up Positive Romberg Foam Pad Romberg which diminishes

proprioception – hallmark Help by increasing proprioceptive feedback –

assistive device, practice.

MOTION SICKNESS

CHRONIC SENSITIVITY TO MOTION OTHER PERSON DRIVING DISCOMFORT WITH MOTION VESTIBULAR REHAB: HABITUATION

Mal de Debarquement

Persistence of perception of motion after a cruise Psychophysiological (?)

Bibliography

www.susqneuro.com– “Dizziness Explained”, “Benign Positional Vertigo”,

“Vertigo: A Logical Approach” www.thain.com. by Tim Hain, MD www.ivertigo.net by Todd Troost, MD www.onbalance.com: Posturography