Transcript document - Basildon and Brentwood CCG

Vertigo
Paul Chatrath
Consultant ENT/Head & Neck Surgeon
Charing Cross Hospital (Imperial Healthcare NHS Trust)
Honorary Senior Lecturer
Anglia Ruskin University, Chelmsford
Visiting Professor of Rhinology
Canterbury Christ Church University, Kent
6th September 2016
Objectives
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Dizziness / vertigo in
general
ENT causes for
vertigo
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Meniere’s
BPPV
Labyrinthitis
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Other ENT causes of
dizziness
‘red flags’
Case - Dizziness
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Please see this 40
year old female
suffering with short
lived episodes of
vertigo
Occurring almost daily
Occurs whenever
moves head in any
direction
Clinical approach
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Vertigo vs dizziness
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Vertigo
Rotatory
 Suggests a peripheral vestibular or cerebellar
problem
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Dizziness / lightheadedness
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Non-specific
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‘whoozy’ ‘ lightheaded’ ‘unsteady’ ‘drunken’
Suggests non-vestibular pathology
Types of Dizziness
Rotation (Spinning)
Unsteadiness (Imbalance)
Light headedness (faint feeling)
If the patient has ever lost consciousness: it is not ENT!
Vertigo - causes
Vestibular
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Viral labyrinthitis
BPPV
Meniere’s disease
Acute Otitis Media
Trauma
Cholesteatoma
Drug induced
Postsurgical
Central
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Migraine
Vertebrobasilar ischaemia
MS
Tumours
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Cerebellopontine angle
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Acoustic neuroma
Brainstem
CVA
Psychogenic
Non-specific dizziness:
Causes
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Cardiovascular
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Arrhythmias
Reduced cardiac output
Carotid artery stenosis
Arteriosclerosis
Hypotension (postural)
Peripheral neuropathy
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Proprioception
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Arthritis (cervical and other)
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DM
Hypothyroidism
Hypercholesterolaemia
Anaemia
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B1, B6, B12
Genetic - Refsum’s disease
Toxins
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Leprosy, TB, syphilis
Vitamin deficiencies
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Metabolic
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DM
Renal or hepatic failure
Alcohol
Vasculitis
Infections
Lead, metronizadole
Psychogenic
Vertigo:
Duration is key
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Brief (<1min)
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- specific head movement
- any head movement
Hours
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BPPV
Psychogenic
BPPV
Psychogenic
Meniere’s
Migraine
Days (>24hrs)
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Viral labyrinthitis
Meniere’s
Migraine
- classic triad
- classic headache
Nystagmus
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Movement of the eyes:
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Rhythmic
Oscillating
Synchronous
Involuntary
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Two phases
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Slow phase
(pathological)
Fast phase (corrective)
Direction described in
terms of fast phase
Nystagmus
Normal labyrinths
Abnormal Right Labyrinth
R
L
Eyes central
L
X
Slow drift to right
Rapid corrective flick to left
= Left nystagmus
Vertigo:
Compensation
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Vestibular
phenomenon
Steady
accommodation to
the effects of vertigo
Gradual resolution of
symptoms over time
Typically occurs 6-12
weeks after acute
insult
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Mechanisms
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Habituation
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Reduced output good
side
Increased output
affected side
Sensory substitution
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Increased reliance on
eyes and
musculoskeletal system
Vertigo:
Compensation
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Impaired
compensation due to:
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Poor visual acuity
Musculoskeletal
problems
Reduced peripheral
sensory input
Ongoing vestibular
pathology
Medication (prolonged
stemetil)
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Rehabilitation:
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General fitness
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Physical programs
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Vision, walking stick
Cawthorne-Cooksey
Psychological support
Specific exercises
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Eg. Brandt-Daroff
exercises for BPPV
Vertigo:
Vestibular v Central
Vestibular
Central
Type of dizziness
Vertigo
Vertigo / Dizzy
Effect of head movement
Worse
Equivocal
Tinnitus/hearing loss
May be present
Absent
Compensation
Occurs
Does not occur
Nystagmus
Horizontal
+ unilateral
+ away from
affected ear
Horizontal or vertical
+ bilateral
Vestibular rehabilitation:
Cawthorne - Cooksey
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Head movements
Balance tasks
Coordination of eyes with head
Total body movements
Eyes open & closed
Noisy environments
Causes early exacerbation of vertigo
Caution:
Prochlorperazine
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Powerful vestibular sedative
Suppresses acute vertiginous symptoms
BUT
Also suppresses natural compensatory
response
LT use:‘non-specific dizziness’persists
Psychogenic
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Type of dizziness: any (nonspecific or vertigo)
Frequency: constant
Duration: Typically brief <1min
Trigger: Stress, anxiety, crowds
Associated features: palpitations, sweating,
tremor
Examination: Normal
Labyrinthitis
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History
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Vertigo
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>24hrs
Vomiting
Constitutional symptoms
Usually following URTI
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Treatment
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Examination
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Nystagmus
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Fast phase away from
affected ear
Pyrexia
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Bed rest
Vestibular sedatives
Fluids
Cawthorne-Cooksey
vestibular
rehabilitation exercises
Rule of threes - 3
days: v bad, 3 weeks,
a lot better, 3 months
resolved
Meniere’s Disease
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Key features:
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Vertigo
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Tinnitus/hearing loss
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Before/during/after vertigo
Other symptoms
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Hours
Pressure feeling
Nausea
Natural history
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One episode
Episodic
Increasing frequency
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Salt restriction
Diuretics - thiazides
Vasodilators
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Betahistine, cinnarizine
Evidence – no RCTs
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Cinnarizine > placebo
Diuretics = placebo
Serc of marginal
benefit
Salt restriction of
marginal benefit
Intratympanic therapy:
Steroids or Gentamicin
BPPV:
Benign Paroxysmal Positional Vertigo
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Calcific debris in
semicircular canals
Vertigo
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Brief (<1min)
On head turn in a
particular direction
Typically self-limiting
Primary
Secondary
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Trauma (HI)
Prolonged bed rest
Otological condition (up
to 70%)
Posterior SCC
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In plane on
lying in bed
Hallpike’s test
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Nystagmus on
lying back to
one side
BPPV - Epley
Epley, 1992
BPPV - Brandt & Daroff
Brandt & Daroff, 1980
Migraine
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Clinical features
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Lifestyle change
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Family history
Motion intolerance
Vertigo occurs with classical headache either before or after
ENT/vestibular examination usually NAD
Exercise, diet, avoidance of stimulants
Medication:
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Abortive therapy eg. Sumatriptan
Prophylactic therapy eg. B blockers
Other ENT conditions causing
dizziness
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Ear:
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Nose/Sinus
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Malignant OE
Otitis media
Cholesteatoma
Sinusitis
Thyroid disturbance
Dizziness/Vertigo:
Indications for Urgent Referral
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Vertigo
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Intense
Disabling
Unremitting
Nystagmus
Sudden SNHL
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Features to suggest
malignant pathology
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Elderly with
granulation in ear
canal
VIIn palsy
Post-traumatic
TM perforation +
vertigo
Conclusion
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Must define the
dizziness / vertigo
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Rotatory or not
Frequency
Triggers
History is the most
important factor
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Duration
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Vertigo
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BPPV (cervical / psychogenic)
Meniere’s (Migraine)
Labyrinthitis (Drug / multifactorial)
ENT causes for vertigo
When to refer urgently
Case



Please see this 40
year old female
suffering with short
lived episodes of
vertigo
Occurring almost daily
Occurs whenever
moves head in any
direction
Vertigo
Paul Chatrath
Consultant ENT/Head & Neck Surgeon
Charing Cross Hospital (Imperial Healthcare NHS Trust)
Honorary Senior Lecturer
Anglia Ruskin University, Chelmsford
Visiting Professor of Rhinology
Canterbury Christ Church University, Kent
[email protected]
6th September 2016