Transcript Dr Sohrab Rabiei otolaryngologist

By Dr Sohrab Rabiei
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Clinical evaluation & Approach
Dr Sohrab Rabiei
otolaryngologist
By Dr Sohrab Rabiei
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Clinical evaluation & Approach
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History
Physical examination
Testing - laboratory & office
Radiologic
Differential diagnosis
Diagnostic criteria
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Acute care/hospitalization
Medical therapy
Invasive approach
Complication
Especial circumstances
Consult and refer
Prognosis
Pt education
Follow up
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History
1)
Attempt to define the true qualitative nature of
the symptom complex by asking for an exact
description of what the patient means by
"dizziness," without biasing the outcome by
providing descriptive words
2) Ask about the temporal course of the symptoms.
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3)Ask about associated symptoms, such as
tinnitus, hearing loss, double vision, numbness,
nausea, or vomiting.
4)Review the patient's general medical history
and records for evidence of hypertension,
diabetes mellitus, heart disease, endocrine
disease, or psychiatric illness.
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5) Review the patient's history of drug use
(prescription, OTC, herbal) and any adverse
effects .
6) Ask about precipitating factors such as
trauma, undue stress, or apparent viral
infection.
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A minimum vertigo history should
address the following:
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the duration of the individual attack, that is, hours
versus days
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frequency, that is, daily versus monthly
the effect of head movements, that is, worse, better, or
no effect
inducing position or posture, for example, rolling onto
the right side in bed
associated aural symptoms such as hearing loss and
tinnitus
concomitant or prior ear disease and/or ear surgery
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Vertigo duration
1)Vertigo lasting minutes to
hours :
a. Idiopathic endolymphatic hydrops
(meniere's disease)
b. Secondary endolymphatic
hydrops
(1) Otic syphilis
(2) Delayed endolymphatic
hydrops
(3) Cogan's disease
(4) Recurrent vestibulopathy
2)Vertigo lasting seconds:
benign paroxysmal positional vertigo
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3)Vertigo lasting days:
vestibular neuronitis
4)Vertigo of variable duration:
a. Inner ear fistula
b. Inner ear trauma
(1) Nonpenetrating trauma
(2) Penetrating trauma
(3) Barotrauma
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Physical Examination
1) Perform a general physical examination,
focusing on orthostatic measurements and
other cardiovascular signs.
2) Evaluate the patient's motor coordination
and sensory function for the presence of
unsteady gait, past-pointing, or ataxia.
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4) Examine the eyes (preferably in a
dim light) for nystagmus.
3) Perform the Romberg test (using
necessary precautions to protect the
patient from injury) to assess
proprioceptive function.
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5) As a means to diagnose BPPV in patients
presenting with vertigo, perform the DixHallpike provocative maneuver .
6) Examine the patient for middle-ear
disease or hearing loss using an otoscope
and the Rinne test.
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Bedside examination
 General
ENT examination
 PTA and audiologic evaluation
 Cranial nerve examination
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Spontaneous Nystagmus
Head-shaking nystagmus
Positional nystagmus
Dynamic visual acuity
Valsalva induced nystagmus
Hyperventilation
Nystagmus due to sound or pressure
Tullio (vertigo induced by sound )
Henneberg’s ( vertigo induced by pressure )
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Testing : office and laboratory
1) Target laboratory tests to suspected
conditions .
2) Consider requesting electronystagmography
to evaluate vestibular function in patients with
questionable/complex disorders.
3) Consider computerized rotational testing
to quantitate bilateral reduced vestibular
function, such as occurs with drug ototoxicty.
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4) Consider requesting posturography, if
available, to quantify the Romberg test in
patients with equivocal balance disorders.
5) Perform an audiogram in patients with
possible hearing loss.
6) Consider brainstem auditory evokedresponse testing in patients with
unexplained hearing loss.
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Basic screening
1-Blood glucose level Possible diabetes
2- Complete blood count Possible infection or
anemia
3- Electrolyte levels Possible imbalance :
hyponatremia, hypocalcemia
4-Thyroid-function test (e.g., serum TSH, T4)
Possible hypothyroidism
5- Lipid levels Possible hyperlipidemia
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Radiologic
1)
Obtain a CT head scan in patients with
suspected central nervous system pathology.
2) Obtain a head MRI for patients with
persistent symptoms that suggest a disorder
of the central nervous system.
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Differential Diagnosis
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First, based on the history and
physical examination findings,
determine whether the patient's
dizziness is most likely to be
caused by a peripheral, central, or
systemic disorder
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Second,
compare the clinical findings
with the characteristic manifestations of
each of the diseases within the most likely
category (i.e., peripheral, central, or
systemic).
Third,
if the diagnosis is still not
obvious, focus further investigations
on the limited number of remaining
diagnostic possibilities.
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Diagnostic Criteria
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Based on the clinical history, physical
examination findings (especially
nystagmus), and laboratory test results (if
needed), classify the cause of dizziness
into one of three categories (peripheral,
central, or systemic) . Then, if possible,
make a specific diagnosis based on the
same information.
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Acute Care/Hospitalization
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Immediately hospitalize patients
with new onset of vertigo
accompanied by neurologic signs
and symptoms such as double vision,
limb numbness, or slurred speech.
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Medical Therapy
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Treat the underlying disorder in
patients with a definitive diagnosis.
Consider
the use of vestibular
suppressants for symptomatic treatment of
dizziness of probable peripheral origin
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Prescribe
exercise therapy, such as an
Epley-type maneuver, as therapy in all
patients with BPPV.
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Invasive Approaches
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Consider surgery as a last resort for patients
with clearly defined severe attacks of
peripheral vestibulopathy that are
refractory to medical therapy.
Direct
surgical treatment of
central causes of dizziness to the
underlying diagnosis.
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Special Circumstances
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Be aware of syncope, presyncope, and
severe lightheadedness as common
accompaniments of pregnancy.
Be
alert for faintness or
lightheadedness in patients with medical
conditions that affect blood pressure.
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When to Consult or Refer
Refer
to a otolaryngologist Patients
with BPPV
Refer to a otolaryngologist Patients
with progressive, disabling Meniere's
disease
Consider
referring patients
with cardiovascular findings to
a cardiologist.
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Refer to a neurologist patients with central
nervous system signs or symptoms:
Patients with central vestibular, cerebellar,
or focal neurologic findings, who should
undergo further neurologic testing
Atypical nystagmus or central nystagmus
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If
the patient has psychiatric problems
(e.g., panic disorder or depression) that do
not sufficiently respond to simple
reassurance and standard drug
management, consider referral to a
psychiatrist.
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Patient Education /General Advice
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If appropriate, instruct patients with
BPPV on how to perform exercise
therapy at home.
Reassure
patients with peripheral
vestibulopathy that most symptoms
improve with time.
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To
help relieve the side effects of anxiety
and depression, extra understanding and
patience should be used with patients with
chronic dizziness who have seen many
physicians.
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Characteristics of Peripheral Versus Central Positional Vertigo
Characteristic
Peripheral positional vertigo
Central positional vertigo
Latency (time to onset of vertigo
or nystagmus)
0-40 sec (mean, 7.8 sec)
Begins immediately
Duration (signs and symptoms of
single episode)
<1 min
Symptoms may persist
Fatigability or habituation
(lessening signs and symptoms
with repetition of provocative
maneuver)
Yes (in 87%)
No
Nystagmus direction
Direction fixed, torsional, upward,
upper pole of eyes toward ground
Direction changing, variable
Intensity of signs and symptoms
Severe vertigo, marked nystagmus,
systemic symptoms such as
nausea
Usually mild vertigo, less
intense nystagmus, rare nausea
Reproducibility
Inconsistent
More consistent
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Differential Diagnosis of Typical Causes of Dizziness/Vertigo
Clinical findings
Diagnosis
Further tests and
interpretation
Brief episodes of vertigo associated with a
change in head position
Benign paroxysmal
positional vertigo
Positive Dix-Hallpike test with a
typical rotary nystagmus
Recurrent attacks of severe vertigo
accompanied by vomiting, tinnitus,
fluctuating hearing loss, and a sensation of
ear fullness
Meniere's disease
Audiometry;
electronystagmography may be
useful in patients with atypical
manifestations
Transient clumsiness, loss of vision, perioral
numbness, diplopia, ataxia, dysarthria
Brain stem ischemia
MRI; MR or conventional
angiography may be needed;
neurologic findings (often subtle)
and characteristic types of
nystagmus are diagnostic clues
Sudden, severe vertigo of longer duration,
sometimes preceded by a upper respiratory
tract infection
Vestibular neuronitis
Typical nystagmus, absent
response to caloric stimulation
on one side--absence on both
sides suggests drug or alcohol
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etiology
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Attacks last a few minutes to 1 hr; may or may
not be associated with headache
Migraine
None necessary if symptoms meet
standard criteria for migraine
headaches and neurological
examination normal
Recurrent lightheadedness when the patient first
stands up
Orthostatic hypotension
Check blood pressure before and
after standing.
Recurrent attacks that last minutes and are
associated with high anxiety and
hyperventilation
Panic attacks
None necessary if patient meets
standard psychiatric criteria for
panic attacks or another anxiety
disorder
Progressive hearing loss and tinnitus, possibly
accompanied by mild vertigo
Eighth-nerve tumor
Audiometry, brainstem auditory
evoked response test, MRI
Disorientation or disequilibration worsened by
walking or standing, often in elderly patients
Multiple sensory deficit
Assess vision, hearing, motor
coordination (e.g., gait, Romberg),
and somatosensory system (e.g.,
peripheral neuropathy)
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Diagnostic Criteria for Benign Paroxysmal Positional Vertigo
Vertigo associated with a characteristic mixed torsional and vertical
nystagmus provoked by the Dix-Hallpike test
A latency (typically of 1-2 sec) between the completion of the DixHallpike test and the onset of vertigo and nystagmus
Paroxysmal nature of the provoked vertigo and nystagmus (i.e., an
increase and then a decline over a period of 10-20 sec)
Fatigability (i.e., a reduction in vertigo and nystagmus if the Dix-Hallpike
test is repeated)
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Potential Tests for Patients with Dizziness/Vertigo
Findings/clinical scenario
Test
Interpretation/reason for
test
Thyroid-function test (e.g.,
serum TSH, T4)
Possible hypothyroidism
Blood glucose level
Possible diabetes
Complete blood count
Possible infection or anemia
Electrolyte levels
Possible imbalance, e.g.,
hyponatremia, hypocalcemia
Lipid levels
Possible hyperlipidemia
Laboratory tests
Basic screening
Hearing fluctuation
Serologic testing for syphilis
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Possible neurosyphilis
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History of syncope or
presyncope
Electrocardiogram
Possible cardiomyopathy,
arrhythmia
Rhythm strip
Possible arrhythmia
Holter monitor
Possible infrequent arrhythmia
Echocardiography
Possible cardiomyopathy, valvular
lesion
Carotid Doppler
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Possible carotid artery stenosis
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Suspected vestibular
abnormality: e.g., neuronitis,
Meniere's disease, or peripheral
vestibulopathy
ENG
Helpful in determining whether
abnormality is unilateral or bilateral,
and distinguish between peripheral
and central disorders. Sensitivity
69%-74%; specificity 50% or lower.
Bilateral vestibular loss,
suspected ototoxicity
Rotational testing
Helpful in determining response
patterns, and for assessing possible
bilateral ear injury when ototoxicity
is suspected
Patients who have more than ear
disease or in whom malingering
is suspected
Posturography
Quantifies Romberg test and helps
identify defective system or to
exclude organic disease
Suspected hearing loss
Audiogram
Hearing loss may suggest acoustic
tumor in the affected ear or
Meniere's disease (especially if
fluctuating). Acoustic tumors may
cause a disproportionate loss of
speech discrimination in relation to
the pure-tone audiogram.
Suspected acoustic neuroma
Brainstem auditory-evoked
response testing
May help identify lesions of the
eighth nerve and brainstem;
relatively low sensitivity but good
specificity.
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Radiologic tests
Suspected central
pathology
CT head scan
More sensitive than plain skull films,
but less sensitive than MRI
Significant neurologic
abnormalities on physical
examination
MRI with
gadolinium
contrast
Can identify small tumors close to
the tissue-bone interface (coronal
and sagittal reconstructions); also
useful in diagnosing multiple
sclerosis [Figure 8] and cerebellar
infarction.
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Classifying Dizziness Based on Symptoms
Type of dizziness
Suggestive symptoms
Peripheral
True spinning vertigo, dizziness
accompanied by tinnitus or fluctuating
hearing lossa
Central
Clumsiness, dysequilibration, facial
weakness or numbnessa
Systemic
Lightheadedness, faintness, grayed-out
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Thanks for your attention
Please send your comments to :
[email protected]
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