Transcript Common Nasal Conditions - Welcome to the BHBT Directory

Dizziness
Paul Chatrath
Consultant ENT Surgeon
Barking Havering & Redbridge Hospitals NHS Trust
21st January 2009
Objectives
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Definitions
Clinical history & examination
Multiple factors
Key conditions – BPPV, Meniere’s,
labyrinthitis, non-vestibular
“Dizziness”
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Presyncopal faintness
Loss of balance/imbalance
Unsteadiness
Light-headedness
Whooziness
Vertigo
Feeling of rotation or movement
Balance
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Vestibular system
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Peripheral vestibular (labyrinth)
Cerebellar
Visual system - VOR
Proprioceptive system - VSR
Vestibular Labyrinth
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3 semicircular canals
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rotational movement
cupula
2 otolithic organs - utricle & saccule
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linear acceleration
macula
Clinical approach
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Vertigo vs dizziness
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Vertigo – peripheral vestibular or cerebellar
Dizziness – non vestibular
Questions to establish causes for each of
these
Vertigo vs Dizziness
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Definition of vertigo:
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Illusion of movement of oneself or the
surroundings
Typically rotatory
Looking for vestibular causes
If no rotatory component:
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Likely to be nonspecific dizziness
Looking for non-vestibular causes
Vertigo vs Dizziness:
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Vertigo:
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Unclear?
Rotatory
Worse on head movements
Nausea/vomiting on head movements
Vague descriptions: rarely true vertigo
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
History:
•
Vertigo
Onset
• After URTI or ear infection
• Duration
• >24hrs: Viral labyrinthitis
• Several hours: Meniere’s, migraine
• <1min: BPPV, Psychogenic
• Associated ear features
• Tinnitus
• Hearing loss
• Headache
• Discharge
Vestibular
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Viral labyrinthitis
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BPPV
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Meniere’s disease
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Acute Otitis Media
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Trauma
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Cholesteatoma
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Drug induced
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Postsurgical
Central
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Migraine
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Vertebrobasilar ischaemia
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MS
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Tumours
 Cerebellopontine angle
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Acoustic neuroma
Brainstem
CVA
Psychogenic
History:
Vertigo
Associated central features
• Face or arm weakness/numbness
• Frequency
• Single: labyrinthitis, MS
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• Constant:
• decompensation
• neurological
• psychogenic
• Trauma
• Drug history
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Aminoglycosides
Diuretics
Aspirin
Chemotherapy
• Surgery
Vestibular
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Viral labyrinthitis
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BPPV
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Meniere’s disease
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Acute Otitis Media
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Trauma
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Cholesteatoma
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Drug induced
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Postsurgical
Central
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Migraine
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Vertebrobasilar ischaemia
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MS
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Tumours
 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
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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
Examination
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Ears
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Nystagmus:
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Cerebellar
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Posture
TMs
Cranial nerves
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All are useful!
General examination
‘rhythmic
oscillating involuntary
movement of eyes’
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Romberg’s
Unterberger’s
Hallpike’s
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:
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
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
Cawthorne - Cooksey
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Developed in 1940s
Head movements
Balance tasks
Coordination of eyes with head
Total body movements
Eyes open & closed
Noisy environments
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Early exacerbation of vertigo
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Investigations
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Radiology (anatomical
imaging)
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MRI – good for IAM’s
CT – good for
vestibular anatomy
Audiogram
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Asymmetry needs
further imaging
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Tests of vestibular
function
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ENGs
(electronystagmography)
Caloric tests
Rotation tests
Symptomatic Tx
Acute phase
 Phenothiazines
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Antihistamines
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Prochlorperazine
(Stemetil)
Cinnarizine (Stugeron)
Cyclizine (Valoid)
Promethazine (Avomine)
Histamine analogues
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Betahistine (Serc)
Longer term:
 Depends on specific
condition
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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Otitic
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Infective
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Viral (serous)
Bacterial (suppurative)
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Strep pneumoniae
Haemophilus
Moraxella
Other causes
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CMV, influenza,
adenovirus
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Other source
cholesteatoma
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Meningeal
TB
Syphilis
Neoplasia
Haematogenic
Labyrinthitis
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History
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Vertigo
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>24hrs
Vomiting
Constitutional symptoms
Examination
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Nystagmus
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Fast phase away from
affected ear
Pyrexia
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Treatment
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Bed rest
Vestibular sedatives
Fluids
Cawthorne-Cooksey
vestibular
rehabilitation exercises
Meniere’s Disease
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Key features:
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Vertigo
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Hours not minutes or
days
Associated tinnitus and
hearing loss
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Before, during or after
vertigo
Other symptoms
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Pressure feeling
Nausea
Aetiology
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Vascular
‘Hydrops’
Natural history
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One episode
Episodic
Increasing frequency
Meniere’s Disease:
Medical therapy
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Salt restriction
Diuretics
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Thiazides - Na
absorption in distal
tubule
Side effects hypokalemia,
hypotension,
hyperuricemia,
hyperlipoproteinemia
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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
Meniere’s Disease:
Surgical therapy
Hearing preservation
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Vestibular preservation
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Endolymphatic sac drainage
Intratympanic injection of
steroid
Vestibular destruction
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VIII nerve section
Hearing destruction
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Intratympanic injection
gentamicin
Labyrinthectomy
ITAG
BPPV:
Benign Paroxysmal Position Vertigo
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Calcific debris in
semicircular canals
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Cupulolithiasis
Canalolithiasis
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Brief (<1min)
On head turn in a
particular direction
Typically self-limiting
Primary
Secondary
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Vertigo
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Trauma (HI)
Prolonged bed rest
Otological condition (up
to 70%)
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Labyrinthitis
Central
BPPV:
Benign Paroxysmal Position Vertigo
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Posterior SCC
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Hallpike’s test
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In plane on lying in bed
Nystagmus on lying
back to one side
Problem: how to
distinguish BPPV from
central causes
BPPV:
Hallpike’s test – Character of Nystagmus
BPPV
Central
Latency
5-10s
None
Adaptation
Gone in 50s
Persists
Fatiguable
Yes
No
Vertigo
Always
Absent
Direction
Rotatory (geotropic)
Variable
Incidence
Common
Rare
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
ENT/vestibular examination usually NAD
exercise, diet, avoidance of stimulants
Medication:
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Abortive therapy eg. Sumatriptan
Prophylactic therapy eg. B blockers
Vertebrobasilar Insufficiency
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Vertigo, diplopia, dysarthria, ataxia, sensory and
motor disturbance
NOT synonymous with cervicogenic vertigo
30% of TIA’s
Aspirin
Dizziness
Any Questions?
Paul Chatrath
Consultant ENT Surgeon
Queen’s/King George’s Hospitals
Email:
[email protected]
[email protected]
A Final Thought......
Q
In a patient with vertigo, if you had
only one question to ask him/her, what
would it be?
A
How long does the vertigo last for?
- BPPV
Seconds
- Meniere’s
- Labyrinthitis
Hours
Day