Transcript Going For A Spin A Guide to the Balance System

Going For A Spin
A Guide to the Balance System
Martyn Leggett
Peripheral Vestibular System
• Semicircular Canals
• Otolith Organs
– Utricle
– Saccule
• Vestibular Nerves
• Vestibular Nuclei
History
• Symptom
• Tempo
• Circumstance
• Past History
Symptoms
• Clear
– Relatively easy to categorize
• Vague
– Frustrating
– Often the key to Psychological Cause
Symptom
• Disequilibrium
– Loss or Lack of Stability
– Loss of Vestibulospinal, Proprioception, Visual,
Psychological
• Lightheadedness/Presyncope
– Reduced Blood flow to Brain
• Sensation Rocking/Swaying
(Mal de Debarquement)
– Problem with Vestibular adaptation, Anxiety
Symptom
• Motion Sickness
– Visuovestibular mismatch
• Nausea/ Vomiting
– Stimulation of Medulla
• Oscillopsia
– Severe Bilateral Loss of Vestibulo-ocular Reflex
Symptom
• Floating, Swimming, Rocking, Spinning inside
Head
– Anxiety, Depression
• Vertical Diplopia
– Skew eye deviation
• Vertigo (Rotatory, Linear, Tilt)
– Hallucination of Movement
– Imbalance of Tonic Neural Activity to Vestibular
Cortex
Tempo
• Seconds to Minutes
– BPPV
– Microvascular Compression
• 30 min-24 hours
– Hydrops
– Migraine
• 48-72 hours
– Acute Vestibular Failure
Circumstance
• Precipitating Factors
• Occuring
– Before
– During
– After
• Associated
Symptom Generation
• “One-off” Vestibular Event with Sequelae
– Problems with Compensation
• Recurrent Vertigo
• Positional Vertigo
• Chronic Subjective Dizziness Syndrome
– Psychological
Past History
• First Attack
– Pathology
• Subsequent Attacks
– Pathology
– Decompensation
First Attack
• Acute Vestibular Loss
– Most Severe Attack
– May be only pathological event suffered
• Recurrent Vertigo
– Not necessarily most severe attack
• “Have you ever had an attack which went on
for days?”
Examination
• Physiology
• Pathophysiology
• Vestibulo-ocular reflex
Vestibulo-Ocular Reflex
• Maintains Steady Gaze during Head
Movement
• Normal Activities
– <550° /sec
• Responds up to
– 6000° /sec
• Response Time
– 5-7 msec
Nystagmus
• Cause
– Tonic Imbalance
• Drift (Slow Phase)
– Towards underactive side
• Correction (Fast Phase)
– Away from underactive side
• Enhanced looking in direction of Fast Phase
• Enhanced in the absence of Ocular Fixation
Grades of Nystagmus
• First Degree
– Looking in direction of Fast Phase
• Second Degree
– Looking Straight ahead and in direction of Fast
Phase
• Third Degree
– All Three Positions
Clinical Examination
• Ocular Range of Movement
• Smooth Pursuit
– Conjugate Movement
– Jerky Movement
• Impaired Smooth Pursuit
• Nystagmus
• Nystagmus
– Jerky Movement with Target Stationary
Clinical Examination
• Saccades
– Abnormal- Cerebellar
• VOR Suppression
• Head Thrust
– Horizontal
Clinical Examination
• Saccades
– Abnormal- Cerebellar
• VOR Suppression
• Head Thrust
– Horizontal
• Dynamic Visual Acuity
Clinical Examination
• Romberg
– Vestibulo-spinal reflex
– Proprioception
• Unterberger
– Unreliable except within one week of Acute
Dysfunction
• Dix-Hallpike
Anything Else
• Problem
– Often Asymptomatic when seen
– Abnormal Signs Disappeared
• Video Eye Movements when Symptomatic
– 10 sec looking straight ahead
– 10 sec looking to left
– 10 sec looking to right
• Have They Nystagmus when Symptomatic?
Acute Vestibular Dysfunction
• Acute Tonic Imbalance
– Acute Vertigo
– Nystagmus
– Nausea and Vomiting
• Recovery of Function
• Central Compensation
– Static and Dynamic
Compensation Inhibition
• Prolonged use of Suppressant Medication
• Lack of Stimulation
Acute Vestibular Loss- Causes
• Trauma
– Fractured Temporal Bone
– Surgery
Acute Vestibular Loss- Causes
• Trauma
– Fractured Temporal Bone
– Surgery
• Labyrinthitis
– Viral
– Bacterial
Acute Vestibular Loss- Causes
• Trauma
– Fractured Temporal Bone
– Surgery
• Labyrinthitis
– Viral
– Bacterial
• Vestibular Neuronitis
Vestibular Neuronitis
• Virus Particles isolated in Scarpa’s Ganglion
• Superior Vestibular Nerve
– Superior Canal
– Horizontal Canal
• Inferior Vestibular Nerve
– Posterior Canal
Management
• Vestibular Suppressants
– Reduces Tonic Asymmetry
– 48-72 hours
• Rehabilitation
Compensation
• Static
• Dynamic
– Requires Stable input
– Requires Stimulation
• Get off Suppressant Medication
• Start Exercises
Problems
• Incomplete Compensation
• Partial Decompensation
• Complete Decompensation
Decompensation
• Causes
– Unusual Movement
– Another Illness
• Management
– Rehabilitation
Recurrent Vertigo
• Recurrent Pathological Events
• Recurrent Alteration of Tonic Activity
• Implies
– Partial Damage
– Recovery of Function
• Total
• Partial
Causes
• Migraine
• Meniere’s
• Vascular Loops
• Susac’s Syndrome
• Syphilis
Meniere’s Disease
• Episodic Vertigo
– 20 min- 24 hours
• Fluctuating Low Tone Sensori-neural Hearing
Loss
• Tinnitus
• Sensation Pressure in Ear
Stages
• Hearing returns to normal between Attacks
• Permanent Low Tone Loss
– Worse during attack
• Permanent Loss
– Doesn’t change
Diagnosis
• History
• Evidence of Canal Paresis
• Serial Audiometry
Variants
• Cochlear Hydrops
– No Vestibular Symptoms
• Vestibular Hydrops
– Probably Migraine
• Tumarkin Otolithic Crisis
– Sudden Collapse
Management
Medical
• Low salt Diet
• Cinnarizine in acute phase
• Betahistine
– Dose: 8-16mg tds
– High Dose: 96-160 mg tds
Non-Response to Medical Treatment
• Revisit Diagnosis
– Why couldn’t it be Migraine?
• Surgical Options
Surgical
• Chemical Labyrinthectomy
– Gentamicin
• Delivery
– Grommet
– Transtympanic Injection
– Tympanotomy
• Apply directly to Round Window Membrane
Surgical Options
• Endolymphatic Sac Decompression
• Vestibular Nerve Section
Migrainous Vertigo
• Migraine without Aura
• Migraine with Aura
– Migraine with Prolonged Aura
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Basilar Migraine
Migraine Aura without Headache
Childhood Periodic Syndromes
Migrainous Infarction
Basilar Migraine
• Two or more:• Vertigo, Tinnitus,Hearing Loss, Ataxia,
Dysarthria, Diplopia, Paraesthesia, Paresis
• Headache
• Vertigo
– 5-60 min
Migraine Aura without Headache
• Past History Classical Migraine
• Family History Migraine
• Response to Triptans
Undiagnosed Recurrent Vertigo
• 30% Develop Migraine or BPPV
• Some Migraine
• Bilateral Involvement
• Vestibular Migraine, Meniere’s, Epilepsy, MS
• BPPV
• All may have atypical presentations
Differential
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Meniere’s
BPPV
TIAs
Vestibular Epilepsy
Perilymph Fistula
Case Study 1
• Early 50’s
• 2 months
• Recurrent Dizziness
History
• Symptom
– Mostly lightheadedness
– Severe episodes- Spinning
• Tempo
– 15-60 sec
– Multiple Times a day
Symptoms
• Circumstance
– Accompanying
• Palpitations
– Causation
• Eating Solids
Examination
• ENT
– Normal
• ECG
– Normal
Test Feed
• Pre-Food
– Heart Rate 65
– BP 132/70
• Post Feed
– Heart Rate
– Rhythm
120-160
• Atrial Extrasystoles
• Flutter Rhythm
• Terminates with Increasing AV block
Case 2
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52 yr old Female
No Past History Dizziness
Turned Suddenly
Acute Rotatory Vertigo
Nausea and Vomiting
Given Cyclizine
Referred to Hospital
Admission
• Severe Vertigo
• Severe Nausea and Vomiting
• No Nystagmus
Benign Paroxysmal Positional
Vertigo
Causes
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Idiopathic
Head Injury
Vestibular Neuronitis
Labyrinthitis
Anterior Vestibular Artery Ischaemia
Idiopathic
• Highest Incidence
– 6th-7th Decade
• >70 years
– 25% patients presenting with “dizziness” had
BPPV
• Referrals to Vestibular Clinic
– 23% BPPV
– Mean age 61
Idiopathic
• Undiagnosed
– Increased Risk Falls
– Impaired Daily Living
• General Medical Clinic
– 9% Positive Dix-Hallpike Test but no balance
complaints
Canal Involved
• Posterior
– 76%
• Anterior
– 13%
• Posterior or Anterior
– 6%
• Horizontal
• 5%
Symptoms
• Vertigo
• Light-headedness
• Floating Sensation
Vertigo
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Lying Down
Getting Up
Rolling Over in Bed
Looking Up
Light-Headedness
Floating Sensation
• Hours
• Days
Forms
• Canalithiasis
– Otoconia floating in Canal
– Move to most dependent part of canal
– Pull on Cupula ceases when Otoconia stop moving
• Cupulolithiasis
– Otoconia stuck to Cupula
– Gravitational Distortion of Cupula persists as long
as position maintained
– Some Vestibular Adaptation occurs
Dix-Hallpike Test
• Latent Period
– 3-40 sec
• Nystagmus
• Fatigues
• Adaptation with repeat testing
Nystagmus
• Upbeat
• Torsional
– Upper Pole beating towards undermost Ear
Treatment
• Particle Repositioning Manoeuvre
– Epley
• Liberatory Manoeuvre
– Semont
• Slam-Dunk
• Brandt-Daroff Exercises
– Habituation
Treatment
• Canalithiasis
– Epley
• Cupulolithiasis
– Liberatory
– Re-test
– If now Canalithiasis
– Epley
Other Nystagmus
• Not Posterior Canal BPPV
• Horizontal Jerk Nystagmus
– Horizontal Canal BPPV
Horizontal Canal BPPV
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Roll Test
Lie on Back- Head 20-30 degrees up
Turn quickly to Right or Left
Observe for Nystagmus
Move Head slowly back to Neutral Position
Wait 20-30 sec
Repeat on opposite side
Results
• Effect turning to both sides
• Stimulating in one direction
• Inhibiting in opposite direction
• One side
– More severe symptoms
– More Pronounced Nystagmus
– Longer duration of Nystagmus
Treatment
• Canalithiasis
– Bar-B-Que Roll
– Appiani Manoeuvre
• Cupulolithiasis
– Casani Manoeuvre
Bar-B-Que Manoeuvre
• Turn head to affected side
– Wait 15 seconds after symptoms stop
• Turn head 90 degrees to the Vertical
– Wait as before
• Another 90 degrees
– Wait
• Another 90 degrees
– Wait
CHRONIC SUBJECTIVE DIZZINESS
SYNDROME
Precise(ish) Symptoms
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True Vertigo
Light Headed
Presyncope
Pressure Sensation
Postural Imbalance
Ataxia
Psychogenic Symptoms
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Chronic Heavy Head
Light Headed
Tightness in Head
Floor Rising and Falling
CSD Symptoms
• >3 months
– Non-vertigo dizziness
– Light Headed
– Heavy Headed
– Feeling inside head spinning
– Feeling Floor moving
– Disassociation from Environment
CSD Symptoms
• Chronic Hypersensitivity
– One’s own movement
– Movement of Objects in Environment
• Exacerbation of Symptoms
– Situation of Complex Visual Stimuli
– Supermarket
– Computer screen
Age and Sex
• Age
– Adolescent to Old Age
– Peak 40-60
• Sex
– Female 2 - Male 1
Pathogenesis
• Psychological Problem
– 93%
• General Anxiety
• Panic Attacks/ Phobia
• Minor Anxiety
Pathogenesis
• Few
– Depression
– Post Traumatic Stress Disorder
– Hypochondriasis
– Conversion Disorder
Relationship with Neuro-otological or
Neurological Conditions
• Many had
– Vestibular Neuronitis
– Migraine
– BPPV
• Acute Vestibular Problem Precipitates Acute
Anxiety
• Requirement
– Treat underlying Psychopathology
Otogenic CSD
• No Prior History of Anxiety
• Anxiety precipitated by Neuro-otologic Illness
Psychogenic CSD
• Dizziness develops during Anxiety attack
Interactive CSD
• Prior History of Anxiety
• CSD Develops or worsens after
– Acute Vestibular Event
– Transient Mild Rotatory Vertigo
Continuing Problem
• Psychological Process plays Principal Role in
Sustaining
– Symptoms
– Functional Impairment
Key to Therapeutic Success
• Address Psychological Problems
Treatment
• Psycho-education
• Most Believe
– Physical Disorder
• Need
– Explanation of how Psychological Disease
produces and sustains Physical Symptoms
Pharmacology
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SSRI
Complete Remission 50%
Positive Effect
70%
Initial Increase in Symptoms
– Benzodiazepines may help in first few weeks
• 20% intolerant
Other Treatments
• Cognitive Behaviour Therapy
• Vestibular Rehabilitation