a case-based approach to the dizzy patient and the...

A case-based approach to the dizzy patient and the evaluation of vertigo

Jennifer Wipperman, MD, MPH Via Christi Family Medicine

University of Kansas School of Medicine - Wichita

se-based approach to the dizzy patient anevaluation of vertigo

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Objectives • Use the four classic dizziness sub-categories to

differentiate between causes of dizziness.

• Perform classical office tests for dizziness diagnosis, such as the Dix-Hallpike, visual fixation and head thrust tests.

• Differentiate between central (serious) and peripheral (benign) causes of vertigo.

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Objectives

• Diagnose and manage common causes of vertigo

• Describe how the approach to dizziness may differ in an elderly patient, and identify several ways to prevent falls and maintain function in the elderly patient with dizziness.

• Perform the modified Epley maneuver for treatment of benign positional vertigo.

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Dizziness

• Common medical complaint in primary care – Most causes benign, but can be serious

• Often frustrating

• Clinical Diagnosis

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Dizziness Jennifer Wipperman, MD

Family Medicine Winter Symposium December 5, 2014

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Case 1: 67 YOF who can’t go to the salon

• “I feel like the room is spinning”

• “Comes and goes” • Lasts only seconds • Brought on by rolling over to get out of bed in the morning, looking up to a shelf • No hearing loss or tinnitus • Feels fine between these

“spells”

Case 1: 67 YOF who can’t go to the salon

• “I feel like the room is spinning”

• “Comes and goes”• Lasts only seconds • Brought on by rolling over to get out of bed in the morning, looking up to shelf • No hearing loss or tinnitus• Feels fine between these

“spells”

o

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67 YOF with bad hair

• Medications: HCTZ • PMH: HTN • FH: mom had a stroke in

her late 80’s • SH: quit smoking 20

years ago, no ETOH


• Medications: HCTZ• PMH: HTN • FH: mom had a stroke in

her late 80’s• SH: quit smoking 20

years ago, no ETOH

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• What are the four types of dizziness?

• What kind of dizziness does this patient have?

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Describe “Dizziness”

• Wait for it… let the patient describe • What are the four types?

– Presyncope – Vertigo – Dysequilibrium – Non-specific dizziness

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Vertigo

• A false sense of motion – Self or environment

• Spinning • Amusement park ride • Swaying or tilting

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• List some common causes of vertigo

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Causes of Vertigo Peripheral “Benign” • BPPV • Vestibular neuritis • Meniere’s disease • Perilymphatic fistula • Herpes zoster oticus • Acoustic neuroma • Ototoxicity • Otitis media • Vestibular hypofunction • Semicircular canal

dehiscence syndrome

Central “Serious” • Migrainous vertigo • Intracranial mass • Stroke

– Cerebellar/brainstem • Vertebrobasilar

insufficiency • Chiari malformation • Multiple sclerosis

Causes of Vertigo Peripheral “Benign” • BPPV • Vestibular neuritis• Meniere’s disease • Perilymphatic fistula• Herpes zoster oticus • Acoustic neuroma • Ototoxicity • Otitis media • Vestibular hypofunction• Semicircular canal

dehiscence syndrome

Central “Serious”• Migrainous vertigo • Intracranial mass• Stroke

– Cerebellar/brainstem • Vertebrobasilar

insufficiency • Chiari malformation• Multiple sclerosis

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Historical Clues

• Timing – Episodic vs Constant • Duration – Seconds vs hours vs days • Recurrence

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Narrowing your diagnosis

Duration Timing Episodic Constant

Seconds BPPV Minutes-Hours Meniere’s

Migraine TIA

Days Migraine Vestibular neuritis CVA

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Historical Clues

• Triggers – position changes, head movement, pressure changes

• Associated symptoms – neurologic, hearing loss, tinnitus, headache

• PMH – diabetes, CVD, HTN, head trauma • FH – stroke, migraine, Meniere’s, BPPV • Medications – antihypertensives,

anticonvulsants

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• What do you look for on physical exam?

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Physical Exam

• Ear: cerumen, vesicles on TM, middle ear effusion, hearing

• Eye: nystagmus, ocular movements, vision • CV: carotid bruits, murmur, arrhythmia, signs

of PAD • Neurologic: Rhomberg, cerebellar signs

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• Vitals: AF, HR 62, BP 145/92 • HEENT: some cerumen in canals bilaterally • Neck: No carotid bruits • CV: RRR, no murmurs • Ext: DP +2 b/l, no edema • Neuro: wnl, no nystagmus

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What should you do next?

at shouhou d you do nldou ndo n

DIX-HALLPIKE

http://www.firstpost.com/topic/disease/benign-paroxysmal-positional-vertigo-geotropic-torsional-nystagmus-video-LUjPwbh9vOI-50844-8.html

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Benign Paroxysmal Positional Vertigo

• Most common cause of vertigo – Increasing incidence with age

• Brief episodes lasting < 1 minute • Triggered by head position changes

– No vertigo between attacks

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BPPV - Treatment

• Most spontaneously improve in 4-6 weeks • Best: Epley maneuver • Physical Therapy (vestibular rehabilitation) • Avoid symptomatic medications

– Meclizine, antiemetics, benzodiazepines

• Counsel about recurrence, evaluate fall risk

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Epley maneuver

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Case 2: 45 YOM truck driver who can’t drive

• Severe “dizziness” for 2 days • Nauseas and vomiting • Whenever he opens his eyes, feels like everything is moving • Prefers to lie still with eyes closed • Recent URI • No hearing loss or tinnitus

e

osseedd

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• What do you think is going on?

• What do you look for on physical exam?

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6

45 YOM who can’t open his eyes • HEENT: TM’s normal

• CV: RRR, no murmurs • Neuro:

– spontaneous unilateral nystagmus to right – Rhomberg normal – gait – veers towards the left but can walk

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What tests might help differentiate vestibular neuritis from a CVA?

HEAD THRUST TEST

VISUAL FIXATION

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Head thrust test

Adapted from Pract Neurol 2008; 8: 211–221.

Positive test

Normal test

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Visual fixation

• Have a patient focus on a visual target – Nystagmus stops if lesion is peripheral

• Place a blank sheet of paper in front of the patient’s face – Nystagmus returns

• Central lesions will not be suppressed by visual fixation

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Peripheral Central BPPV Vestibular Neuritis

History -Brief, recurrent -Triggered by positional changes -No vertigo between attacks

-Subacute onset -Constant and severe vertigo lasting days

-Sudden onset -Risk factors for stroke -Severe headache

Nystagmus -Up-beating and torsional -Horizontal and unidirectional

-Direction changing -Purely vertical -Purely torsional

Gait -Unaffected between episodes

-May veer towards affected side

-Unable to walk

Specialized physical exam tests

-Positive Dix-Hallpike maneuver -Positive supine roll test

-Positive head thrust test -Visual fixation stops nystagmus

-Negative head thrust test -Visual fixation does not stop nystagmus

Additional Neurologic Signs

-Rare -Rare -Common (such as dysarthria, aphasia, incoordination, weakness, or numbness)

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Vestibular neuritis

• Second most common cause of vertigo – 50% have had recent URI – Hypothesized to be a viral infection (HSV) of CN8

• Sudden, constant severe vertigo • Oscillopscia with spontaneous nystagmus • May veer towards affected side

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• What treatment could you offer this patient?

• Would you advise symptomatic medication (anti-emetics, anti-cholinergic, etc) and if so, for how long?

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Vestibular neuritis - Treatment

• Rest, gradually improves in a few weeks • Vestibular suppressants for first few days ONLY

– antiemetics, antihistamines, benzodiazepines

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Vestibular neuritis - Treatment

• Corticosteroids controversial – 2011 Cochrane review found insufficient evidence

for routine use – Studies show earlier return of vestibular function

testing but mixed evidence for earlier recovery of symptoms

– Prednisone burst for 10 days

• BEST – vestibular rehabilitation

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Vestibular rehabilitation • Facilitates “vestibular

adaptation” – brain compensates for vestibular dysfunction

• Quicker recovery and decreased long-term sequelae

Vestibular rehabilitation • Facilitates “vestibular

adaptation” – brain –compensates for vestibuladysfunction

• Quicker recovery and decreased long-term sequ

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Case 3: 13 year old who is missing school from “dizzy spells”

• Describes as spinning sensation, often triggered by movement

• Lasts hours, sometimes days.

• Associated with nausea and vomiting and photophobia

• Often seems to occur around time of menstruation

Case 3: 13 year old who is missingschool from “dizzy spells”

• Describes as spinning sensation, often triggered bymovement

• Lasts hours, sometimes days.

• Associated with nausea and vomiting and photophobia

• Often seems to occur around time of menstruation

y p

y

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13 year old with dizziness, photophobia, and phonophobia

• PMH: chronic headaches • Meds: NSAIDs, APAP as needed • FH: Migraines in mother, CVA in grandmother • PE: no abnormal findings including neurologic

exam and gait

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• What is the likely diagnosis?

• What tests would you consider? – What if this patient was 65 years old

with a history of HTN, DM2 and 30 pack-year smoking history?

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Vestibular migraine

• Common, unrecognized cause of vertigo • Migraine variant • Often a history of migraine • Vertigo may occur with headache • Duration and triggers similar to

migraine

Vestibular migraine

• Common, unrecognized cause of vertigo • Migraine variant • Often a history of migraine • Vertigo may occur with headache • Duration and triggers similar to

migraine

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Vestibular migraine

• Exam usually normal • Clinical diagnosis of exclusion

– Obtain audiometry and vestibular function testing to exclude other etiologies

– Consider MRI brain, esp. if red flags/stroke risk factors

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Diagnostic Criteria for Vestibular Migraine

A. At least five episodes fulfilling criteria C and D

B. A current or past history of migraine without aura or migraine with aura

C. Vestibular symptoms of moderate or severe intensity, lasting between 5 minutes and 72 hours

D. At least 50 percent of episodes are associated with at least one of the following three migrainous features: 1. Headache with at least two of the following four characteristics: a) Unilateral location b) Pulsating quality c) Moderate or severe intensity d) Aggravation by routine physical activity 2. Photophobia and phonophobia 3. Visual aura

E. Not better accounted for by another ICHD-3 diagnosis or by another vestibular disorder

Lempert 2012. 41

Vestibular Migraine: Treatment

• Same as for migraine – Improvement of vertigo with triptans can be both

therapeutic and diagnostic – Trigger avoidance – Prophylaxis if frequent or debilitating

• Vestibular suppressants

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Case 4: A dizzy 37 YOF with an earful of ocean

• Last week, had vertigo, nausea, and vomiting – Lasted 3-4 hours – Spontaneously resolved

• Recurred this morning • Difficulty walking • “Sounds like the ocean is in

my left ear”

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37 YOF with dizziness and roaring in her left ear

• PMH: Hypertension • Meds: HCTZ, OCP • FH: Grandfather with a “dizziness problem” • SH: Occasional ETOH, former smoker

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37 YOF with dizziness and roaring in her left ear

• Vitals: AF, BP 132/85, HR 77, RR 18 • General: Lying supine, uncomfortable-

appearing • HEENT: Horizontal nystagmus with left gaze;

decreased hearing in left ear • CV: RRR, no murmurs, no bruits • Neuro: + Rhomberg, mild gait ataxia

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• What do you think is going on? • What further testing is needed? • How would you treat her acute

symptoms? Prevent future episodes? ?

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Meniere’s Disease

• Classic triad of vertigo, hearing loss, and tinnitus/aural fullness – HL is fluctuating, occurs

with vertigo, initially low frequency

Bope ET, Kellerman RD 2013.

Meniere’s Disease

• Classic triad of vertigo, hearing loss, andtinnitus/aural fullness – HL is fluctuating, occurs

with vertigo, initially low frequency

Bope ET, Kellerman RD 2013.

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Meniere’s disease

• Overtime, can lead to permanent disability – Permanent hearing loss – Vestibular function loss leads to chronic imbalance

and positional vertigo

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Meniere’s Disease: Diagnosis

• Clinical diagnosis • Audiometry • MRI/MRA - rule out other causes • +/- Vestibular function testing

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Diagnostic criteria for Meniere’s disease

Definite Meniere’s Disease

A. ≥ 2 definitive spontaneous episodes of vertigo 20 min or longer

B. Audiometrically documented hearing loss on at least 1 occasion

C. Tinnitus or aural fullness in the treated ear D. Other causes excluded

Otolaryngol Head Neck Surg. 1995;113(3):181.

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Treatment

• Goals: decrease frequency/severity of vertigo, improve balance, preserve hearing and QOL

• Acute: Symptomatic meds, steroid • Prophylaxis:

– Diet: Decrease salt, caffeine, alcohol, MSG, nicotine – Diurectics: e.g. triamterene-hydrochlorothiazide

(Dyazide) 37.5-25 mg

• Educate: No “cure” but most can get good improvement of vertigo

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Other treatment modalities (from most to least conservative)

• Vestibular rehabilitation • Meniett device • Intratympanic gentamicin • Endolymphatic sac procedures • Vestibular neurectomy • Labyrinthectomy

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Case 5: 72 YOF who gets dizzy when putting the dishes away

• Feels like things are spinning

• Noticed that it occurs whenever she looks up to put dishes away on high shelves

• Lasts about a minute, resolves if she “holds still”

• Normal between episodes

Case 5: 72 YOF who gets dizzy when putting the dishes away

• Feels like things arespinning

• Noticed that it occurs whenever she looks up to put dishes away on highshelves

• Lasts about a minute, resolves if she “holds still”

• Normal between episodes

y

”s

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72 YOF who gets dizzy when putting the dishes away

• Medications: Lisinopril-HCTZ, ibuprofen • PMH: HTN • SH: ½ ppd x 45 years, no ETOH • FH: Father died of MI age 62

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• Vitals: BP 157/82, HR 89 • HEENT: TMs clear, swollen turbinates • Neck: bilateral carotid bruits • CV: RRR, no murmur • Ext: DP 1+ B/L • Neuro: WNL, no nystagmus

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• What do you think is going on? • What is your first step in further evaluating

this patient?

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• Orthostatics: BP → 145/76,↑ 113/68 – Stopped diuretic – symptoms unchanged

• Dix-Hallpike: +vertigo on right, ? nystagmus • Carotid doppler

– Right ICA 50-69% stenosis – Reversal of flow in left vertebral artery: Subclavian Steal Syndrome

• Symptoms resolve with stenting of left subclavian artery (90% stenosis)

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Vertebrobasilar insufficiency (TIAs)

• Brainstem ischemia – Embolic, atherosclerotic

occlusions of vertebrobasilar arterial system

– Subclavian steal syndrome – Rotational vertebral artery

syndrome

Vertebrobasilar insufficiency (TIAs)

• Brainstem ischemia – Embolic, atherosclerotic

occlusions of vertebrobasilararterial system

– Subclavian steal syndrome– Rotational vertebral artery

syndrome

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Vertebrobasilar insufficiency • Recurrent, abrupt episodes lasting min - hours • +/- diplopia, ataxia, weakness, drop attacks,

dysarthria – Isolated vertigo if ischemia is in the distribution of

the vertebral artery

• Crescendo pattern • KEY: Risk factors for cardiovascular disease

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Indications for further testing • Diagnosis uncertain or refractory BPPV

– Vestibular function testing – BPPV can occur along with other vestibular

disorders

• Red flags rule out central cause – Included are risk factors for CVD

• MRI/MRA, Carotid doppler

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84 YO dizzy male who was told he was just “getting old”

• Chronic dizziness • Unsteady on feet, which he

notes “go numb” • Curtailing activities • PMH: Advanced macular

degeneration, hearing loss, DM2, HTN

• Meds: metformin, lisinopril, ASA 81mg, Tylenol PM

84 YO dizzy male who was told he was just “getting old”

• Chronic dizziness • Unsteady on feet, which he

notes “go numb”• Curtailing activities • PMH: Advanced macular

degeneration, hearing loss,DM2, HTN

• Meds: metformin, lisinopril, ASA 81mg, Tylenol PM

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84 YO dizzy male who was told she was just “getting old”

VS: Temp 36.8, HR 62, BP 110/70 HEENT: VA 20/200 OU, PEERLA, Cerumen obscuring both TMs, cannot decipher words spoken softly in either ear CV: RRR, systolic murmur at RUSB Neuro: Gait –hesitant, improves if he can touch his hand to a counter/your arm. Decreased sensation to light touch, temperature and vibratory sense in LE bilaterally.

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• What other physical exam tests would you do?

• What do you think is contributing to his dizziness?

• What can you offer him?

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Dizziness in the elderly • Over 1/3 of elderly

experience dizziness • Increases fall risk,

disability, institutionalization, and death

• Usually multiple contributors, therefore evaluate all possible contributing factors

Dizziness in the elderly • Over 1/3 of elderly

experience dizziness • Increases fall risk,

disability,institutionalization, anddeath

• Usually multiple contributors, therefore evaluate all possible contributing factors

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Take home points • Dizziness is not a disease, it is a symptom • Most dizziness can be diagnosed with history

and physical exam alone • Do further testing if dx unclear or red flags

– neurologic sx’s/signs, risk factors for vascular disease

–––––––––––––––––

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Take home points • Use the Dix-Hallpike and Epley maneuvers to

diagnose and treat BPPV • Vestibular rehabilitation reduces fall risk,

improves outcomes • Avoid using vestibular suppressants for BPPV,

and no more than 2-3 days for VN • Dizziness in the elderly often multifactorial

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References 1. Bope ET, Kellerman RD: Conn's Current Therapy 2013. Philadelphia, Saunders, 2012, p 301 2. Bhattacharyya N, Baugh RF, Orvida L, et al: Clinical practice guideline: Benign paroxysmal positional

vertigo, Otolaryngol Head Neck Surg 139:S47-S81, 2008. 3. Committee on Hearing and Equilibrium guidelines for the diagnosis and evaluation of therapy in

Meniere's disease. American Academy of Otolaryngology-Head and Neck Foundation, Inc. Otolaryngol Head Neck Surg . Sep 1995;113(3):181-185.

4. Fishman JM, Burgess C, Waddell A. Corticosteroids for the treatment of idiopathic acute vestibular dysfunction (vestibular neuritis). Cochrane Database Syst Rev. 2011(5):CD008607.

5. Lempert T, Olesen J, Furman J, et al. Vestibular migraine: diagnostic criteria. Journal of vestibular research : equilibrium & orientation. 2012;22(4):167-172.

6. Wipperman J. Dizziness and vertigo. Primary care. Mar 2014;41(1):115-131. 7. Dix-Hallpike video. YouTube. https://www.youtube.com/watch?v=kEM9p4EX1jk Accessed 11/22/14 8. Epley video. YouTube. https://www.youtube.com/watch?v=ZqokxZRbJfw Accessed 11/22/14

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