DizzinessDizziness

Paul ChatrathConsultant ENT Surgeon

Barking Havering & Redbridge Hospitals NHS Trust

21st January 2009

ObjectivesObjectives

DefinitionsDefinitions Clinical history & examinationClinical history & examination Multiple factorsMultiple factors Key conditions – BPPV, Meniere’s, Key conditions – BPPV, Meniere’s,

labyrinthitis, non-vestibularlabyrinthitis, non-vestibular

““Dizziness”Dizziness”

Presyncopal faintnessPresyncopal faintness Loss of balance/imbalanceLoss of balance/imbalance UnsteadinessUnsteadiness Light-headednessLight-headedness WhoozinessWhooziness VertigoVertigo Feeling of rotation or movementFeeling of rotation or movement

BalanceBalance

Vestibular systemVestibular system Peripheral vestibular (labyrinth)Peripheral vestibular (labyrinth) CerebellarCerebellar

Visual system - VORVisual system - VOR Proprioceptive system - VSRProprioceptive system - VSR

Vestibular LabyrinthVestibular Labyrinth

3 semicircular canals3 semicircular canals rotational movementrotational movement cupulacupula

2 otolithic organs - utricle & saccule2 otolithic organs - utricle & saccule linear accelerationlinear acceleration maculamacula

Clinical approachClinical approach

Vertigo vs dizzinessVertigo vs dizziness Vertigo – peripheral vestibular or Vertigo – peripheral vestibular or

cerebellarcerebellar Dizziness – non vestibularDizziness – non vestibular

Questions to establish causes for Questions to establish causes for each of theseeach of these

Vertigo vs DizzinessVertigo vs Dizziness

Definition of vertigo:Definition of vertigo: Illusion of movement of oneself or the Illusion of movement of oneself or the

surroundingssurroundings Typically rotatoryTypically rotatory Looking for vestibular causesLooking for vestibular causes

If no rotatory component:If no rotatory component: Likely to be nonspecific dizzinessLikely to be nonspecific dizziness Looking for non-vestibular causesLooking for non-vestibular causes

Vertigo vs Dizziness:Vertigo vs Dizziness: Unclear? Unclear?

Vertigo:Vertigo: RotatoryRotatory Worse on head movementsWorse on head movements Nausea/vomiting on head movementsNausea/vomiting on head movements

Vague descriptions: rarely true Vague descriptions: rarely true vertigovertigo

Vertigo - causesVertigo - causes

VestibularVestibular Viral labyrinthitisViral labyrinthitis BPPVBPPV Meniere’s diseaseMeniere’s disease Acute Otitis MediaAcute Otitis Media TraumaTrauma CholesteatomaCholesteatoma Drug inducedDrug induced PostsurgicalPostsurgical

CentralCentral MigraineMigraine Vertebrobasilar ischaemiaVertebrobasilar ischaemia MSMS TumoursTumours

Cerebellopontine angleCerebellopontine angle Acoustic neuromaAcoustic neuroma

BrainstemBrainstem CVACVA

PsychogenicPsychogenic

History: History: VertigoVertigo VestibularVestibular Viral labyrinthitisViral labyrinthitis BPPVBPPV Meniere’s diseaseMeniere’s disease Acute Otitis MediaAcute Otitis Media TraumaTrauma CholesteatomaCholesteatoma Drug inducedDrug induced PostsurgicalPostsurgical

CentralCentral MigraineMigraine Vertebrobasilar ischaemiaVertebrobasilar ischaemia MSMS TumoursTumours

Cerebellopontine angleCerebellopontine angle Acoustic neuromaAcoustic neuroma

BrainstemBrainstem CVACVA

PsychogenicPsychogenic

• 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

History: History: VertigoVertigo VestibularVestibular Viral labyrinthitisViral labyrinthitis BPPVBPPV Meniere’s diseaseMeniere’s disease Acute Otitis MediaAcute Otitis Media TraumaTrauma CholesteatomaCholesteatoma Drug inducedDrug induced PostsurgicalPostsurgical

CentralCentral MigraineMigraine Vertebrobasilar ischaemiaVertebrobasilar ischaemia MSMS TumoursTumours

Cerebellopontine angleCerebellopontine angle Acoustic neuromaAcoustic neuroma

BrainstemBrainstem CVACVA

PsychogenicPsychogenic

• Associated central features• Face or arm weakness/numbness

• Frequency• Single: labyrinthitis, MS• Constant:

• decompensation• neurological• psychogenic

• Trauma• Drug history

• Aminoglycosides• Diuretics• Aspirin• Chemotherapy

• Surgery

Non-specific dizziness:Non-specific dizziness:

CausesCauses CardiovascularCardiovascular

ArrhythmiasArrhythmias Reduced cardiac outputReduced cardiac output Carotid artery stenosisCarotid artery stenosis ArteriosclerosisArteriosclerosis Hypotension (postural)Hypotension (postural)

ProprioceptionProprioception ArthritisArthritis

MetabolicMetabolic DMDM HypothyroidismHypothyroidism HypercholesterolaemiaHypercholesterolaemia AnaemiaAnaemia

Peripheral neuropathyPeripheral neuropathy DMDM Renal or hepatic failureRenal or hepatic failure AlcoholAlcohol VasculitisVasculitis InfectionsInfections

Leprosy, TB, syphilisLeprosy, TB, syphilis Vitamin deficienciesVitamin deficiencies

B1, B6, B12B1, B6, B12 Genetic - Refsum’s diseaseGenetic - Refsum’s disease ToxinsToxins

Lead, metronizadoleLead, metronizadole

PsychogenicPsychogenic

ExaminationExamination EarsEars

TMsTMs

Cranial nervesCranial nerves All are useful!All are useful!

General General examinationexamination

Nystagmus: Nystagmus: ‘rhythmic ‘rhythmic oscillating involuntary movement oscillating involuntary movement of eyes’of eyes’

CerebellarCerebellar

PosturePosture Romberg’sRomberg’s Unterberger’sUnterberger’s

Hallpike’sHallpike’s

NystagmusNystagmus

Movement of the Movement of the eyes:eyes: RhythmicRhythmic OscillatingOscillating SynchronousSynchronous InvoluntaryInvoluntary

Two phasesTwo phases Slow phase Slow phase

(pathological)(pathological) Fast phase Fast phase

(corrective)(corrective) Direction described Direction described

in terms of fast in terms of fast phasephase

XL

NystagmusNystagmus

Eyes central Slow drift to rightRapid corrective flick to left

= Left nystagmus

L R

Normal labyrinths Abnormal Right Labyrinth

Vertigo:Vertigo:

Vestibular v CentralVestibular v CentralVestibularVestibular CentralCentral

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 Horizontal or vertical+ unilateral + bilateral+ away from affected ear

Vertigo:Vertigo:

CompensationCompensation Vestibular Vestibular

phenomenonphenomenon Steady Steady

accommodation to accommodation to the effects of vertigothe effects of vertigo

Gradual resolution of Gradual resolution of symptoms over timesymptoms over time

Typically occurs 6-12 Typically occurs 6-12 weeks after acute weeks after acute insultinsult

MechanismsMechanisms HabituationHabituation

Reduced output Reduced output good sidegood side

Increased output Increased output affected sideaffected side

Sensory substitutionSensory substitution Increased reliance Increased reliance

on eyes and on eyes and musculoskeletal musculoskeletal systemsystem

Vertigo:Vertigo:

CompensationCompensation Impaired Impaired

compensation due to:compensation due to: Poor visual acuityPoor visual acuity Musculoskeletal Musculoskeletal

problemsproblems Reduced peripheral Reduced peripheral

sensory inputsensory input Ongoing vestibular Ongoing vestibular

pathologypathology Medication (prolonged Medication (prolonged

stemetil)stemetil)

Rehabilitation:Rehabilitation: General fitnessGeneral fitness

Vision, walking stickVision, walking stick Physical programsPhysical programs

Cawthorne-CookseyCawthorne-Cooksey Psychological Psychological

supportsupport Specific exercisesSpecific exercises

Eg. Brandt-Daroff Eg. Brandt-Daroff exercises for BPPVexercises for BPPV

Cawthorne - CookseyCawthorne - Cooksey

Developed in 1940sDeveloped in 1940s Head movementsHead movements Balance tasksBalance tasks Coordination of eyes with headCoordination of eyes with head Total body movementsTotal body movements Eyes open & closedEyes open & closed Noisy environmentsNoisy environments Early exacerbation of vertigoEarly exacerbation of vertigo

InvestigationsInvestigations

Radiology Radiology (anatomical (anatomical imaging)imaging) MRI – good for IAM’sMRI – good for IAM’s CT – good for CT – good for

vestibular anatomyvestibular anatomy AudiogramAudiogram

Asymmetry needs Asymmetry needs further imagingfurther imaging

Tests of vestibular Tests of vestibular functionfunction ENGs ENGs

(electronystagmograp(electronystagmography)hy)

Caloric testsCaloric tests Rotation testsRotation tests

Symptomatic TxSymptomatic Tx

Acute phaseAcute phase PhenothiazinesPhenothiazines

ProchlorperazineProchlorperazine

(Stemetil)(Stemetil) AntihistaminesAntihistamines

Cinnarizine (Stugeron)Cinnarizine (Stugeron) Cyclizine (Valoid)Cyclizine (Valoid) Promethazine (Avomine)Promethazine (Avomine)

Histamine analoguesHistamine analogues Betahistine (Serc)Betahistine (Serc)

Longer term:Longer term: Depends on Depends on

specific conditionspecific condition

Caution:Caution:

ProchlorperazineProchlorperazine Powerful vestibular sedativePowerful vestibular sedative Suppresses acute vertiginous Suppresses acute vertiginous

symptomssymptoms

BUTBUT Also suppresses natural compensatory Also suppresses natural compensatory

responseresponse LT use: ‘non-specific dizziness’ LT use: ‘non-specific dizziness’

persistspersists

PsychogenicPsychogenic Type of dizziness: Type of dizziness: any (nonspecific or any (nonspecific or

vertigo)vertigo) Frequency: Frequency: constantconstant Duration:Duration: Typically brief <1min Typically brief <1min Trigger: Trigger: Stress, anxiety, crowdsStress, anxiety, crowds Associated features: Associated features: palpitations, palpitations,

sweating, tremorsweating, tremor Examination: Examination: NormalNormal

LabyrinthitisLabyrinthitis

OtiticOtitic InfectiveInfective

Viral (serous)Viral (serous) CMV, influenza, CMV, influenza,

adenovirusadenovirus Bacterial Bacterial

(suppurative)(suppurative) Strep pneumoniaeStrep pneumoniae HaemophilusHaemophilus MoraxellaMoraxella

Other causesOther causes cholesteatomacholesteatoma

Other sourceOther source MeningealMeningeal TBTB SyphilisSyphilis NeoplasiaNeoplasia HaematogenicHaematogenic

LabyrinthitisLabyrinthitis

HistoryHistory VertigoVertigo

>24hrs>24hrs VomitingVomiting Constitutional Constitutional

symptomssymptoms ExaminationExamination

NystagmusNystagmus Fast phase away from Fast phase away from

affected earaffected ear PyrexiaPyrexia

TreatmentTreatment Bed restBed rest Vestibular sedativesVestibular sedatives FluidsFluids Cawthorne-Cooksey Cawthorne-Cooksey

vestibular vestibular rehabilitation rehabilitation exercisesexercises

Meniere’s DiseaseMeniere’s Disease

Key features:Key features: VertigoVertigo

Hours not minutes or Hours not minutes or daysdays

Associated tinnitus Associated tinnitus and hearing lossand hearing loss

Before, during or Before, during or after vertigoafter vertigo

Other symptomsOther symptoms Pressure feelingPressure feeling NauseaNausea

AetiologyAetiology VascularVascular ‘‘Hydrops’Hydrops’

Natural historyNatural history One episodeOne episode EpisodicEpisodic Increasing Increasing

frequencyfrequency

Meniere’s Disease:Meniere’s Disease:

Medical therapyMedical therapy Salt restrictionSalt restriction DiureticsDiuretics

Thiazides - Na Thiazides - Na absorption in distal absorption in distal tubuletubule

Side effects - Side effects - hypokalemia, hypokalemia, hypotension, hypotension, hyperuricemia, hyperuricemia, hyperlipoproteinemiahyperlipoproteinemia

VasodilatorsVasodilators Betahistine, Betahistine,

cinnarizinecinnarizine Evidence – no RCTsEvidence – no RCTs

Cinnarizine > placeboCinnarizine > placebo Diuretics = placeboDiuretics = placebo Serc of marginal Serc of marginal

benefitbenefit Salt restriction of Salt restriction of

marginal benefitmarginal benefit

Meniere’s Disease:Meniere’s Disease:

Surgical therapySurgical therapy

Hearing preservationHearing preservation Vestibular preservationVestibular preservation

Endolymphatic sac Endolymphatic sac drainagedrainage

Intratympanic injection of Intratympanic injection of steroidsteroid

Vestibular destructionVestibular destruction VIII nerve sectionVIII nerve section

Hearing destructionHearing destruction Intratympanic injection Intratympanic injection

gentamicingentamicin

LabyrinthectomyLabyrinthectomy

ITAGITAG

BPPV:BPPV:Benign Paroxysmal Position Benign Paroxysmal Position

VertigoVertigo Calcific debris in Calcific debris in

semicircular canalssemicircular canals CupulolithiasisCupulolithiasis CanalolithiasisCanalolithiasis

VertigoVertigo Brief (<1min)Brief (<1min) On head turn in a On head turn in a

particular directionparticular direction Typically self-Typically self-

limitinglimiting

PrimaryPrimary SecondarySecondary

Trauma (HI)Trauma (HI) Prolonged bed restProlonged bed rest Otological condition Otological condition

(up to 70%)(up to 70%) LabyrinthitisLabyrinthitis

CentralCentral

BPPV:BPPV:Benign Paroxysmal Position Benign Paroxysmal Position

VertigoVertigo Posterior SCCPosterior SCC

In plane on lying in In plane on lying in bedbed

Hallpike’s testHallpike’s test Nystagmus on lying Nystagmus on lying

back to one sideback to one side

Problem: how to Problem: how to distinguish BPPV distinguish BPPV from central causesfrom central causes

BPPV:BPPV:Hallpike’s test – Character of Hallpike’s test – Character of

NystagmusNystagmus

BPPVBPPV CentralCentral

Latency 5-10s None

Adaptation Gone in 50s Persists

Fatiguable Yes No

Vertigo Always Absent

Direction Rotatory (geotropic) Variable

Incidence Common Rare

BPPV - EpleyBPPV - Epley

Epley, 1992

BPPV - Brandt & DaroffBPPV - Brandt & Daroff

Brandt & Daroff, 1980

MigraineMigraine Clinical featuresClinical features

family historyfamily history motion intolerancemotion intolerance Vertigo occurs with classical headacheVertigo occurs with classical headache ENT/vestibular examination usually NADENT/vestibular examination usually NAD

Lifestyle changeLifestyle change exercise, diet, avoidance of stimulantsexercise, diet, avoidance of stimulants

Medication:Medication: Abortive therapy eg. SumatriptanAbortive therapy eg. Sumatriptan Prophylactic therapy eg. B blockersProphylactic therapy eg. B blockers

Vertebrobasilar InsufficiencyVertebrobasilar Insufficiency

Vertigo, diplopia, dysarthria, ataxia, Vertigo, diplopia, dysarthria, ataxia, sensory and motor disturbancesensory and motor disturbance

NOTNOT synonymous with cervicogenic synonymous with cervicogenic vertigovertigo

30% of TIA’s30% of TIA’s AspirinAspirin

DizzinessDizziness

Paul ChatrathPaul ChatrathConsultant ENT SurgeonConsultant ENT SurgeonQueen’s/King George’s Queen’s/King George’s HospitalsHospitals

Any Questions?

Email:Email:paul.chatrath@bhrhospitals.nhs.ukpaul.chatrath@bhrhospitals.nhs.uk

paul@chatrath.compaul@chatrath.com

A Final Thought......A Final Thought......

QQ In a patient with vertigo, if you In a patient with vertigo, if you had had only one question to ask him/her, only one question to ask him/her, what what would it be?would it be?

AA How long does the vertigo last for?How long does the vertigo last for?- BPPV- BPPV SecondsSeconds

- Meniere’s- Meniere’s HoursHours

- Labyrinthitis- Labyrinthitis DayDay