peripheral vestibular disorders - diagnostic tools
TRANSCRIPT
Common Peripheral Vestibular Disorders
Diagnostic Tools
Sasan Dabiri, MD, Assistant Professor
Department of Otorhinolaryngology – Head & Neck Surgery
Amir Alam Hospital – Tehran University of Medical Sciences
November 2016
Common Peripheral Vestibular Disorders – Diagnostic Tools
I n t r o d u c t i o n
Vertigo
Presyncope
Disequilibrium
Psychiatric
Not specific
Dizziness - Etiology
Common Peripheral Vestibular Disorders – Diagnostic Tools
I n t r o d u c t i o n
Vertigo
Presyncope
Disequilibrium
Psychiatric
Not specific
Dizziness - Etiology
Peripheral
Central
Dizziness - Etiology
Common Peripheral Vestibular Disorders – Diagnostic Tools
Ve r t i g o - D i a g n o s t i c To o l s
T h e a c c u ra te d i a g n o s i s o f t h e u n d e r l y i n g e t i o l o g y
i s a n i m p o r t a n t f i r s t s te p i n t h e t r e a t m e n t o f v e r t i g o
Common Peripheral Vestibular Disorders – Diagnostic Tools
Ve r t i g o - D i a g n o s t i c To o l s
ImagingAudio-
Vestibular Tests
Physical Exam.
History
T h e a c c u ra te d i a g n o s i s o f t h e u n d e r l y i n g e t i o l o g y
i s a n i m p o r t a n t f i r s t s te p i n t h e t r e a t m e n t o f v e r t i g o
Common Peripheral Vestibular Disorders – Diagnostic Tools
Ve r t i g o - D i a g n o s t i c To o l s
ImagingAudio-
Vestibular Tests
Physical Exam.
History
T h e a c c u ra te d i a g n o s i s o f t h e u n d e r l y i n g e t i o l o g y
i s a n i m p o r t a n t f i r s t s te p i n t h e t r e a t m e n t o f v e r t i g o
Common Peripheral Vestibular Disorders – Diagnostic Tools
Ve r t i g o - D i a g n o s t i c To o l s
ImagingAudio-
Vestibular Tests
Physical Exam.
History
T h e a c c u ra te d i a g n o s i s o f t h e u n d e r l y i n g e t i o l o g y
i s a n i m p o r t a n t f i r s t s te p i n t h e t r e a t m e n t o f v e r t i g o
Common Peripheral Vestibular Disorders – Diagnostic Tools
Ve r t i g o - D i a g n o s t i c To o l s
T h e a c c u ra te d i a g n o s i s o f t h e u n d e r l y i n g e t i o l o g y
i s a n i m p o r t a n t f i r s t s te p i n t h e t r e a t m e n t o f v e r t i g o
ImagingAudio-
Vestibular Tests
Physical Exam.
History
Common Peripheral Vestibular Disorders – Diagnostic Tools
Ve r t i g o - D i a g n o s t i c To o l s
History
True or pseudo vertigo One attack or more Episodic or continuous Duration of each episode How starts in first time
(straining, trauma)
Effect of head movement, life style, environment
Effect of ear pressure changes Associated symptoms Associated histories
(medical, family, psychologic)
Common Peripheral Vestibular Disorders – Diagnostic Tools
Ve r t i g o - D i a g n o s t i c To o l s
Physical Exam.
History
Otoscopic Examination (Normal) Nystagmus Vibration (SSCD, MD, VN) Hyperventilation (phobia, demyelination
[pressure by AN or vascular])
Sound/Pressure H I T test SVV (otolith dysfunction) Head shaking Positional testing (Hallpike)
Common Peripheral Vestibular Disorders – Diagnostic Tools
Ve r t i g o - D i a g n o s t i c To o l s
Audio-Vestibular
Tests
Physical Exam.
History
VNG (saccade, pursuit, nystagmus) evaluation as evoked in VNG
• Caloric Test lower freq. • Head Shaking 1-2 Hz• V-HIT 3-5 Hz
VEMP Rotatory Chair C D P ECOG PTA-SRT-WRS, AR
Common Peripheral Vestibular Disorders – Diagnostic Tools
Ve r t i g o - D i a g n o s t i c To o l s
ImagingAudio-
Vestibular Tests
Physical Exam.
History
C T :• SSCD Sx.• LVA Sx.
M R : • Meniere’s Disease• R/O CP Angle lesions & Other DDx
Common Peripheral Vestibular Disorders – Diagnostic Tools
C o m m o n D i s o r d e r s
BPPVMeniere’s
Disease
SSCD Sx.Vestibular Neuritis
Common Peripheral Vestibular Disorders – Diagnostic Tools
Robert BárányAustrian Anatomist
1876 - 1936
Common Peripheral Vestibular Disorders – Diagnostic Tools
B e n i g n Po s i t i o n a l Pe r i p h e r a l Ve r t i g o
Short episodes of severe vertigo after specific movements of head rolling over in bed extreme posterior extension of head
• changing a light bulb• looking under a sink
Turning head to one side (Lt or Rt)
History of trauma, Vestibular Neuritis, Meniere’s D., Surgery (Stapes), Bed rest
Dix-Hallpike test + appropriate historythe most important factors for Diagnosis
History
Physical Exam.
Common Peripheral Vestibular Disorders – Diagnostic Tools
B e n i g n Po s i t i o n a l Pe r i p h e r a l Ve r t i g o
Differential Diagnoses :
Vestibular Paroxysmia
(Dx Criteria , Carbamazepine responsive)
Differentiate with Clinical Findings (and Paraclinics if needed)
Central causes of Positional Nystagmus Demyelinating diseases (MS)
Cerebellar diseases
Around 4th Ventricle lesions
Differentiate with Nystagmus specifications
History
Physical Exam.
Common Peripheral Vestibular Disorders – Diagnostic Tools
Prosper MeniereFrench Physician
1799 - 1862
Common Peripheral Vestibular Disorders – Diagnostic Tools
M e n i e r e ’s D i s e a s e
Clinical Triad with special attention to : Incapacitating spinning vertigo, usually in the horizontal axis
Aural fullness as an equivalent to tinnitus
Life style effect (diet)
Environmental effect (weather, allergy)
Positive Family History
Tumarkin attack (sudden falling without vertigo or consciousness loss)
Lermoyes feature (unusual improvement of associated symptoms)
Horizontal nystagmus as the cardinal finding (during attacks)
Vibration induced nystagmus
History
Physical Exam.
Audio-Vestibular
Tests
Imaging
Common Peripheral Vestibular Disorders – Diagnostic Tools
M e n i e r e ’s D i s e a s e
Caloric test Increased warm & Diminished cold response in affected ear (DP)
ECoG Amplitude : SP/AP more than 0.4
Duration : AP more than 3 ms
Limitations :• Variability in recording technique
• Variability in electrode placement
• Variability with age
• Not good reproducibility
• Under the effect of hearing loss
• Under the effect of stage of disease
• False positive (20%) & False Negative (40%)
History
Physical Exam.
Audio-Vestibular
Tests
Imaging
Common Peripheral Vestibular Disorders – Diagnostic Tools
M e n i e r e ’s D i s e a s e
cVEMP Reduced amplitude
Higher threshold
Not good response to routine sound frequency (1000 Hz is better than 500 Hz)
Video HIT is rarely useful
MRI Axial 3T MRI of the inner ear, 3D Flair,
4 hours after double dose IV Gd (!)
History
Physical Exam.
Audio-Vestibular
Tests
Imaging
Common Peripheral Vestibular Disorders – Diagnostic Tools
M e n i e r e ’s D i s e a s e
Differential Diagnoses :
Vestibular Migraine Diagnostic Criteria
Overlap with each other
Otosyphilis Related History
CT and MR findings
Extra temporal findings
History
Physical Exam.
Audio-Vestibular
Tests
Imaging
Common Peripheral Vestibular Disorders – Diagnostic Tools
Antonio ScarpaItalian Anatomist
1752 - 1832
Common Peripheral Vestibular Disorders – Diagnostic Tools
Ve s t i b u l a r N e u r i t i s
Sudden onset of severe vertigo (days) + Vegetative symptoms
Head Thrust (HIT)
Vibration induced nystagmus
Audiometry (not new changes)
Caloric test
Video HIT
VEMP is rarely useful
Central Mimickers : Brainstem lesions
Differentiation by clinical findings
History
Physical Exam.
Audio-Vestibular
Tests
used to identify the side of involvement
Common Peripheral Vestibular Disorders – Diagnostic Tools
S u p e r i o r S e m i c i r c u l a r C a n a l D e h i s c e n c e S y n d .
Clinical findings : Autophony
Tullio phenomenon (not in all patients)
Hennebert Sign
Cough / Strain induced symptoms
Tinnitus (mostly pulsatile)
Conductive Hearing Loss (NL middle ear)
Bizzare symptoms (hearing of eye movement)
Easy Dizzy
Weber test to the lesion (even from foot !!!!! )
Vibration induced nystagmus
Sound / Pressure / Valsalva induced nystagmus
Variations of symptoms
between Patients
History
Physical Exam.
Audio-Vestibular
Tests
Imaging
Common Peripheral Vestibular Disorders – Diagnostic Tools
S u p e r i o r S e m i c i r c u l a r C a n a l D e h i s c e n c e S y n d .
Audiometry CHL (Change in Bone threshold) with preserved stapedial reflex
VEMP
lower thresholds for response & increased amplitude of response
oVEMP is better than cVEMP (bone stimulation is better)
ECoG May show some abnormalities ?????
History
Physical Exam.
Audio-Vestibular
Tests
Imaging
Common Peripheral Vestibular Disorders – Diagnostic Tools
S u p e r i o r S e m i c i r c u l a r C a n a l D e h i s c e n c e S y n d .
Temporal bone HRCT (bone window , reformatted view)
History
Physical Exam.
Audio-Vestibular
Tests
Imaging
Common Peripheral Vestibular Disorders – Diagnostic Tools
S u p e r i o r S e m i c i r c u l a r C a n a l D e h i s c e n c e S y n d .
Differential Diagnosis :
Perilymph Fistula
(to endolymph) or (to middle ear) Hx. of trauma, cholesteatoma, ear surgery (may be present)
Hx. from childhood
Direct disease related hearing loss is SNHL
History
Physical Exam.
Audio-Vestibular
Tests
Imaging
Large Vestibular Aqueduct Hyrtl’s fissure
Common Peripheral Vestibular Disorders – Diagnostic Tools
R e f e r e n c e s• Rose BD et al. UpToDate. http://www.uptodate.com/contents/search (last seen: Oct. 2016)
• Approach to the patient with dizziness
• Evaluation of the patient with vertigo
• Pathophysiology, etiology, and differential diagnosis of vertigo
• Overview of nystagmus
• Pharmacologic use of glucocorticoids
• Flint PW et al. Cummings Otolaryngology - Head & Neck Surgery, 6th ed. (2015)
• Principles of applied vestibular physiology
• Evaluation of the patient with dizziness
• Peripheral vestibular disorders
• Surgery for vestibular disorders
• Bronstein AM et al. Oxford Textbook of Vertigo and Imbalance. 1st ed. (2013)
• Hain TC. MRI Imaging of Meniere's Disease/Syndrome. http://www.dizziness-and-balance.com/disorders/ menieres/mri-hydrops.html (last modified: Jul. 2016)
• Baráth K et al. Detection and Grading of Endolymphatic Hydrops in Meniere Disease Using MR Imaging. Am J Neuroradiol 2014; 35: 1-6
• Curthoys IS. The Interpretation of Clinical Tests of Peripheral Vestibular Function. Laryngoscope 2012; 122: 1342–52
• … and some web sources for photos