DizzinessandVer,go

InvernessCPD–August31,2018DrBlairWilliamsMDFRCSC

Otolaryngology–head&necksurgery

DisclosureSlide

•  Thisspeakerhasbeenaskedtodisclosetotheaudienceanyinvolvementwithindustryorotherorganiza,onsthatmaypoten,allyinfluencethepresenta,onofanyeduca,onalmaterial.

•  Receivingevalua,onsiscri,caltotheaccredita,onprocess.– ARertheprogram,pleaseprovidefeedbackathSps://surveys.dal.ca/opinio/s?s=44738

Abitaboutme…

•  FromBarney’sRiverSta,on,NS

•  Medical/surgicaltrainingatDalhousieUniversity

•  Startedprac,ceinSydneyinJuly2017•  IhaveaninterestandafellowshipinHeadandNeckOncology– Skincancer,thyroid,paro,d,throat,oral– AlsoofferBotox(medicalandcosme,c)

Objec,ves–DizzinessandVer,go

•  Todifferen,atever,gofromothertypesofdizziness

•  Todeterminewhetherver,goisofcentralorperipheralorigin

•  Todescribethepresenta,onandtreatmentofperipheralves,bularcondi,ons

Dizziness

•  Thisisanon-specificterm,oRenusedbypa,entsthatcouldmeananynumberofsymptoms– Lightheadedness– Presyncope– Ver,go– Ataxia– Unsteadiness– Dysequilibrium

•  Amorespecificterm/descrip,onwillhelpguidetreatment,inves,ga,on,andappropriatereferrals

TrueSpinning

Ves$bulare$ology

Toandfrorocking

Lightheadedness Ataxia

Dizziness

Balance

Visual

Propriocept

Soma,csensa,on

Ves,bular

Sensory

Input

BrainstemCerebellumCortex

SensoryIntegra$on

Muscletone

BalanceOutput

Dizziness–Ves,bularornot?

Vesitbular•  Ver,go•  Episodic•  Vomi,ng

•  OtologicSymptoms•  Worsewithheadmovement

Other•  Lightheadedness•  Chronicdisequilibrium•  Cardiacsymptoms

•  Neurologicsymptoms•  LossofConsciousness

Ver,go

•  Thesensa,onofmovementintheabsenceofmovement– Mostcommonlyspinning

•  Typicallyves,bularinorigin–innerear,CNVIII,brainstemnuclei

SemicircularCanalPhysiology

Push/PullSystem

FiringRate

0

RightHC

LeRHC

Differen,alisDrivingVOR

Push/PullSystem

Ver,go

•  Thesensa,onofmovementintheabsenceofmovement– Mostcommonlyspinning

•  Typicallyves,bularinorigin–innerear,CNVIII,brainstemnuclei

•  Historyisthekeytodiagnosis– Featuresofthesensa,on– Timingoftheepisodes– Associatedsymptoms– Triggers

Ver,goDifferen,al

Timing HearingPreserved HearingLoss

Seconds-Minutes BPPV

Minutes-Hours Ves,bularMigraine Meniere’sDisease

Days Ves,bularNeuri,s Labyrinthi,s

FeaturesSugges,ngCentralVer,go

•  Five“D’s”– Dysarthria– Dysphagia– Dysmetria– Diplopia– Downbea,ngorDirec,onchangingnystagmus

•  Hemifacialorhemibodysensoryormotordeficit

•  DropaSacks,visualloss,confusion

Unlikelyperipheralwiththesefeatures!

AcuteVer,go–CentralvsPeripheral

HINTSStudyKaSahetal,2009.Stroke.

•  AcuteVer,goPresenta,on– N=101,25ves,bularand76central

•  Bedsideexamandimagingforeveryone

•  AnormalHINTStestcorrectlyruledoutstrokeat96%,superiortoMRIwithDWI(12%falsenega,ve)

HINTSExam

AbsenceofALLofthesefeatures(IN-FA-RCT)essen,allyrulesoutacentrale,ology

PERIPHERALVESTIBULARCONDITIONS

SECONDSTOMINUTES-BPPV

BenignParoxysmalPosi,onalVer,go

•  Mostcommoncauseofver,go(90%)– Alsothebest:oRencanbecuredintheoffice!• Nomeds,noscans

•  Brief,intenseepisodes– Rollingover,,tlingheadback,etc

BPPV

•  Looseotoconiainsemi-circularcanals– Con,nueds,mula,onaRerheadmovementstops

•  Diagnosedbymovingtheotoconia

•  Treatedbyguidingtheotoconiatotheutricle

BPPV–PosteriorCanal

!  DixHallpike(Diagnosis)

BPPV–PosteriorCanal

!  Epley(Reposi,oning)

BPPV–LateralCanal

!  RollTest(Diagnos,c) !  BarbecueRoll(Reposi,oning)

BPPV–HomeExercises

•  Thoughttoworkthroughhabitua,onratherthanreposi,oning–  Repeat10-20xpersession–  Upto3xperday

•  Minimalevidencetosupport–  Highrateofspontaneousresolu,oninBPPV

•  Stopwhensymptomsresolve–  Doesnotpreventrecurrence

hSps://www.uptodate.com/contents/images/NEURO/63738/Brandt_Daroff_maneuver.jpg

!  Brandt-Daroff

hSps://www.uptodate.com/contents/images/NEURO/63738/Brandt_Daroff_maneuver.jpg

BPPVSummary

•  Freepar,clesinthesemicircularcanals•  Diagnosisandtreatmentatbedside– Noneedforimaging

– Noneedformeds

•  Lowthresholdtotrythemaneuvers

•  Physiotherapiststrainedinves,bularrehabarereallygoodatthis!

MINUTESTOHOURS:MENIERE’S&MIGRAINE

Meniere’sDisease

•  Episodicver,go(20minutestohours)– Transienthearingloss,,nnitus,auralfullnesswiththever,go– Typicallyunilateral

•  Thoughttoarisefromendolympha,chydrops– S,llpoorlyunderstooddespitebeingdescribed>150yearsago

•  Treatmentaimstopreventdistensionoftheendolympha,csac

Meniere’sDisease

•  HearinglossfluctuateswithepisodesBUTtheretendstobesomebaselinelossover,me

Meniere’sDisease

•  Betahis,ne(betahis,ne)istypicallyfirstline:– Innerearvasodila,onwhichhelpsprevent/relievethehydrops– Notgivenrou,nelyforanythingbutMeniere’s– Worksbestasapreven,vemedica,on,notPRN– Startaslowas8mgTID,safeinhigherdosesifincompletesymptomscontrol

•  Thiazidediure,cs,lowsodiumdiet,avoidtriggers

•  Proceduraltreatments,iffailureofmedicalmanagement

Meniere’sDiseaseSummary

•  Episodicver,golas,nghours•  Prominent,transientunilateralauralsymptoms– Hearingloss,,nnitus,fullness

•  Audiogramhelpfulindiagnosis

•  Treatmentsaddressendolympha,chydrops

•  Regularbetahis,nedosingfirstlinebutlimitedevidenceforanytreatment

Ves,bularMigraine

•  Rela,velynewdiagnosis(~20years)•  Truever,go,typicallylas,nghours– Imbalance,mo,onintol,boat-likerocking– Visualtriggers–movingscenes,traffic,etc

•  Similartriggerstoothermigraine– Sleepdepriva,on,stress,hormonalchanges

– Canoccurseveral,mesperyearorasfrequentlyasdaily

Ves,bularMigraine

•  Typicalmigraineheadache–  Doesnothavetooccurwithver,goepisodes–  Canprecedever,gobyyears

•  1+non-headachesymptom–  Photophobia,phonophobia,aura–  Auralsymptomsuncommon

•  MorecommonthanMeniere’s–  Someoverlapexists

–  Canbedifficulttodifferen,ate

Ves,bularMigraine

ICHD-3CriteriaforVes$bularMigraine

A.AtleastfiveepisodesfulfillingcriteriaCandD

B.Acurrentorpasthistoryofmigrainewithoutauraormigrainewithaura

C.Ves,bularsymptomsofmoderateorsevereintensity,las,ngbetween5minutesand72hours

D.Atleast50percentofepisodesareassociatedwithatleastoneofthefollowingthreemigrainousfeatures:

1.Headachewithatleasttwoofthefollowingfourcharacteris,cs:

a)Unilateralloca,on

b)Pulsa,ngquality

c)Moderateorsevereintensity

d)Aggrava,onbyrou,nephysicalac,vity

2.Photophobiaandphonophobia

3.Visualaura

E.NotbeSeraccountedforbyanotherICHD-3diagnosisorbyanotherves,bulardisorder

Goodforresearch,cumbersomeforclinicaluse!

Ves,bularMigraine

•  Treatment– LiSleavailabledata(caseseriesandretrospec,vestudies)

•  Currentapproachbasedonothermigrainevariants

– Lifestyle•  Adequaterest,exercise,diet•  Avoidknowntriggers

– Triptansasanabor,vetherapy– Preven,on

•  Considerfrequency,dura,on,severityofaSacks•  Venlafaxine37.5mgdaily•  TCAs,CCBs(flunarizine)

Ves,bularMigraineSummary

•  Suspectifnoassociatedauralsymptoms•  Historyofmigrainecommon

•  Prominentvisualsymptoms

•  ORenexhibitsaura,photo/phonophobia•  Typicalmigrainetriggers–avoidance!

•  Treatasmigraine–triptansifinfrequent,prophylacitcmedsiffrequentandsevere

LASTINGDAYS–VESTIBULARNEURITIS

Ves,bularNeuri,s

•  Acuteonsetofsevere,unrelen,ngver,go– Nystagmus,ataxia,nausea/vomi,ng,intoleranceofheadmovement

•  Uncleare,ology– Neurotrophicvirus– Inflammatory,microcirculatory

•  +/-hearingloss(termed‘labyrinthi,s’ifunilateralSNHL)

Ves,bularNeuri,s

•  Selflimi,ng– Ruleoutischemicevent

– Variablerecoveryinves,bularfunc,on•  Suppor,vemeasuresforfirstfewdays– Steroids,an,-eme,cs,benzos

•  Avoidlong-termbedrestandsuppressants– Delaysadapta,ontonewlevelofves,bularinput

AcuteTreatmentofVes,bularNeuri,s

•  Shorttermuseonly– 3-5days

•  Prolongedusewilldelaycompensa,on

•  Noestablishedroleforbetahis,ne

hSps://www.uptodate.com/contents/ves,bular-neuri,s-and-labyrinthi,s?topicRef=5097&source=see_link#H9

FiringRate

0

RightHC

LeRHC(affectedear)

Ves,bularNeuri,s

DizzinessSummary

•  Ver,goversusothercause•  Ifver,go,centralvsperipheral(innerear)•  Ifperipheral,limitednumberofcauses– Timingiskey– Associatedsymptomshelp– Tailortreatmenttothemostlikelycause

– Ifineffec,ve,reassessdiagnosisandtrysomethingelse

RealityCheck

•  Itsnicetohavelabelsbut…–  SooRenpa,entdon’tfitnicelyintooneofthesecategories–  Symptomsarevagueorthereareelementsofmul,plecondi,ons

•  Videonystagmography(VNG)canhelp–  Peripheralvscentrale,ology– AvailablethroughNSHearingandSpeech

•  Ves,bularrehabilita,oncanhelpmostpeopleregardlessofe,ology–  Visionstability,posturetraining,strengthening

KeyMessages

•  Ruleoutcentralcause•  BPPVismostcommon–noneedforRxorscan•  Betahis,neshouldbereservedasfirstlinemedforsuspectedMeniere’sDisease

•  Ves,bularmigraineismorecommonthanMeniere’ssosuspec,ngthisandtrea,ngasmigrainecandoalotofgood!

•  Compensa,oniskeyinVes,bularneuri,s,solimitsuppressivemedica,ontoseveraldaysdura,on

Thankyou

•  ThankyouforyouraSen,onandyourreferrals•  Iwelcomeyourfeedback

• Manyimagesarecopyrightedandcannotbeposted–Icansendbyemailifyouwantthefullpresenta,on– bw@dal.ca

Sources

•  CummingsOtolaryngology–Head&NeckSurgery6thEdi,on

•  UpToDate.com

•  Dizziness-and-balance.com

•  Evalua,onandTreatmentofDizzyPa,ent-HalifaxOtolaryngologyReviewCourse