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Guidelines on vertigo
1. IntroductionIn 1985, the Royal Belgian Ear Nose and Throat, Head and Neck Surgery Society and the Belgian Professional Union of Ear Nose and Throat, Head and Neck Surgery founded the Otoneurological and Expertie’s Commission.
Since this time, the Professor R. Bonivrer is the president. Actual members of this commission are :
Professors Christian DESLOOVERE, Naïma DEGGOUJ , Floris WUYTS,
Physicians Sarah CASTELEYN, Stéphane DEJARDIN, Anne ENGLEBERT, Chantal GILAIN, Catherine HENNAUX, Christian VAN NECHEL.
In 1986, the publication, in the Acta O.R.L. Belgica of expertise’s recommendations for ear nose and throat specialists already talk about vestibular exploration.
In lack of evidence based medicine for this specific subject and under Doctor ROBILLARD’s impulse, the commission, since December 2003, wrote guidelines on exploration and treatment of vertigo. Those recommendations are established both on the commission’s members experience and the daily scientific advances on vertigo.
Specials articles wil be joined in the publication in B-ENT, the journal of the Royal Belgian ENT Society : they explain tests and explorations. An (*) sign rises to annexes.
Guidelines are based on more recent otoneurological’s findings and will be actualised in the future.
Annexed references give lector’s possibility to go deeper on this subject.
2. Patient history
2.1. Vertigo or dizziness
Description (rotatory vertigo, horizontal or vertical linear sensations , postural imbalance)
Start, duration, frequency
Provocative event (e.g. position, orthostatism, spontaneous, Valsalva, Tullio (*))
Initial manifestations
Autonomic symptoms
Gait : quality and perturbating factors
Direction of body tilt or imbalance (lateral, posterior )
Falls : circumstances (curent occupations, situation)
2. Patient history
2.1. Vertigo or dizziness
2.1.1. Visual influence (*) Mobile environment intolerance Acrophobia (*)
2.1.2. Agoraphobia (*), Anxiety (HAD and PHQ scale annexed) (*) 2.1.3. Effect on life quality evaluation (DHI scale annexed) (*)
2. Patient history2.2. Otologics symptoms
(for each complain, look for the laterality and the temporality with vertigo)
2.2.1. Hypoacousia of hyperacousia, fluctuating hearing, diplacousia,
distorsion 2.2.2. Tinnitus continuous, pulsating, positional
2.2.3. Hearing fulness or pressure
2.2.4. Otalgia
2.2.5. Otorrhea
2. Patient history
2.3. Visual manifestations (*)
2.3.1. Amaurosis 2.3.2. Horizontal or vertical diplopia 2.3.3. Oscillosia 2.3.4. Visual field inversion
2.3.5. Refraction correction related
2. Patient history2.4. Neurological manifestations
(precise temporality with vertigo)
2.4.1. Migraines, headache and facial pain
2.4.2. Sensitive and motors manifestations (e.g. Precision movement of
superior members)
2.4.3. Symptoms related to other cranial nerves disorders
2.4.4. Symptoms related with cervical spine disorders (e.g. cervicalgia)
2. Patient history2.5. Prior history
2.5.1. Hereditary (according to curent pathology study)
2.5.2. E.N.T.
2.5.3. Neurologicals
2.5.4. Traumatics
2.5.5. Cardio-vascular and vascular risk factors (hypertension, diabete, cholesterol, smoking
2.5.6. Metabolic and hormonal
2.5.7. Infectious
2.5.8. Immunological
2.5.9. Locomotricity (rheumatologic, orthopedic)
2.5.10. Strabismus, amblyopia, multifocal refracted lenses (*)
2.5.11. Gait habits (lack of activity, long time lying position …), Sport (diving …)
2.5.12. Occupation
2.5.13. Toxic (drugs, professional, alcohol, smoking)
2. Patient history
2.6. Treatment
Curent, recent modification
Prior (ototoxic)
Physiotherapy, cervical manipulation, vestibular training or repositioning maneuvers (to be precised)
3. Clinical examination3.1. Otorhinologic
3.2. Oculomotor and nystagmus
3.1.1. Otomicroscopic examination 3.1.2. Rhinologic exam depending on symptoms
3.2.1. Visual control test
3.2.1.1. Gaze holding hability
3.2.1.2. Vertical or horizontal ocular misalignment (*)
3.2.1.3. Restriction in ocular amplitud movements
3.2.1.4. Smooth pursuit and saccade testing
3.2.1.5. Inibitory testing of vestibulo-ocular reflex (VOR) (*)
3.2.2. Halmagyi test(*)
3. Clinical examination3.2. Oculomotor and nystagmus
3.2.3. Under videoscopic or Frenzel glasses (without fixation)
3.2.3.1. Spontaneous and other gaze holding abnormalities
3.2.3.1.1. Vestibular nystagmus (*)
3.2.3.1.2. Non vestibular nystagmus (*)
3.2.3.2. Positioning nystagmus (to be done at the end of the clinical evaluation)(*)
3.2.3.2.1. Méthodology (patient sitting, head to knees, supine, 90°lateal rotating of the whole body and head to the right and after to the left, supine + head rotating, Hallpike or Brandt and Daroff, Rose ) sequences not necessary in this order (*)
3.2.3.2.2. Clinical signification (diagnostic criterias)
3.2.3.3. Horizontal and vertical Head shaking test (*)
3.2.3.3. Dynamic visual hability (*)
3. Clinical examination3.3. Other cranial nerves
3.4. Members
Face sensitivity defect (If neurinoma is suspected, complete facial sensitivity exploration, front pain sensitivity and corneal reflex included)
Claude Bernard Horner’s sign
Face and oropharyngolaryngal sensitivity
3.4.1. Superior’s members cerebellars signs (dysmétria, adiadocokinesia) 3.4.2. Sensitive or motor inferior members defect
3. Clinical examination3.5. Stato-kinetic tests
3.5.1. Index’s test, finger pointing test
3.5.2. Romberg’s test (standard or sensitivated)
3.5.3. Unterberger or Fukuda (*)
3.5.4. Standard gait and star’s gait tests
3.5.5. Gait exploration
3.5.6. Dynamic Gait Index*
4. Diagnostic Progression4.1. Isolated Vertigo
4.1.1. Isolated positioning vertigo (*)
4.1.1.1. Positioning vertigo : 1° episod
4.1.1.1.1. If history evocative of benign paroxysmal positioning vertigo (BPPV.) Otomicroscopy and hearing test Searching for the pathological canal Execute the Repositioning maneuver After one week see :
If asymptomatic : end of investigation If residuals symptoms still after 2 or 3 repositioning maneuvers : see 4.1.1.1.2.
4.1.1.1.2. If history and clinical presentation “atypic”
Baseline explorations : Complete clinical examination(see chapter 3), Hearing test, Brainstem Evoked Response Audiometry (BERA), Videonystagmography (VNG) Electronystagmography (ENG) + oculomotricity, Subjective visual vertical perception test (SVV.), Vestibular Evoked Myogenic Potentials (VEMP)
4.1.1.2. Positioning vertigo : relapse Baseline exploration (seen in 4.1.1.1.2) + Temporal bone scanner if conductive hearing loss
4. Diagnostic Progression
4.1. Isolated Vertigo
4.1.2. Non positioning isolated vertigo
4.1.2.1. If baseline exploration (see 4.1.1.1.2.) non contributive: review patient history and test:
Metabolic exploration (glycemia and thyroïd) Cardio-vascular exploration Psychological exploration (anxiety, phobia …) Migraines event
4.1.2.2. If baseline exploration suggesting labyrinthic pathology (see VNG or ENG criterias)
Study of peripheral vestibular aetiologic pathology : If no result : VEMP to exclude inferior vestibular neuritis. If cardio-vascular risk : exploration
4.1.2.3. If baseline exploration finding nonlabyrintic pathology
(see VNG or ENG, BERA, Oculomotricity criterias) Neurological exploration Specific neurological imaging
4. Diagnostic Progression4.2. Vertigo and hearing signs
In any case, baseline exploration : hearing test, fistula test, BERA, VNG or ENG + oculomotricity, VVS, VEMP
4.2.1. Conductive hearing loss
Tympanometry + acoustic reflex Temporal bone’s TDM if otosclerosis suspected, acqueduc dilatation, superior canal dehiscence syndrome …
4.2.2. Perceptive hearing loss
Tympanometry +acoustic reflex (level of reflex,"reflex Decay” test-R.D.T.) Supraliminar tests Otoacoustic-emissions Temporal bones and pontocerebellar angle MRI if retro-cochlear lesions suspected (EcoG if Meniere’s desease suspected) Genetic research if familial history (DFNA9)
4. Diagnostic Progression4.3. Vertigo and neurological symptoms
4.3.1. Vertigo and headache or facialgy
4.3.1.1. Patient with unusual vertigo and brutal headache = Emergency (unusual intensity and localisation) Exploration have to be done within hours.
4.3.1.1.1. Latero-cervical pain:
Look for vertebral dissection (MRI)
4.3.1.1.2. Occipital pain: Look for : Expansive lesion of posterior fossa (infratentorial
tumor, blood collection …) (TDM) Arnold-Chiari decompensation (MRI) Basilar aneuvrism (TDM)
4. Diagnostic Progression4.3. Vertigo and neurological symptoms
4.3.1.2. Vertigo and usual known headache
4.3.1.2.1. vestibular migraine (*) Personal and familial history Usuals starting events like migraines
4.3.1.2.2. Anxious tension headache and vertigo
Cervicalgia, whiplash Imbalance without vertigo
4. Diagnostic Progression4.3. Vertigo and neurological symptoms
4.3.2.Vertigo, imbalance and visuals symptoms
4.3.2.1. Ocular desalignement or diplopia (*)
4.3.2.1.1. horizontal
4.3.2.1.1.1. convergent Nuclear or post nuclear VI nerve lesion Somewhere near vestibular nuclei Orbital trauma Convergent spasmus (post-traumatic)
4.3.2.1.1.2. divergent Mesenceplalic lesion or nerve III Orbital lesion
4.3.2.1.2. vertical
4.3.2.1.2.1. Skew, Ocular Tilt Reaction (*) Vertical saccades palsy in under- thalamic lesions near otolitics’s pathway
4.3.2.1.2.2 Nerve IV lesion (post-traumatic in 30%)
4. Diagnostic Progression4.3. Vertigo and neurological symptoms
4.3.2.2. Non vestibular nystagmus and oscillopsia (*) Gaze evoked nystagmus Acquired pendular nystagmus Flutter, opsoclonus Congenital nystagmus (idiopathic, latent uncompensed) Oculomotricity palsy (loss of vestibulo-ocular gain)
4.3.2.3. Excessive visual dependance (*)
(generally after vestibular deficiency) 4.3.2.4. Post refraction change
Multifocal lenses Important and recent refraction correction
4. Diagnostic Progression
4.4. Other vertigo
4.4.1. Child’s vertigos Like adult specifications but special attention to: Serous otitis Familial history of migraines Tumor are more frequent Food Familial stress BPPV less frequent before 10 years of age
4. Diagnostic Progression
4.5. Imbalance without vertigo4.5.1 Imbalance with hearing loss or not, without any neurological sign
4.5.1.1. Drug side effect or interference (local or general), ototoxicity
4.5.1.2 Hemodynamic troubles blood pressure arythmia
4.5.1.3 Metabolic troubles diabete dysthyroïdia surrenal dysfunction
4.5.1.4. Genetic (DFNA9 – COCH gene …)
4.5.1.5 Anxiety, agoraphobia (*)
4.5.2. Combine with neurological defect Neurological exploration must be done
5. Laboratory examination(Following §4 Diagnostic criteria indications)
5.1. Hearing testTonal, vocal, supraliminar depending on pathology
5.2. Tympanometry/Stapedial (acoustic) reflex
5.3. Auditory brainstem response
5.4. Electrocochleography (If Meniere desease or perilymph fistula suspected)
5.5. Otoacoustic-emissions
5.6. Vestibular-evoked myogenic potentials (VEMP) (*)
5. Laboratory examination(Following §4 Diagnostic criteria indications)
5.7. VNG or ENG (*norminative data)5.7.1. Gaze holding in primar and lateral positions under
fixation (20 to 30° maximum )
5.7.2. Exploration for spontaneous and positional nystagmus without fixation
5.7.3. Ocular poursuit
5.7.4. Saccade analysis
5.7.5. Optokinetic poursuit
5.7.6. Rotatory/pendular tests
5.7.7. Caloric test (see “CRITERES ATTEINTE CENTRALE” in Acta ORL belgica 1986,40,907-915)
5. Laboratory examination(Following §4 Diagnostic criteria indications)
5.8. Vertical or horizontal visual perception test (*)
5.9. Posturography5.9.1. Static
5.9.2. Dynamic
5.10. Vibratory nystagmus (*)
5.11. Otolith linear and rotatory test (*)5.11.1. Excentric rotative test
5.11.2. OVAR
6. Treatment Strategy
6.1. Medical treatment (*)
6.2. Vestibular rehabilitation : soon in BE-ENT (Symposium in november 2005)
6.3. Psychologic approach (*)6.3.1. Anxiolytic
6.3.2. Relaxation
6.3.3. Comportemental
6.3.4. Psychotherapia
6.4. Surgical Treatment (*)
• Norminative data in ENG and VNG
• Benign paroxysmal nystagmus:diagnosis and treatment
• Neuro-ophtalmological symptoms in vertigo and dizziness
• Head shaking nystagmus
• Vibration induced nystagmus
• Tullio’s phenomenom
• Vestibular evoked myogenic potentials
• Unilateral centrifugation
• Static and dynamic balance clinical investigation
• Vertigo and psychological troubles
• Medical treatment of vertigo
• Surgical treatment of vertigo
• Index
References
Brandt Th.Vertigo. Its Multisensory SyndromsSpringer Verlag Edit., 2th edition, 2000, ISBN, 3-540-19934-9
Leigh R.J., Zee D.S.The Neurology of Eye Movement.Oxford University Press, 1999, 3th edition
Balow R.W., Honrubia V.Clinical Neurophysiology of the Vestibular System.Oxford University Press, 2001, 3th editionLuxon L.
Text book of Audiological Medicine.Clinical Aspects of Hearing and Balance.Martin Dunitz edit. London : 2003.
ReferencesBrandt Th., Strupp M.General Vestibular Testing.Clinical Neurophysiology 2005, 116, 406-426
Fife T.D., Tusa R.J., Furman J.M., Zee D.S., Frohman E., Baloh R.W.,Hain T., Goebel J., Demer J., Eviatar L.Assessment: Vestibular testing techniques in adults and children.Report of the Therapeutics and Technology Assessment Subcommittee
ofthe American Academy of Neurology.Neurology 2000; 55: 1431-1441
Expertise Médicale en Oto-Rhino-Laryngologie. Recommandations.Acta O.R.L. Belgica, 1986, 40, 907-915.
Vertiges chez l’Adulte : Stratégies diagnostiques.Place de la rééducation vestibulaire.On te Website www.anaes.fr in Publications:Neurologie:Septembre 1997ISBN 2 910653-33-1
www.orl-nko.be
