Neuro-Otology:DiagnosisandManagementofDizziness

Ma8hewBoykoReviewedbyDr.SureshSubramaniam

PleaseviewthispresentaDonasaslideshowtolistentotheaccompanyingaudio.Usethearrowkeysormouseclicktomovetothenextslide.

ProsperMénière(1799-1862)

ObjecDves

• Whatisdizziness?•  Anatomyofhearingandbalance

•  ApproachtohistoryandphysicalexaminaDon

•  DisDnguishingcentralvs.peripheralcauses•  InvesDgaDonsandtreatment

Dizzy Adjec've|diz!zy|\’di-zē\

:havingawhirlingsensaDonintheheadwithatendencytofall

:mentallyconfused

merriam-webster.com

Inmedicine,dizzinesscanmean…

•  Spinning•  VerDgo•  Lightheadedness•  Presyncope•  Imbalance•  VisualdistorDon•  DisorientaDon•  Anxiety•  Hearingloss•  Tinnitus

PossibleEDologies

Peripheral:BPPV,Meniere’sdisease,vesDbularneuriDs,vesDbularparoxysmia,perilymphfistula,superiorcanaldehiscence,otosclerosis,immunerelated(Cogansyndrome,sarcoidosis,lymphoma,carcinomatousmeningiDs),structural(acousDcneuroma,vesDbularschwannoma),infecDous(meningiDs,bacterial/fungal,syphiliDclabyrinthiDs),trauma(labyrinthconcussion),vesDbulartoxicity(gentamicin).

Central:stroke,TIA,MS,epilepsy,migraine,demyelinaDngdisease,tumor,neurodegeneraDvedisorders,rotaDonalvertebralarterysyndrome,familialataxiasyndromes,familialbilateralvesDbulopathy,familialhemiplegicmigraine,posteriorfossastructuralabnormaliDes(glioma,ChiariformaDon,AVM,cavernoma)

Other:orthostaDchypotension,irregularheartrhythm,OA,poorvision

CommonEDologies

•  PeripheralvesDbulardysfuncDon(40%)•  CentralbrainstemvesDbularlesion(10%)

•  Psychiatricdisorder(15%)•  Otheri.e.presyncope,disequilibrium(25%)

Epidemiology

•  30%ofpopulaDonhasexperiencedmoderatetoseveredizziness(Neuhaseretal.2005)– 25%ofthesepaDentshadtrueverDgo

• Morecommonamongstelderlyandfemales

•  Largeimpactonhealthcare!– 80%ofdizzypaDentsseekmedicalcareatsomepoint

Ear

•  Organofhearingandbalance•  Threeparts:

1.  Externalear"auricleandexternalcanal

2.  Middleear"cavityinthepetrouspartofthetemporalbone;connectedtopharnyx

3.  Internalear"seriesofcaviDesinthepetrouspartofthetemporalbonebetweenmiddleearandacousDcmeatus

Auricle

Externalauditorycanal

Tympanicmembrane

Ossicles

Innerear

Eustachiantube

Middleear

•  TransmitsvibraDonsfromthetympanicmembranetotheinnerear– Tympanicmembrane"malleus"incus"stapes

•  Communicateswithmastoidposteriorlyandpharynxanteriorly

Innerear

•  Bonylabyrinth:linedwithperiosteumandcontainsperilymphfluid– VesDbule– 3semicircularcanals– Cochlea

•  Membranouslabyrinth:conDnuoussystemofductsandsacsthatissuspendedwithinthebonylabyrinthandcontainsendolymph– Semicircularducts– Cochlearducts– Utricleandsaccule(sacs)

Hearing:•  Cochlearduct

–  AuditoryossiclesconvertairbornewavesfromtympanicmembranetofluidwavesincochleathatsDmulatereceptorcells

Balance:“VesDbularapparatus”•  Semicircularducts

respondtomovementintheplaneoftheiranatomicalaxis–  Horizontal:“no-no”–  Anterior:lateralDlDng–  Posterior:“yes-yes”

•  Utricle"respondstocentrifugalandverDcalacceleraDon

•  Saccule"respondstolinearacceleraDon

VesDbulocochlearnerve[VIII]

•  Specialsensoryafferentnerve•  Carriesafferentfibers– Cochleardivision"hearing– VesDbulardivision"balance

•  ExitstemporalboneviainternalacousDcmeatus"crossesposteriorcranialfossa"enterslateralbrainstembetweenponsandmedulla

•  FiberseithersynapseontheVesDbularnucleiorformtheVesDbulocerebellartractanddirectlyenterthecerebellum

VesDbularnuclei

•  Locatedintherostralmedullaandcaudalpons•  Fournuclei:

1.  Lateral2.  Inferior3.  Medial4.  Superior

•  Alsoreceiveafferentinputfromcerebellum,spinalcord,andreDcularformaDon

•  FormconnecDonswithcerebellum,spinalcord,oculomotorsystem,andcortex

Input:mainlyutricleandsaccule

Input:mainlysemicircularcanals

GoalsofourevaluaDon

#1Definedizziness

#2RuleoutcommonperipheralvesDbularcauses

#3Considerneurologicalcentralcauses

History

1.DefinethesymptomsIfpaDentunable,thenclassifythesymptomsaseither:

1.  VerDgo2.  Lightheadedness3.  Strictlyimbalance(noheadsymptoms)

2.Completeafullhistoryforthesymptoms

3.Determineotherdetails1.  Constantvs.episodic?Ifepisodic,duraDonandfrequency?2.  Accompanyingsymptoms?3.  Howdiditbegin?4.  AggravaDngandalleviaDngfactors?5.  Triggers?

VesDbulardysfuncDon

ManifestaDonsinclude:•  VerDgo•  Oscillopsia•  Nausea/vomiDng

•  Nystagamus

•  PastpoinDng•  Lateropulsion

GeneralMedicalExam

•  Vitals– EspeciallyorthostaDcBP

•  Cardiac– Ruleoutarrhythmia

•  Pulmonary

•  Abdominal

• MSK– ArthriDscanimpairgait

VesDbularPhysiology

AdaptedfromDeJong’s7thEdiDon

GeneralNeurologicalExam

•  MentalStatusandlanguage•  Cranialnerves

–  Importanttoruleoutcentralcauses–  Nystagamus–  EOM–  VAanddynamicVA

•  Motor–  Bulk,tone,strength,reflexes

•  SensaDon–  Pinprick,temperature,vibraDon,propriocepDon

•  CoordinaDon–  Finger-nose,heel-shin,RAMslookingforpast-poinDngandincoordinaDon

•  GaitandRomberg–  Tandemgait,Fukudasteppingtest

Neuro-otologicalExam

1.  VesDbulospinalreflexes–  PastpoinDng–  Romberg–  FukudaSteppingtest

2.  VesDbulo-ocularreflexes–  Oculocephalic(Doll’seyes)"performedslowlyina

comatosepaDent–  Headimpulse"performedquicklyinanawakepaDent–  DynamicVA–  CalorictesDng(coldwaterstunstonicacDvityfrom

labyrinthonirrigatedside)3.  Nystagamus

Dix-HallpikeManeuver

•  Performedbyturninghead45degreesthenmovingpaDentfromuprightposiDontosupinewithheadslightlyextended

•  PosiDveifup-beaDngandrotaDonalnystagamustowardearthatisdown– DiagnosDcofposteriorcanalBPPV– Nystagamususuallylasts<60secondsandcanfaDgue– Usually<15secondlatencybeforenystagamusisseen

•  EsDmatedsensiDvity79%andspecificity75%

Halkeretal.2008

PleaserefertoYoutubeforvideosdemonstraDngnystagamusandtheDix-

HallpikeManeuver

HINTSEXAM

•  HINTSincludes:– HeadImpulse– Nystagamus(direcDonchangingineccentricgaze)– TestofSkew(verDcalocularmisalignment)

•  NormalheadimpulsewithpresenceofdirecDon-changingnystagamusandskewdeviaDonissuggesDveofstrokewith100%sensiDvityand96%specificity

•  Be8erthanMRIwithDWIforrulingoutstrokeinfirst24-48hoursazersymptomonset

•  EarlyMRIwasfalselynegaDvein12%ofstrokeswhenperformedwithin48hoursofsymptomonset

Ka8ahetal.2009

PhysicalExamReview

WashingtonUniversityrecommends6specifictestsforvesDbulardysfuncDononphysicalexam:1.  Spontaneousandgaze-evokednystagamus2.  Extra-ocularmovements3.  VesDbulo-ocularreflexes4.  Dix-Hallpikemaneuver5.  LimbcoordinaDon6.  GaitandRomberg

AdaptedfromDeJong’s7thEdiDon

InvesDgaDons

•  Tailortothepresumedunderlyingdiagnosis– Electronystagmography

– RotarychairtesDng– Posturography

•  UsefultoidenDfycentralcausessuchasstroke•  OtherwiseBPPV,Meniere’sdisease,andVesDbularneuriDsdonothaveidenDfiableimagingcharacterisDcs

Centralvs.Peripheral

Central Peripheral

Ver9go Lesssevere Associatedn/v

Nystagamus ChangesdirecDonsandNOTaffected

byfixaDon

DoesNOTchangedirecDons,

faDgable,latencytoonset,affectedbycompensatorymechanisms

Presenta9on Severeimbalance,otherneurologicalorbrainstemsigns

common

Associatedhearingloss,auralsymptoms,

autonomicsigns

Treatment

Specifica) BPPV"Dix-Hallpiketo

diagnosisandEpleytotreat.AvoidheadhangingacDviDes.

b) Meniere’s"LowsaltdietanddiureDcs.MaytryintratympanicgentamicininjecDon.MaytrylabyrinthorvesDbularnervesurgicalablaDon.

c) VesDbularneuriDs"SymptomaDctreatmentandvesDbularrehabilitaDon.

SymptomaDcVS.

An9histamines Dimenhydrinate50mgq4hDiphenhydramine50mgq4hMeclizine50mgq6hBetahisDne24mgbid

An9cholinergics ScopolaminepatchorSC

Benzodiazepines Lorazepam1-2mgq8hDiazepam5-10mgq12h

Benzamide Metoclopramide10mgq6h

Phenothiazine Prochlorperazine10mgq6h

AdaptedfromBradley’s6thEdiDon

Case#1

86yoFdevelopsacuteonsetroomspinningaroundheruponstandingupoutofbedinthemorning.Symptomslast30secondsthenresolvedbutconDnuetooccureverymorningwhenstandingupoutofbed.

BPPV

BenignParoxysmalPosiDonalVerDgo

•  InnerearcondiDoncharacterizedbyverDgowhenheadismovedrelaDvetogravity

•  Otolithsbreakfreefromsaccule/utricle,se8leinsemicircularcanals,thenmoveandsDmulatehaircells

•  Diagnosis:Dix-Hallpike•  Treatment:EpleymaneuverorvesDbularrehabilitaDon

– MedicaDonsrecommendedforusepriortousingparDclereposiDoningmaneuverssuchasanDhistamineoranD-emeDc

– BetahisDne24mgbidx1week

Case#2

40yoMdevelopswarm,fullsensaDonintherightear.AlsomenDonsringinginhisears.OccasionallyhehasassociatedhearinglossverDgolasDngupto1daythatcanbetriggeredbysaltyfoods.

Meniere’sdisease

Meniere’sdisease

•  EsDmatedincidence10-1500per100,000•  BilateraldiseasecanoccurinuptohalfofpaDents•  EndolymphaDchydropsdistendthemembranesofthelabyrinth

–  Unclearwhythisfluidbuildupoccurs•  Audiometryimportanttoassessforhearingloss•  Treatment

–  Lifestyle:avoidtriggers(salt<2gperday,alcohol,caffeine,nicoDne),–  MedicaDons:AnDhistamines,anDcholinergics,orbenzodiazepinesfor

symptomaDctreatment–  RehabilitaDon–  IntervenDonaltherapiesforrefractorycases:intratympanic

gentamicin,labyrinthectomy,vesDbularneurectomy,surgicalendolymphaDcdecompression

FunFact!

IndividualsaffectedbyMeniere’sdisease:•  EmilyDickinson

•  KrisDnChenoweth•  AlanB.Shepard•  JonathanSwiz•  DanaWhite

•  VincentVanGogh

Case#3

72yoMwithHTN,T2DM,anddyslipidemiapresentswithacuteonsetverDgothathasnotresolvedsincestarDng.Alsolimbataxiaanddysarthria.

Stroke(centralcause)

Stroke

•  Likelyvertebrobasilarstroke•  PerformHINTSexam– Wouldexpectnormalheadimpulsetestbutgaze-evokednystagamusinalldirecDonsandskewdeviaDon

•  ObtainurgentCT/CTA!

References

•  Bradley’sNeurologyinClinicalPracDce6thEdiDon.•  Uptodate.com.•  Gray’sAnatomyforStudents2ndEdiDon.•  DeJong’sTheNeurologicExaminaDon7thEdiDon.•  Ka8ahJC,TalkadAV,WangDZ,HsiehY,Newman-TokerDE.

HINTStodiagnosestrokeintheacutevesDbularsyndrome.Stroke.2009;40(11):3504-3510.

•  HalkerRB,BarrsD,DavidM,WllikKE,WingerchukDM,DemaerschalkBM.EstablishingadiagnosisofbenignparoxysmalposiDonalverDgothroughthedix-hallpikeandside-lyingmaneuvers:AcriDcallyappraisedtopic.TheNeurologist.2008;14(3):201-204.