Vertigo Paul Chatrath Consultant ENTHead Neck Surgeon Charing

Vertigo Paul Chatrath Consultant ENT/Head & Neck Surgeon Charing Cross Hospital (Imperial Healthcare NHS Trust) Honorary Senior Lecturer Anglia Ruskin University, Chelmsford Visiting Professor of Rhinology Canterbury Christ Church University, Kent 6 th September 2016

Objectives n n Dizziness / vertigo in general ENT causes for vertigo n n n Meniere’s BPPV Labyrinthitis n n Other ENT causes of dizziness ‘red flags’

Case - Dizziness n n n Please see this 40 year old female suffering with short lived episodes of vertigo Occurring almost daily Occurs whenever moves head in any direction

Clinical approach n Vertigo vs dizziness n Vertigo Rotatory n Suggests a peripheral vestibular or cerebellar problem n n Dizziness / lightheadedness n Non-specific n n ‘whoozy’ ‘ lightheaded’ ‘unsteady’ ‘drunken’ Suggests non-vestibular pathology

Types of Dizziness Rotation (Spinning) Unsteadiness (Imbalance) Light headedness (faint feeling) If the patient has ever lost consciousness: it is not ENT!

Vertigo - causes Vestibular n n n n Viral labyrinthitis BPPV Meniere’s disease Acute Otitis Media Trauma Cholesteatoma Drug induced Postsurgical Central n n Migraine Vertebrobasilar ischaemia MS Tumours n Cerebellopontine angle n n n Acoustic neuroma Brainstem CVA Psychogenic

Non-specific dizziness: Causes n Cardiovascular n n n Arrhythmias Reduced cardiac output Carotid artery stenosis Arteriosclerosis Hypotension (postural) Peripheral neuropathy n n n Proprioception n n Arthritis (cervical and other) n n DM Hypothyroidism Hypercholesterolaemia Anaemia n n B 1, B 6, B 12 Genetic - Refsum’s disease Toxins n n Leprosy, TB, syphilis Vitamin deficiencies n Metabolic n DM Renal or hepatic failure Alcohol Vasculitis Infections Lead, metronizadole Psychogenic

Vertigo: Duration is key n Brief (<1 min) BPPV n Psychogenic n n Hours Meniere’s n Migraine n n Days (>24 hrs) n Viral labyrinthitis BPPV Psychogenic Meniere’s Migraine - specific head movement - any head movement - classic triad - classic headache

Nystagmus n Movement of the eyes: n n Rhythmic Oscillating Synchronous Involuntary n Two phases n n n Slow phase (pathological) Fast phase (corrective) Direction described in terms of fast phase

Nystagmus Normal labyrinths Abnormal Right Labyrinth R L Eyes central L X Slow drift to right Rapid corrective flick to left = Left nystagmus

Vertigo: Compensation n n Vestibular phenomenon Steady accommodation to the effects of vertigo Gradual resolution of symptoms over time Typically occurs 6 -12 weeks after acute insult n Mechanisms n Habituation n Reduced output good side Increased output affected side Sensory substitution n Increased reliance on eyes and musculoskeletal system

Vertigo: Compensation n Impaired compensation due to: n n n Poor visual acuity Musculoskeletal problems Reduced peripheral sensory input Ongoing vestibular pathology Medication (prolonged stemetil) n Rehabilitation: n General fitness n n Physical programs n n n Vision, walking stick Cawthorne-Cooksey Psychological support Specific exercises n Eg. Brandt-Daroff exercises for BPPV

Vertigo: Vestibular v Central Vestibular Central Type of dizziness Vertigo / Dizzy Effect of head movement Worse Equivocal Tinnitus/hearing loss May be present Absent Compensation Occurs Does not occur Nystagmus Horizontal + unilateral + away from affected ear Horizontal or vertical + bilateral

Vestibular rehabilitation: Cawthorne - Cooksey n n n Head movements Balance tasks Coordination of eyes with head Total body movements Eyes open & closed Noisy environments Causes early exacerbation of vertigo

Caution: Prochlorperazine n n Powerful vestibular sedative Suppresses acute vertiginous symptoms BUT Also suppresses natural compensatory response LT use: ‘non-specific dizziness’persists

Psychogenic n n n Type of dizziness: any (nonspecific or vertigo) Frequency: constant Duration: Typically brief <1 min Trigger: Stress, anxiety, crowds Associated features: palpitations, sweating, tremor Examination: Normal

Labyrinthitis n History n Vertigo n n n >24 hrs Vomiting Constitutional symptoms Usually following URTI n Treatment n n Examination n Nystagmus n n Fast phase away from affected ear Pyrexia n Bed rest Vestibular sedatives Fluids Cawthorne-Cooksey vestibular rehabilitation exercises Rule of threes - 3 days: v bad, 3 weeks, a lot better, 3 months resolved

Meniere’s Disease n Key features: n Vertigo n n Tinnitus/hearing loss n n Before/during/after vertigo Other symptoms n n n Hours Pressure feeling Nausea Natural history n n n One episode Episodic Increasing frequency n n n Salt restriction Diuretics - thiazides Vasodilators n n Betahistine, cinnarizine Evidence – no RCTs n n Cinnarizine > placebo Diuretics = placebo Serc of marginal benefit Salt restriction of marginal benefit

Intratympanic therapy: Steroids or Gentamicin

BPPV: Benign Paroxysmal Positional Vertigo n n Calcific debris in semicircular canals Vertigo n n n Brief (<1 min) On head turn in a particular direction Typically self-limiting Primary Secondary n n Trauma (HI) Prolonged bed rest Otological condition (up to 70%) Posterior SCC n n In plane on lying in bed Hallpike’s test n Nystagmus on lying back to one side

BPPV - Epley, 1992

BPPV - Brandt & Daroff, 1980

Migraine n Clinical features n n n Lifestyle change n n Family history Motion intolerance Vertigo occurs with classical headache either before or after ENT/vestibular examination usually NAD Exercise, diet, avoidance of stimulants Medication: n n Abortive therapy eg. Sumatriptan Prophylactic therapy eg. B blockers

Other ENT conditions causing dizziness n Ear: Malignant OE n Otitis media n Cholesteatoma n n Nose/Sinus n n Sinusitis Thyroid disturbance

Dizziness/Vertigo: Indications for Urgent Referral n Vertigo n n n Intense Disabling Unremitting Nystagmus Sudden SNHL n Features to suggest malignant pathology n n Elderly with granulation in ear canal VIIn palsy Post-traumatic TM perforation + vertigo

Conclusion n Must define the dizziness / vertigo n n Rotatory or not Frequency Triggers History is the most important factor n Duration n Vertigo n n n BPPV (cervical / psychogenic) Meniere’s (Migraine) Labyrinthitis (Drug / multifactorial) ENT causes for vertigo When to refer urgently

Case n n n Please see this 40 year old female suffering with short lived episodes of vertigo Occurring almost daily Occurs whenever moves head in any direction

Vertigo Paul Chatrath Consultant ENT/Head & Neck Surgeon Charing Cross Hospital (Imperial Healthcare NHS Trust) Honorary Senior Lecturer Anglia Ruskin University, Chelmsford Visiting Professor of Rhinology Canterbury Christ Church University, Kent paul. chatrath@nhs. net 6 th September 2016