Evaluation & Management of the Dizzy Patient An otolaryngology perspective

1. Evaluation & Management of the Dizzy PatientAn otolaryngology perspective Miguel V. Valdez PA-C ENT for the PA-C April 13, 2012

2. DisclosureNo relationships with commercial interests • Objectives: • Differentiate between vestibular and non-vestibular dizziness • Accomplish the appropriate history and physical for evaluation of dizziness • Understand the different causes of dizziness • Order appropriate studies and establish a treatment plan for patients with dizziness

3. Definition • Vertigo: An abnormal sense of motion characterized by a spinning sensation • Disequilibrium is considered a form of vertigo • Oscillopsia

4. Dizziness may be described in other terms, but these are not generally considered vertigo

5. Anatomical considerations • Three anatomical areas are responsible for maintaining equilibrium • eyes • labyrinth • central nervous system • Injury to any one of these can produce symptoms of true vertigo

6. Functional considerations • THE LABYRINTH • will fatigue • can be suppressed • will compensate

7. Assessment • History: Ask the patient to describe what he/she is feeling without using the words dizzy or vertigo • Onset and duration of symptoms • Frequency of occurrence • Associated symptoms • Recent illness • Significant past medical and surgical history • Drug use (Rx or Non-Rx) (ETOH)

8. Assessment • A physical examination must be done on all patients complaining of dizziness • Place special emphasis on the • eyes • ears • neurologic exam • Dix-Hallpike • Fukuda Stepping Test (Marching Rhomberg) • 90% of the time or more the examination will be normal. However, a thorough exam will help rule out/in significant etiologies

9. Assessment • THE PATIENT’S MAJOR CONCERN IS TWO-FOLD • First, the patient wants to be assured the practitioner believes he/she is experiencing a problem • Second, that he/she does not have a serious problem

10. Differential Diagnosis • TRAUMA • Blunt Injury • temporal bone fx (basilar skull fx) • Acute tympanic membrane perforation • with ossicular disarticulation or oval / round window rupture • Barotrauma • such as flying and scuba diving • Benign Paroxysmal Positional Vertigo • Perilymph Fistula

11. Differential Diagnosis • CONGENITAL • There are many congenital syndromes having vertigo as a symptom. All have other co-existing anomalies. Many of these children don’t survive childhood • Congenital cholesteatoma • Migraine related dizziness

12. Differential Diagnosis • INFECTIOUS / INFLAMMATORY • Viral Vestibular Neuronitis • Viral Labyrinthitis • Otitis Media • Mastoiditis • Meningitis • Encephalitis • Syphilis • Lyme Disease • Meniere’s Disease

13. Differential Diagnosis • NEOPLASTIC • Primary Carcinoma • Metastatic Carcinoma (breast) • Acoustic Neuroma (Vestibular Schwannoma) • Facial Nerve Neuroma • Leukemia • Histiocytosis-x (Eosinophilic Granuloma) • Cholesteatoma

14. Differential Diagnosis • METABOLIC AND OTHER • Superior Canal Dehiscence • Thyroid Disease • Anemia • Rheumatoid Arthritis • Lupus • Hyperlipidemia • Diabetes Mellitus • Hypoglycemia (reactive) • Pregnancy

15. Differential Diagnosis • METABOLIC AND OTHER (Cont.) • Drugs (ETOH) (Minocycline) (Beta blockers) • Cardiovascular Problems • hypertension • arrhythmias • Multiple Sclerosis • Migraine with or without headache • Allergy • Hyperventilation Syndrome • Psychogenic

16. Assessment • TESTS • Audiogram (Most important) • Positional Testing (Dix-Hallpike Test) • Electronystagmogram (ENG) • Brainstem evoked response (BSER) (ABR) • Electrocochleography (Ecog) • CT of Temporal Bones • MRI with Gadolinium (Gold Standard) • LABS: CBC (with Diff) Chemistry Profile (fasting), Lipid Studies, T3, T4, TSH, RPR/FTA, Lyme titer, ANA, RF, Sed. Rate, HCG

17. Treatment • NO DRIVING !!! • This may often be a CURE

18. Treatment • Treatment should be directed towards a specific cause, if identified. • Canalith repositioning procedure (Epley) for positional vertigo • Meniere’s disease requires; low salt diet <2gm/day, diuretics, vasodilators, avoidance of caffeine and alcohol, intratympanic gentamycin, ultimately surgery

19. Treatment • PRIMARILY SYMPTOMATIC • Teach the patient to use common sense • Depends on how debilitating symptoms are. • DIAZEPAM 2.5 MG P.O. T.I.D. • Can also be used as a diagnostic tool • OTHER DRUGS • Can be used depending on preference • Antivert (meclizine) 25 mg. p.o. q6h is a favorite • Transderm scopolamine • Droperidol (Inapsine) 2-3 gtts. sl q4-6 hrs. (Caution) • Recipe: Mix 2 cc droperidol (2.5mg/cc) with 13cc sterile water, put in a brown bottle

20. The Dizziest Patient • ACUTE PROSTRATING VERTIGO • Patient presents to the E.D. • Priority #1 (Quick Evaluation) • R/O CATASTROPHIC EVENT • MI CVA DKA • Priority #2 (establish an intravenous line) • REPLACE FLUIDS AND ELECTROLYTES • Priority #3 (Treatment) • STOP VOMITING AND VERTIGO • DROPERIDOL 1cc I.V. (2.5 Mg.) OR VALIUM 5-15 Mg. I.V. • Priority #4 (Re-evaluate) • PERFORM A COMPLETE H & P • ARRANGE FOR FOLLOW UP & WORK UP

21. Pearls THERE ARE MORE NON-ENT CAUSES OF DIZZINESS

22. Pearls CONSTANT NYSTAGMUS THINK CENTRAL LESION

23. Pearls CONSTANT VERTIGO THINK CENTRAL LESION

24. Pearls VERTICAL NYSTAGMUS THINK CENTRAL LESION

25. Pearls VERTIGO WITHOUT NYSTAGMUS THINK CENTRAL LESION

26. Pearls NYSTAGMUS WITHOUT VERTIGO THINK CENTRAL LESION

27. Pearls IF SYMPTOMS DON’T RESOLVE OR IMPROVE WITHIN A REASONABLE AMOUNT OF TIME THINK CENTRAL LESION

28. Pearls THERE ARE NO ENT REASONS FOR SYNCOPE!

29. Recommendations • Epley J “The Canalith Repositioning Procedure: For Treatment of Benign Paroxysmal Positional Vertigo” Otolaryngology Head and Neck Surgery 107: 3 Sept. 1992 pp 399-404 • Epley J. M. “Caveats in Particle Repositioning for Treatment of Canalithiasis (BPPV): Operative Techniques in Otolaryngology Head and Neck Surgery, Vol 8 No 2 June 1997; 8:68-76 • Johnson, Glen D “Medical Management of Migraine-Related Dizziness and Vertigo, Laryngoscope 108: January 1998 Supplement pp1-28

30. THANK YOU !