VERTIGO sclerosis

Document Sample
VERTIGO sclerosis Powered By Docstoc
					    VERTIGO



   AYESHA SHAIKH
        PGY2
EMORY FAMILY MEDICINE
     09.17.2008
                CASE
31,female doctor, otherwise healthy,
 post partum week 5.
First episode, sudden feeling of room
 spinning, while entering patient data
 in computer, during Family Medicine
 Clinic… One fine day last year same
 time!
               DIZZINESS
•   Vertigo
•   Lightheadedness
•   Pre syncope
•   Dys-equilibrium
               VERTIGO
FALSE SENSE OF MOTION, usually rotational.

2 TYPES
1- CENTERAL VESTIBULAR CAUSES
(Brain stem or cerebellum)
2- PERIPHERAL VESTIBULAR CAUSES
( Labyrinth or vestibular nerve)
       CAUSES OF VERTIGO
CENTRAL               PERIPHERAL
Cerebellopontine      Acute labrynthitis
 angle tumor           Vestibular neuritis
                       BPPV
Cerebrovascular
                       Cholestotoma
 disease
                       Menier’s disease
Migraine
                       Ostosclerosis
Multiple sclerosis    Perilymphatic fistula
                 Causes..
Drugs
Alcohol
Aminoglycosides
Anticonvulsants
Antidepressants
Antihypertensives
Barbiturates
Cocaine
( Slowly progressive Unilateral/Bilateral)
                    History
Timings
Duration
Provoking, aggreviating factors
Associated symptoms
Risk factors for Cardiovascular disease

Q: When you have dizzy spells , do you feel
   lightheaded or do you see the world spin around
   you?
Q: Duration of Vertigo and associated symptoms?
( differentiate peripheral vs central causes)
Typical Duration of Symptoms for Different Causes of Vertigo

Duration of episode                                   Suggested diagnosis

A few seconds                               Peripheral cause: unilateral loss of vestibular function; late stages of
                                            acute vestibular neuronitis; late stages of Ménière's disease

Several seconds
to a few minutes                             Benign paroxysmal positional vertigo; perilymphatic fistula

Several minutes
to one hour                                  Posterior transient ischemic attack; perilymphatic fistula

Hours                                        Ménière's disease; perilymphatic fistula from trauma or surgery;
                                             migraine; acoustic neuroma

Days                                         Early acute vestibular neuronitis*; stroke; migraine; multiple sclerosis

Weeks                                        Psychogenic (constant vertigo lasting weeks without improvement)

*-Vertigo with early acute vestibular neuritis can last as briefly as two days or as long as one week
or more.

Information from references 3, 6, and 12.
Provoking Factors for Different Causes of Vertigo

Provoking factor                       Suggested diagnosis

•Changes in head position           Acute labyrinthitis; benign positional paroxysmal vertigo; cerebellopontine angle tumor;
                                    multiple sclerosis; perilymphatic fistula

•Spontaneous episodes               Acute vestibular neuronitis; cerebrovascular disease (stroke or transient ischemic attack);
 (i.e., no consistent               Ménière's disease; migraine; multiple sclerosis
•provoking factors)

•Recent upper respiratory
  viral illness                      Acute vestibular neuronitis

•Stress                              Psychiatric or psychological causes; migraine

•Immunosuppression
 (e.g., immunosuppressive           Herpes zoster oticus
 medications, advanced age
, stress)

•Changes in ear pressure,             Perilymphatic fistula
 head trauma,
 excessive straining, loud noises

•Information from references 1, 3, 5, 12, and 13.
Associated Symptoms for Different Causes of Vertigo

Symptom                Suggested diagnosis

Aural fullness        Acoustic neuroma; Ménière's disease

Ear or mastoid pain   Acoustic neuroma; acute middle ear disease (e.g., otitis media, herpes zoster oticus)

Facial weakness       Acoustic neuroma; herpes zoster oticus

Focal neurologic       Cerebellopontine angle tumor; cerebrovascular disease;
findings)              multiple sclerosis (especially findings not explained by single neurologic lesion

Headache               Acoustic neuroma; migraine

Hearing loss            Ménière's disease; perilymphatic fistula; acoustic neuroma; cholesteatoma;
                        otosclerosis; transient ischemic attack or stroke involving anterior inferior cerebellar
                       artery,herpes zoster oticus

Imbalance              Acute vestibular neuronitis (usually moderate); cerebellopontine angle tumor
                       (usually severe)

Nystagmus              Peripheral or central vertigo

Phonophobia, photophobia       Migraine

Tinnitus              Acute labyrinthitis; acoustic neuroma; Ménière's disease

Information from references 1, 6, and 12 through 14.
Table 5

Causes of Vertigo Associated with Hearing Loss
Diagnosis                 Characteristics of hearing loss

Acoustic neuroma         Progressive, unilateral, sensorineural

Cholesteatoma             Progressive, unilateral, conductive

Herpes zoster oticus
(i.e., Ramsay Hun
 syndrome)                Subacute to acute onset, unilateral

Ménière's diseases       Sensorineural, initially fluctuating, initially affecting lower frequencies;
                         later in course: progressive, affecting higher frequencies

Otosclerosis             Progressive, conductive

Perilymphatic fistula    Progressive, unilateral

Transient ischemic attack or
stroke involving anterior inferior cerebellar
artery or internal auditory artery          Sudden onset, unilateral

Information from references 9, 12, and 13.
Distinguishing Characteristics of Peripheral vs. Central Causes of Vertigo

Feature              Peripheral vertigo                            Central vertigo

Nystagmus        Combined horizontal and torsional;          Purely vertical, horizontal, or torsional
                inhibited by fixation of eyes onto object;   ; not inhibited by fixation of eyes onto object;
                 fades after a few days; does not change      may last weeks to months
                direction with gaze to either side            ; may change direction with gaze



Imbalance        Mild to moderate; able to walk                Severe; unable to stand still or walk

Nausea           May be severe                                 Varies
, vomiting

Hearing loss,
tinnitus          Common                                       Rare

Nonauditory       Rare                                         Common
neurologic
symptoms

Latency following
provocative
diagnostic        Longer (up to 20 seconds)                    Shorter (up to 5 seconds)
maneuver)

Information from references 14 and 15.
          Physical Exam
Special attention to head and neck
Cardiovascular and neurologic
 symptoms
Provocative diagnostic tests
           Physical Exam
Vertical nystagmus is 80% sensitive for
 central lesions.
Horizontal nystagmus for peripheral
 lesions.
Rhomberg sign : sensitivity 19 % only
 for peripheral causes.
Dix-Hallpike maneuver PPV 83%, NPV
 52 %.
Clues to Distinguish Between Peripheral and Central Vertigo

Clues                  Peripheral vertigo                      Central vertigo

Findings on             Latency of symptoms                      None
Dix-Hallpike            and nystagmus 2 to 40 seconds
maneuver

Severity of vertigo        Severe                                Mild

Duration of nystagmus      Usually< 1 minute                   Usually>1 minute

Fatigability*                Yes                                  No

Habituation†                 Yes                                  No

Other findings

Postural instability       Able to walk;                          Falls while walking;
                            unidirectional instability             severe instability
Hearing loss
or tinnitus                Can be present                      Usually absent

Other neurologic
Symptoms                    Absent                              Usually present

*-Response remits spontaneously as position is maintained.

†-Attenuation of response as position repeatedly is assumed.

Information from references 3 and 4.
                      Diagnosis
 History
 Physical Exam: Orthostatic vital signs, and Otoscopic
  examination,
 Neurologic Exam: Dix-Hallpike Maneuver ( central vs
  Peripheral)
 Complete Audiometric Testing for suspected
  Menier’s disease
                  No LAB testing!
  Brain imaging : MRI with contrast for acute vertigo and
  Sensorineural hearing loss, MRA for vertebrobasilar circulation
Disorder                      Duration           Auditory      Prevalence   Peripheral or central
                                                 symptoms                   vertigo

Benign paroxysmal             Seconds            No            Common       Peripheral
positional vertigo

Perilymphatic fistula (head   Seconds            Yes           Uncommon     Peripheral
trauma, barotrauma)


Vascular Ischemia,TIA         Seconds to hours   Usualy not    Uncommon     Central or
                                                                            peripheral

Meniere’s disease             Hours              yes           common       peripheral
Syphillis                     Hours              yes           Uncommon     central
Vertiginous migraine          Hours              No            Common       Central


Labyrinthitis                 Days               Yes           common       peripheral
Vascular Ischemia: Stroke     Days               Usually not   Uncommon     Central or
                                                                            peripheral

Vestibular neuronitis         Days               No            Common       Peripheral
Anxiety disorder              Variable           Usually not   Common       Unspecified

Acoustic neuroma              months             yes           Uncommon     Peripheral


Multiple sclerosis            Months             no            uncommon     central

Vestibular ototoxicity        months             yes           uncommon     peripheral
General Treatment Principles
 Medication for Acute Vertigo that lasts for few hours
  to several days

 Medications have various combinations of
  acetylecholine, dopamineand histamine receptor
  antagonism.

 Benzodiazepines enhance GABA action ( GABA is
  inhibitory neurotransmitter in vestibular system)
           Strength of Recommendation

Key clinical recommendation

•The canalith repositioning procedure (Epley maneuver) is recommended in patients with benign paroxysmal
positional vertigo. A

•The modified Epley maneuver also is effective in patients with benign paroxysmal positional vertigo.B

•Vestibular suppressant medication is recommended for symptom relief in patients with acute vestibular neuronitis.
C

•Vestibular exercises are recommended for more rapid and complete vestibular compensation in patients with
acute vestibular neuronitis. B

•Treatment with a low-salt diet and diuretics is recommended for patients with Ménière's disease and vertigo.B

•Effective treatments for vertiginous migraine include migraine prophylaxis (e.g., tricyclic antidepressants, beta
blockers, calcium channel blockers), migraine-abortive medications (e.g., sumatriptan [Imitrex]), and vestibular
rehabilitation exercises B

•Selective serotonin reuptake inhibitors can relieve vertigo in patients with anxiety disorders. Because of side
effects, slow titration is recommended.B



A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented
evidence; C = consensus, disease-oriented evidence, usual practice, opinion, or case series. See page 1046 for
more information.
                     Medications
 Meclizine* (Antivert) 12.5 to 50 mg orally every 4 to 8 hour
 Dimenhydrinate* (Dramamine) 25 to 100 mg orally, IM, or IV every 4
  to 8 hours
 Diazepam (Valium) 2 to 10 mg orally or IV every 4 to 8 hours
 Lorazepam (Ativan) 0.5 to 2 mg orally, IM, or IV every 4 to 8 hours
 Metoclopramide (Reglan) 5 to 10 mg orally every 6 hours
                               5 to 10 mg by slow IV every 6 hours
 Prochlorperazine (Compazine) 5 to 10 mg orally or IM every 6 to 8
  hours
                                     25 mg rectally every 12 hours
                                     5 to 10 mg by slow IV over 2
  minutes
 Promethazine (Phenergan) 12.5 to 25 mg orally, IM, or rectally every
  4 to 12 hours
     Vestibular Rehabilitation
             Exercises
 These exercises train the brain to use alternative
  visual and proprioceptive clues to maintain balance
  and gait.


 Improve postural control during the first month
  after acute unilateral vestibular lesions resulting
  from vestibular neuronitis.
   Treatment of Specific Disorders
                     1- BPPV
       (Usually posterior canal Calcium Debris)

 MEDS..?
 Head Rotation Maneuvers
         Eply Maneuver
Contraindication: Severe carotid stenosis, unstable
  heart disease, severe neck disease
Success rate: 80 % after one treatment, 100% with
  repeated treatments.
Recurrence rates: 15% /year, 20% @ 20 months, and
  37% @ 60 months.
    Treatment of specific Disorders

         2- Vestibular Neuronitis
        ( Acute Prolonged Vertigo)

 Symptom relief using vestibular suppressant
  medications, followed by vestibular exercises.

 Vestibular compensations occurs more rapidly and
  more completely if the patient begins twice-daily
  vestibular rehabilitation exercises soon after
  symptom control with medications.
    Treatment of specific disorders

               3-Menier’s Disease
  (Distension of Endolymphatic compartment due to
  impaired endolymphatic filtration and excretion)

 Low salt diet ( < 1-2 gm/day)
 Diuretics ( combo HCTZ and Triamterene)
 Surgery in rare cases - ablation of vestibular hair
  cells)
             4- Vascular Ischemia
     (Sudden onset of vertigo with additional symptoms eg
         diplopia, ataxia, dysphagia, dysarthria)
 TIA /Stroke: BP control, Cholesterol Lowering ,
  smoking cessation, inhibition of platelet function,
  anticoagulation

 Vestibualr suppressant medications plus minimal
  head maneuver on first day, then initiate
  rehabilitation

 Vestibular stents for symptomatic critical vertebral
  artery stenosis.
          6-Migraine Headaches


             Treat Migraine!

Reduce or eliminate Aspartame, chocolate,
  caffeine and alcohol, Lifestyle changes,
  Vestibular rehabilitation exercises.

Meds: BDZ, TCA, BB, SSRI, CCB, Antiemetics.
           7- Psychiatric Disorders
( Anxiety , Panic disorders more common than depression;
   Hyperventilation is the cause.)


 Vesibular supressants and Benzodiazepines-
 transient to inadequate relief.

SSRI show better relief.

Cognitive behaviour therapy may be helpful.
        Physiologic Vertigo
Motion sickness: incongruence in the sensory
 input from the vestibular, visual, and
 somatosensory systems.Visual system does
 not sense the movement.

Bring systems back in congruence! Eg watch
 horizon when on a boat.also scopolamine
 patch behind ear 4 hours before boating.
Disorder                      Duration           Auditory      Prevalence   Peripheral or central
                                                 symptoms                   vertigo

Benign paroxysmal             Seconds            No            Common       Peripheral
positional vertigo

Perilymphatic fistula (head   Seconds            Yes           Uncommon     Peripheral
trauma, barotrauma)


Vascular Ischemia,TIA         Seconds to hours   Usualy not    Uncommon     Central or
                                                                            peripheral

Meniere’s disease             Hours              yes           Common       Peripheral
Syphillis                     Hours              yes           Uncommon     central
Vertiginous migraine          Hours              No            Common       Central


Labyrinthitis                 Days               Yes           Common       Peripheral
Vascular Ischemia: Stroke     Days               Usually not   Uncommon     Central or
                                                                            peripheral

Vestibular neuronitis         Days               No            Common       Peripheral
Anxiety disorder              Variable           Usually not   Common       Unspecified

Acoustic neuroma              months             yes           Uncommon     Peripheral


Multiple sclerosis            Months             no            uncommon     central

Vestibular ototoxicity        months             yes           uncommon     peripheral
Dix-Hallpike Maneuver
Epley Maneuver
Internet resources for patient
          education
http://www.youtube.com/watch?v=hhi
 nu_oU_hM
http://www.youtube.com/watch?v=NQ
 r7MKJBAJY
http://www.youtube.com/watch?v=eO
 uzUi5ckrk
THANKS !
                 References
 Labuguen R. Initial Evaluation of Vertigo. American
  Family Physician. January 15, 2006.
 Swartz R, Longwell P. Treatment of Vertigo.
  American Family Physician. March 15, 2005.

				
DOCUMENT INFO
Shared By:
Categories:
Stats:
views:143
posted:1/20/2011
language:English
pages:37