dizziness and acoustic neuroma - providence health …/media/files/providence or...dizziness and...
TRANSCRIPT
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Dizziness and Acoustic
NeuromaHarold Kim, M.D.
NW Ear Institute
Portland, OR
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What is a Neurotologist? Otolaryngologist (ENT) by residency training.
2 year fellowship in Neurotology/Skull Base Surgery
In sum: the E in ENT
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Agenda Definitions
Primer on dizziness
Acoustic Neuroma
Primer on management
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Dizziness 5-10% of population suffer from it
40% of individuals over age 40 years have it
3.9 million visits to emergency rooms in U.S. for dizziness (2011)
5.4% of visits to ER are due to “serious diagnoses.”
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When Should You Image?
When Should You Refer?
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Predictors of Serious Diagnoses
Focal examination findings
Age over 60 years
Imbalance as symptom
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What Do You Need To Be
Right? Knowledge
Time
Attention
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Definition Dizziness
Imbalance
Vertigo
Lightheadedness
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Initial Work Up Characterize “dizziness”
Gradual or sudden
Intermittent or constant
Associated symptoms
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Associated Symptoms Tinnitus
Hearing loss
Ear fullness
Visual Symptoms
Ear drainage
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Physical Examination How does the patient look when they walk into the
room?
Look in their ears
Look at their eyes
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Old Stand By
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Office Maneuvers To Help Dx
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Relevance of Nystagmus Fast component points toward stronger side
Vertical nystagmus confirms central etiology
Not possible to fake
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Common Causes of Dizziness Benign Paroxysmal Positional Vertigo (BPPV)
Vestibular Migraines
Meniere’s Disease
Vestibular Neuritis
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Epley Maneuver
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Vestibular Migraines 5 vestibular episodes of moderate to severe severity
lasting 5 minutes to 72 hours
Current or previous history of migraine
One or more of the following accompanying 50% of
episodes
Headache
Phonophobia or photophobia
Visual aura
Not better accounted for by another vestibular or ICHD
diagnosis
Cephalagia 33 (9): 629-808
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Meniere’s Disease 2 or more episodes of spontaneous vertigo lasting 20
minutes to 12 hours
Hearing loss
Tinnitus
Aural Fullness
Monsell EM, Otolaryngol Head Neck Surg 1995
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Vestibular Neuritis Acute peripheral vestibular loss from vestibular nerve
hypofunction
Acute rotary vertigo that transitions to imbalance
Hallmark:
Horizontal nystagmus
Suggestive history
No auditory symptoms
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Vestibular Neuritis Treatment is regular ambulation and mobilization
Possible role for corticosteroids of detected early.
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Predictors of Serious Diagnoses
Focal examination findings
Age over 60 years
Imbalance as symptom
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Acoustic Neuroma Comprises 80% of all cerebellopontine angle tumors.
Incidence is 1-2 per 100,000
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Clues to Acoustic Neuroma
Diagnosis
Symptoms refer to one side
Hearing
Tinnitus
Imbalance
Vertigo rare
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How To Diagnose?
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How to Diagnose? MRI of Internal Auditory Canal and Brain with and
without Gadolinium
What about a CT?
Only show large tumors
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Do They Need Contrast?
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Now What? Refer
Neurotologist
Neurosurgeon
But . . .
How do we address this?
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It’s Complicated
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Ways to Treat Acoustic
Neuroma Do Nothing
Surgery
Radiation
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What Goes In Determining
Treatment
Tumor Size
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Hearing Status
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Speech Discrimination Poor speech discrimination is indicative of
retrocochlear pathology
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What About Dizziness? None of the Treatment Modalities Alter Balance
Vestibular Rehabilitation
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Watchful Waiting Repeat MRI in 6 months
If no change, repeat yearly
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Pratnaik et al., 2015 54.5% showed no growth.
7.8% showed slow growth.
1.3% showed fast growth.
87% showed favorable patterns for watchful waiting.
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Outcomes Serial Imaging:
22.3% needed change in treatment approach in 12 years.
24.3% had decline in hearing to non-serviceable levels.
Imbalance and Dysequilibrium at presentation presented
almost 3 fold increase in likelihood of tumor growth.
Jethanamest D, Rivera AM, Ji H, et all, Laryngoscope 2015
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Watchful Waiting Facial nerve sequela very rare.
Progressive imbalance that responds to vestibular
rehabilitation.
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Surgery Hearing Preservation
Hearing Sacrificing
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Outcomes Surgery
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Hearing Dependent on preoperative levels
Up to 80% retain useful hearing if hearing preservation
approach used.
Dependent on surgical approach
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Balance Mild increase in dizziness when measured using the
dizziness handicap index (DHI) at 6 months after
surgery.
Thomeer et al., Otol Neurotol 2015
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Priorities of Surgery Safe delivery from surgery
Complete or near complete excision of tumor
Facial nerve function
Hearing improvement
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Radiosurgery
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Radiosurgery Objective of this treatment
Prevent further growth
Success is defined as not needing further management
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Gamma Knife Radiosurgery
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Radiosurgery Outcomes
Over 90% tumor control
Hearing preservation-
89.7% at 1 year
84.7% at 3 years
76.5% at 5 years,
68.6% at 10 years.
Combs SE et al., Radiother Oncol 2013
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Radiosurgery Outcomes
Facial nerve control-96.2% (Yang et al., Neurooncol
2009).
Dizziness
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What’s The Right Answer For
Me?
It’s Complicated
Treatment modality does determine QoL.
Diagnosis biggest detriment to QoL.
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Biggest Detriments to
Diagnosis/Treatment
Dizziness
Headache
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Questions?