new vertin cme slides final

8/12/2019 New Vertin CME Slides Final

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Diagnosis and Management of

Vertigo


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Todays Talk

Dizziness and Vertigo

Vertigo Diagnosis

Treatment Options Focus of Betahistine in Vertigo Management


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Dizziness

Third most common complaint among all outpatients1

Single most common complaint among patients older than

75 years1

Generic term used to describe a variety of experiencesincluding giddiness, lightheadedness, faintness, vertigo,

fogginess, imbalance, unsteadiness and ataxia2

1. Chawla N, Olshaker J. Med Clin N Am 2006; 90: 291-304

2. Nettina S. Topics in Adv Nurs, [ejournal] assessed online Oct 09


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Dizziness

Dizziness refers to various abnormal sensations relating

to perception of the bodys relationship to space1

Dizziness can be caused by many different medical

conditions2

It is estimated that as many as half of cases are due to

vestibular disorders2

1. Sloane P et al, Ann Intern Med 2001; 134: 823-32

2. Hall C and Cox C. Otolaryngol Clin N Am 2009: 42: 161169


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Types of Dizziness

Vertigo

Presyncopal lightheadedness

Disequilibrium

Other dizziness

Sloane P et al, Ann Intern Med 2001; 134: 823-32


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Vertigo

It is a false sensation that the body or the environment is

moving (usually spinning) and suggests a disturbance of

the vestibular system1

Accounts for 54% of cases of dizziness2

Vestibular vertigo affects more than 5% of adults in 1 year

in the Unites States3

Incidence increases with age4

1. Sloane P et al, Ann Intern Med 2001; 134: 823-32

2. Lauuguen R. Am Fam Physician 2006; 73: 244-54

3. Neurology 2005;65:898-904

4. Samy H et al. www.emedicine.medscape.com as accessed on October 2009
http://www.emedicine.medscape/http://www.emedicine.medscape/


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Types of Vertigo

Peripheral

Central

Other types

Chawla N and Olshaker J. Med Clin N Am 2006; 90: 261-304


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Peripheral Vertigo

Arise from abnormalities in the vestibular end

organs (semicircular canals and utricle), the

vestibular nerve, and the vestibular nuclei.

Most of these causes are benign and readily

treatable



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Peripheral Vertigo

BPPV

Acutesuppurative

labyrinthitis

Vestibular

neuritis

Menieres

Disease

Acoustic

neuroma

TraumaChawla N and Olshaker J.

Med Clin N Am 2006; 90: 261-304BPPV= Benign parosxymal positional vertigo

Types of

Peripheral Vertigo


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Central Vertigo

There is an involvement of the brain especially the

cerebellum

Exhibits more serious consequences and

aggressive treatment is recommended



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Central Vertigo

Cerebellarhemorrhage

Brainstemischemia

VertebrobasilarInsufficiency

Types of

Central Vertigo



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Characteristics Peripheral Central

Severity Severe Mild

Onset Sudden Gradual

Duration Seconds to Minutes Weeks to Months

Positional Yes No

Fatigable Yes No

Postural instability Able to walk;

unidirectional instability

Falls while walking;

severe

Hearing loss or tinnitus Can be present Usually absent

Other neurologic

symptoms

Absent Usually present

Associated Nystagmus Horizontal Vertical

Chawla N and Olshaker J. Med Clin N Am 2006; 90: 261-304. Swartz R. Am Fam Physician 2005; 71: 1129-30

Clues to Distinguish


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Most common causes of Vertigo

Benign Paroxysmal positional vertigo (BPPV)

Menieres disease

Vestibular Neuritis

Brandt T, Zwergal A, Strupp M. Expert Opin Pharmacother 2009; 10: 1537-48


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Todays Talk


Vertigo Diagnosis



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Diagnosis

P ti t l i


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Patient complains

of dizzinessDoes the patient have true vertigo?

Ask: Possible cause Comment

Q. Does the room spin

around?

A. Yes

Vertigo An illusion of movement, often horizontal

and rotatory. Associated nausea and

vomiting indicate a peripheral rather than

central cause.

Q. Do you feel unsteady?

A. Yes

Dysequilibrium May result from peripheral neuropathy,

eye disease, musculoskeletal weaknessor peripheral vestibular disorders.

Q. Do you feel like you may

faint?

A. Yes

Presyncope Caused by cardiovascular disorders

reducing cerebral perfusion

Q. Do you feel lightheaded?

A. Yes

Lightheadedness

is non-specific

and hard to

diagnose

It may result from panic attacks with

hyperventilation

Kanagalingam J et al. BMJ 2005; 330: 523

P ti t l i


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Patient complains


Is the patient taking any

Drug that can cause vertigo?

Continue evaluation appropriate for

Lightheadedness, presyncope, or

disequilibrium

YES NO

Aminoglycosides

Furosemide

Ethacrynic acid,Acetylsalicyclic acid,

Amiodarone

Quinine,

Cisplatinum,

Anti-Alzheimersmedications

Anticonvulsants,

Antidepressants,

Anxiolytics.Alcohol

Nicotine

Caffeine

Medications and substances that can cause dizziness or vertigo

Chawla N and Olshaker JS. Med Clin N Am 2006; 90: 291-304Labuguen RH. Am Fam Physician 2006; 73: 244-51

P ti t l i


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Patient complains





Lightheadedness, presyncope, or

disequilibrium

YES NO

YES NO

Consider stopping

medicationIf possible

Obtain general History


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Obtaining History

Ask for family history including hereditary conditions such

as migraine and risk factors for cerebrovascular disease

Sexual history should also be noted. Certain sexually

transmitted diseases such as syphilis have otologicsymptoms

Consider age, as it is associated with some underlying

conditions (diabetes or hypertension) and these conditions

are associated with higher risk of cerebrovascular causes

of vertigo

Labuguen RH. Am Fam Physician 2006; 73: 244-51

Kanagalingam J et al. BMJ 2005; 330: 523

Patient complains


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Patient complains





Lightheadedness, presyncope, ordisequilibrium

YES NO

Consider stopping


Obtain general HistoryNo history of other possible causes

of vertigo

Obtain history on the duration of vertigo

YES NO


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Features Possible Diagnosis

Spontaneous episodes (i.e. no

consistent provoking factors)

Unilateral loss of vestibular function

Spontaneous episodes (i.e. noconsistent provoking factors)

Nausea and/or vomiting

Late stages of Menieresdisease

Moderate imbalance

Nausea and vomiting

Late stages of acute vestibular neuronitis

Vertigo lasting for few seconds

Goebel J. Otolayngol Clin N Am 2000; 33:483-93

Chawla N and Olshaker JS. Med Clin N Am 2006; 90: 291-304


Hung Kuo C. Aus Fam Physician 2008; 37: 341-47


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Vertigo lasting for several seconds to

few minutes


Induced by position change

History of cervical spine trauma

Nausea and/or vomiting

Benign paroxysmal positional vertigo

Induced by changes in head

position

Changes in ear pressure, head

trauma, excessive straining, loud

noises Hearing loss

Perilymphatic fistula* or

Superior semicircular canal dehiscence

* vertigo with perilymphatic fistula can also last from several minutes to hours

Goebel J. Otolayngol Clin N Am 2000; 33:483-93 Chawla N and Olshaker JS. Med Clin N Am 2006; 90: 291-304Labuguen RH. Am Fam Physician 2006; 73: 244-51 Hung Kuo C. Aus Fam Physician 2008; 37: 341-47


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Vertigo lasting for several minutes to

hours


Cardiovascular risk factors

Neurological symptoms

Hearing loss (In case of involvement

of the inferior cerebellar artery

involvement)

Transient ischemic attack or stroke






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Vertigo lasting for hours


Fluctuating hearing loss

Tinnitus, aural fullness

Menieresdisease

History of migraine Headache#

Visual aura#

Phonophobia, photophobia

Migrainous vertigo

# Typical headache and aura is absent






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Vertigo lasting for days


Severe nausea and vomiting

Recent upper respiratory viral

illness or middle ear illness

Moderate imbalance

Nausea and vomiting

Early acute vestibular neuritis

Labyrinthits (if hearing loss is present)

Imbalance

Focal neurological findings

Cerebellopontine angle tumour;

cerebrovascular disease; multiple sclerosis






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Vertigo lasting for weeks


History of anxiety, panic disorder or

depression

Psychogenic vertigo





Patient complains D th ti t h t ti ?


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Patient complains






YES NO

Consider stopping



of vertigo


YES NO

Perform head and neck

and cardiovascular examination


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Head and Neck Examination

Findings Inference

Vesicles on the tympanic membrane Herpes zoster oticus

Henneberts sign (i.e., vertigo or nystagmus

caused by pushing on the tragus and external

auditory meatus of the affected side)

Perilymphatic fistula

Valsalva maneuver (i.e., forced exhalation with

nose plugged and mouth closed to increase

pressure against the eustachian tube and inner

ear) causes vertigo

Perilymphatic fistula or Superior

semicircular canal dehiscence

Other otoscopic findings Cerumen impaction or any foreign

object in the ear canal

Fluid behind the ear drum, perforation or extensive

scarring

Middle ear disease (ototis media,

chronic otitis, cholesteatoma etc)

Chawla N and Olshaker JS. Med Clin N Am 2006; 90: 291-304 Labuguen RH. Am Fam Physician 2006; 73: 244-51Hung Kuo C. Aus Fam Physician 2008; 37: 341-47


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Cardiovascular Examination

Findings Inference

Orthostatic changes in systolic blood pressure

(e.g., a drop of 20 mm Hg or more) and pulse (e.g.,

increase of 10 beats per minute) upon standing

Orthostatic hypotension, dehydration

etc

Carotid bruit, heart murmur or irregular rhythm Cardiac arrhythmia

Chawla N and Olshaker JS. Med Clin N Am 2006; 90: 291-304 Labuguen RH. Am Fam Physician 2006; 73: 244-51Hung Kuo C. Aus Fam Physician 2008; 37: 341-47

Patient complains Does the patient have true vertigo?


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Patient complains






YES NO

Consider stopping



of vertigo


YES NO

Perform head and neck

and cardiovascular examination

Perform

neurologic examination

Negative


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Neurological Examination

Fixation suppression test

Head Thrust Test (Head Impulse Test)

Posthead shake nystagmus Dix-Hallpike Maneuver

Positional Tests

Goebel J. Semin Neurol 2001: 21: 391-8


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Warning clinical features warranting

neuroimaging

Very sudden onset (seconds) of vertigo that persists and

not provoked by position

Association with new onset of (occipital) headache

Association with deafness but no typical Meniereshistory

Acute vertigo with normal head impulse test

Associated with central neurological signs such as severe

gait and truncal ataxia



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Todays Talk


Vertigo Diagnosis



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Treatment

Vestibular Rehabilitation Therapy (VRT)

Pharmacotherapy


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Vestibular Rehabilitation Therapy

Involves series of maneuvers involving head, eye and body

movements

These stimulate the in-build adaptive mechanism

Helps patients with peripheral vestibular hypofunction toreturn to normal activities of daily living and a high quality of

life

Kirtane M. Ind J Otolaryngol HNS 1999; 51: 27-36

Hall C, Cox C. Otolaryngol Clin N Am 2009;42: 161169


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VRT- Goals

Improve balance

Minimize falls

Decrease subjective sensations of dizziness

Improve stability during locomotion Reduce overdependency on visual and somatosensory

inputs

Improve neuromuscular coordination Decrease anxiety and somatization due to vestibular

disorientation

Zapanta P . http://emedicine.medscape.com/article/883878-print as accessed on December 2009

EXERCISES IN BED EYE AND HEAD MOVEMENTS


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EXERCISES IN BED : EYE AND HEAD MOVEMENTS

Looking up and down

Looking alternately left and right

Convergence Exercises

Bending alternately

forward and backward

Turning alternatively tothe left and then ri ht


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EXERCISES IN STANDING POSITION

Changing from sitting

to standing, initially

with eyes open and

then with the eyes closed

Throwing a small (ping

pong) ball in, an

arc from hand to

hand and following

it with the eyes

Throwing a small ballfrom hand to hand

under the knee


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EXERCISES WHILE WALKING

Throwing and catching

the ball while walking

Playing any game involving bending,stretching and aiming with the ballWalking up and down a flight of stairs

Walking around in the room

with eyes open and closed


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EXERCISES IN SITTING POSITION

Shrugging and

rotating shoulders

Bending forward and

picking up objects from the

floor

Turning head and trunk

alternately to the left and the right


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Aims of Symptomatic treatment

Eliminate vertigo

Enhance or at least non compromise- of the process of

vestibular compensation

Reduction of neuro-vegetative and pyschoaffective signs-nausea, vomiting, anxiety, that often accompany vertigo

Rascol O et al, Drugs 1995; 50: 777-91


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Vestibular compensation (VC)

VC is a natural process bywhich the brain helps thebody overcome the feelingof vertigo

Takes place mainly atvestibular nuclei (astructure present in thebrain stem)

The vestibular nucleireceives inputs from thetwo ears from each side

Lacour M. Curr Med Res Opion 2006; 22: 1651-9

Vestibular Deficit in Vertigo


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Vestibular Deficit in Vertigo

Vestibular

Nuclei

INTACT DAMAGED

Imbalance of activity at vestibular

nuclei causes vertigo

Lacour M. Curr Med Res Opion 2006; 22: 1651

Vestibular

Nuclei

INTACT INTACT

Normal individual

NOSE

EAR


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Reasons for reduced activity at VN of the

damaged side

Vestibular

Nuclei

INTACT DAMAGED

Imbalance of activity at vestibularnuclei causes vertigo

(1) Reduced input

from the ear(2) Inhibition by

the intact VN


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Vestibular Compensation

There is an increase inhistamine levels at VN by thebrain

Histamine helps achieve VC

However, it takes about 3months for by our body toachieve VC and overcomethe symptom of vertigo

Hence, treatment should befocused towards hasteningVC

Vestibular

Nuclei

INTACT DAMAGED


Lacour M. J Clin Pharmacol (In press)


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Classification of Pharmacotherapy for

management of Vertigo

Vestibular Suppressants

Drugs that facilitate compensation process


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Treatment with Vestibular Suppressants

Suppressants reduceactivity at intact side andthus hamper recovery byVC

Hence, they are notrecommended for longterm use

They should bediscontinued as soon aspossible


VestibularNuclei

INTACT DAMAGED

C l d tib l


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Commonly used vestibular

suppressants in practice

Drug Dosage Adverse Reactions

Meclizine 12.5-50 mg TID Sedating, precaution in

prostatic enlargement

Cinnarizine 30 mg TID Sedation, CNS

depression

Prochlorperazine 5 to 10 mg BID or TID Extrapyramidal side

effects


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Vestibular Suppressants

Useful for prevention of nausea and reduce vomiting

(generally to be used for not more that 1-3 days) post an

event

Should be discontinued as soon as possible after eventsubsides

They are not to be used chronically or for prophylaxis

against subsequent attacks


Goebel J. Otolaryngol Clin N Am 2000; 33: 483-93

Brandt T, Vertigo. Its Multisensory Syndromes, 2ndEd: Pg 49-61


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Todays Talk


Vertigo Diagnosis

Treatment Options

Focus of Betahistine in Vertigo Management


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Eff t f b t hi ti


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Effect of betahistine

on locomotor balance recovery in cats

Betahistine treated cats showed a time benefit of

2 weeks in maximum performance

This time benefit was due to early

achievement of compensation

Tighilet B, Leonard J, Lacour M. J Vest Res 1995;5:53-66


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Role of betahistine in VC


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Vestibular

Nuclei

INTACT DAMAGED

Lacour M. Curr Med Res Opion 2006; 22: 1651-9; Lacour M. J Clin Pharmacol (In press)

(2) Increases the activity

of the damaged VN by H1

agonistic action

(3) Reducing inhibition byintact by H3 hetro

antagonistic

action

(1) Increasing the levels

of histamine in the VN by

H3 auto antagonistic action

Betahistine helps achieve the activity of the damaged side within 1 month

Giving a time benefit of 2 months !! As compared to the natural course of VC


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Clinical Studies

Superior to placebo in reducing frequency of


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Superior to placebo in reducing frequency of

vertigo

18 ENT practicesin the Netherlands

82 patients

suffering from

vertigo of

various origins

Oosterweld et al, JDR

J Drug TherRes1989; 14:122-6


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Effective in both Menieresand BPPV

Mira et al,

Eur Arch Otorhinolaryngol 2003; 260: 73-7

144 patients suffering from recurrent vertigo

related to Menieres disease or PPV


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Effective in acute vertigo

N=29 outpatients with acute vertigo Bradoo et al, Indian JOHNS 2000; 52: 151-8

Week 0 Week 1 Week 2 Week 3


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Comparable Efficacy:


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24 mg BID vs. 16 mg TID

N= 120 ptns with well established Meniers Disease Gananca M et al,

Acta Oto-Laryngologia 2008; 1-6

24 mg BID is as effective as 16 TID in terms

of reduction in vertigo spells

There was no difference between groups in terms ofincidence of adverse events

24 mg BID would be of particular importance in

patients non-adherent or partially adherent to treatment


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High Dose, Long Duration Studies


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Effect on cerebral blood flow

SPECT- Indian Study


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MRISPECT

R L R L

Reference Image

Pre-Betahistine Therapy (15.06.1999) No. 2540

Post-Betahistine Therapy (12.07.1999) No.2922

(A)

SPECT Indian Study

Krisha BA, Kirtane MV et al

Neurology India 2000; 48: 255-9

11 patients with no peripheral vertigo

and with probable diagnosis

of ischemia (lack of blood supply) of the

Vertebro-basilar artery were included

Left temporal lobe

SPECT- Indian Study


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MRISPECT

R L R L

Reference Image

Pre-Betahistine Therapy (27.02.1998)

No.791

Post-Betahistine Therapy (10.03.1998) No.1950

(B)

SPECT- Indian Study





Right inferior cerebellar region



SPECT- Indian Study


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Reference Image

SPECT MRI

R L R L

Pre-Betahistine Therapy (17.03.1999)

No.1086

Post-Betahistine Therapy (08.04.1999)No.1599

(C)SPECT Indian Study





Right parieto-occipital region




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Betahistine Versus Other Agents

S i t Ci i i


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Superior to Cinnarizine

Deering RB et,

Curr med Opion 1986; 10: 209-14

88 patients with peripheral vertigo

B t hi ti i t d i d t


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Betahistine associated superior responder rate

88.7 91.6

7582.4

70.5

79.4

65.8

86.2

63.4

81.5

28.9

51.6

0

10

20

3040

50

60

70

80

90100

Meniere's Disease Other vestibular disorders

P

atient(%)

Betahistine Cinnarizine Clonazepam

Flunarizine Gingko Biloba extract No medication

N=1,100 outpatients with established Mniresdisease or other peripheral vestibulopathies

Gananca et al, Rev Bras Otorrinolaringol 2007;73(1):12-8.

Betahistine associated low incidence of adverse


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effects compared to others

0

2.1 3

23.8

7.4

2.3

26.2

9.1

0

29.9

13.4

2.3

0

2.84.5

0

17.114.7

0

5

10

1520

25

30

35

Sleepiness Depression Axiety

Patient

(%)

Betahistine Cinnarizine Clonazepam

Flunarizine Gingko Biloba extract No medication

Gananca et al, Rev Bras Otorrinolaringol 2007;73(1):12-8.

N=1,100 outpatients with established Mnires disease or other peripheral vestibulopathies

Superior to Flunarizine


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Superior to Flunarizine

3.8

0.6

3.9

2

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

Day 0 Day 60

Meanseverityofvertigo

Betahistine Flunarizine

Fraysse B et al,

Acta- Otolaryngologica 1991;

Suppl 490: 3-10

55 patients with recurrent vertigo

Superior to prochlorperazine


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Superior to prochlorperazine

Aantaa E et al; Ann Clin 1976; 8: 284-7

N=30 patients with Menieresdisease


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Jeck-Thole et al, Drug Saf 2006; 29: 1049-59

D


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Dosage

VERTIN, Prescribing Information


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new vertin cme slides final

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